Speech Therapy 101 “ Communication Counts”

1. SpeechTherapy 101“Communication Counts” Rebecca Arevalo M.S. CCC/SLP Deanna Ashley M.A. CCC/SLP Joanne Chwajewski M.S. CCC/SLP Gloria Moncada B.A. TEA Certified Chandra Phillips M.S. CCC/SLP

2. Agenda • Who we are • RTI and SLP Services • HCISD Speech Impairment Eligibility • Medical vs. Educational Model • Service Delivery Model • Missed and Make-up Therapy Sessions • HCISD Dismissal Criteria • Questions

3. Licensure and Credentials Speech-Language Pathologist: • Licensed to practice by the Texas Department of State Health Services • *Master’s or doctorate degree in Communication Disorders • Certificate of Clinical Competence (CCC) from the American Speech Language-Hearing Association or clinical fellowship (intern) in process *Some speech-language pathologists were licensed in 1986 with a Bachelor’s degree and/or TEA Certified and Licensed.

4. Licensure and Credentials Speech-Language Pathology-Assistant: • Licensed to practice by the Texas Department of State Health Services • Bachelor’s degree in Communication Disorders or in a related field with required courses and clinical experience.

5. Roles and Responsibilities STATE BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY GUIDELINES The assistant shall: • use the title “Licensed Assistant in Speech-Language Pathology.” At the direction of the supervising Speech-Language Pathologist (SLP), and with appropriate training, the assistant shall: • conduct or participate in speech, language, and/or hearing screening with the appropriate training; • implement the treatment program or the Individual Education Plan designed by the licensed speech-language pathologist;

6. Roles and Responsibilities Guidelines Continued: • provide carry-over activities that are the therapeutically designed transfer of a newly acquired communication ability to other contexts and situations; • collect data; • administer routine tests, if assistant has been appropriately trained and the assessments are conducted under the direction of the supervisor; • maintain clinical records; • prepare clinical materials; and • participate with the licensed SLP in research projects, staff development, public relations programs, or similar activities as designated and supervised by the licensed SLP.

7. Roles and Responsibilities The assistant shall NOT: • conduct evaluations, even under supervision, since this is a diagnostic and decision-making activity; • interpret results of routine tests; • interpret observations or data into diagnostic statements, clinical management strategies, or procedures; • represent speech-language pathology at staff meetings or at admission/review/and dismissal (ARD) meetings; • attend staffing meetings or ARD meetings without the supervisor being present;

8. Roles and Responsibilities • The assistant shall NOT: • design a treatment program or individual education plan (IEP); • determine case selection; • present written or oral reports of client information; • refer a client to other professionals or other agencies; • use any title that connotes the competency of a licensed SLP; and • practice as an assistant in speech-language pathology without a valid supervisory responsibility statement on file in the State Licensing Board Office.

9. RTI and SLP Services What is RTI? Response to Intervention is an early detection and support system that identifies struggling students and assists them before they fall behind. The goals of RTI are to provide specific supports and then to use data from the student’s response to intervention to assist with identification of speech, language, or learning disabilities. When students have difficulty with academics or behavior, their needs are quickly identified, and interventions are provided to meet those needs. RTI is designed as early intervention to prevent long-term academic failure. Prevention of speech, language, and communication disorders is one of the key roles and responsibilities of school-based SLPs and as such, can compliment and augment RTI services. Texas Speech-Language Hearing Association 2009 www.txsha.org

10. RTI and SLP Services RTI and Workload 1. Intervention to support students as soon as data indicates they are struggling to meet grade-level expectations. 2. Prevention of communication disorders 3. Identification of disabilities and the need for special education. RTI ensures that students who need intervention for explicit, direct instruction receive it. Although school districts are not required to include SLPs in their RTI framework, there is nothing in federal regulations to preclude active participation of SLPs in addressing all three purposes of RTI. Texas Speech-Language Hearing Association 2009 www.txsha.org

11. 3 TIER Model and the SLP Tier 1— The SLP provides mostly indirect services to support quality instruction in the classroom and to participate in prevention activities. Direct services include expanded speech and language screening or providing support for struggling students through a variety of classroom activities that support oral language development. Indirect activities include completing student observations, helping the teacher with resources for targeted interventions and strategies for speech and language, and staff development to promote understanding of students’ language learning needs. Texas Speech-Language Hearing Association 2009 www.txsha.org

12. 3 TIER Model and the SLP Tier 2— The SLP may provide a combination of direct intervention and indirect services. Direct services include targeted group intervention to support students’ speech and language skills in small, same ability groups. Indirect activities include helping to select research based language interventions, completing student observations, and assisting with frequent progress monitoring of Tier 2 language intervention and helping the problem solving team make decisions on how best to meet student’s needs. Texas Speech-Language Hearing Association 2009 www.txsha.org

13. 3 TIER Model and the SLP Tier 3— The SLP provides mostly direct intervention and identification services. Direct services include intensive, individualized intervention to support students’ speech and language skills. Indirect activities include helping to select research based interventions, completing student observations, in TIER 3 intervention, assisting with frequent progress monitoring, and helping the problem solving team make decisions regarding referral for special education evaluation. Student’s receiving TIER 3 direct interventions through a speech therapist must have a signed parental consent. Texas Speech-Language Hearing Association 2009 www.txsha.org

14. RTI and Language Language and RTI is a little more difficult to implement but there are options available that have been proven to work. Below is a list that has been gathered from visiting with SLPs across the state. 1. Story Lab— This is a classroom-based lesson that will facilitate talking and writing about personal experiences. Students will learn to talk about what really matters, talk about events in ways that engage and make sense to the listener, and identify and express feelings related to the event. The program helps the SLP determine the student’s ability to ask and answer questions and expand their language skills. 2. LINC— This is a published classroom based language program. It has been used to determine a child’s language abilities. Through the very clever activities, the SLP will be able to work on vocabulary, following directions, sequencing, problem solving, communicating with peers and adults and much, much more. This program is available through mindworksresources.com. Texas Speech-Language Hearing Association 2009 www.txsha.org

15. RTI and Language General Language Strategies: • Provide corrective feedback on language usage errors. • Present student with correct and incorrect sentence forms and ask student to identify them as a correct or incorrect. Also, have student correct the incorrect sentences. • Teach students the problem-solving model so they will be able to determine their own needs, strengths, weaknesses, and what to do/who to talk to in order to improve their skills. • Provide Venn Diagrams, Describing Charts and visual aids that may be used by classroom teachers and parents/caregivers. Texas Speech-Language Hearing Association 2009 www.txsha.org

16. RTI and Articulation • ARtIC Lab: A bilingual RTI program for elementary school students (grades2-5) exhibiting mild articulation deficits in English and Spanish. It is a 20-hour, evidence-based program that provides sound placement instruction, intensive drill work, and sound generalization activities. This program is available through superduperinc.com. Texas Speech-Language Hearing Association 2009 www.txsha.org

17. RTI and Articulation 2. Quick Artic: This is an RTI approach implemented in Terrebone Parish School System, Louisiana. It is a fourstep process. It is used with students that are identified as at-risk. Children with 3 or more errors move to tier 3. Children with 1 or 2 errors, move through the 4 step process. Children’s speech sounds are probed every 2 weeks. As they reach a mastery of 75% or greater on error sounds, they are exited from the process and return to general education. Texas Speech-Language Hearing Association 2009 www.txsha.org

18. RTI and Articulation General articulation strategies: • Provide corrective feedback on articulation errors. • Use auditory feedback devices to amplify the student’s productions. • Set up a “center” with a list of words for their sound and a recorded auditory bombardment list. • Provide a communication lab for students who are at risk as well as students who have been dismissed since all goals except complete carryover have been mastered. Texas Speech-Language Hearing Association 2009 www.txsha.org

19. RTI and Voice Voice and RTI is an area that has not been addressed at this point. There are some general strategies that can be used with these students. Texas Speech-Language Hearing Association 2009 www.txsha.org

20. RTI and Voice General Voice Strategies: • Use puppets to demonstrate appropriate voicequality versus inappropriatequalitiessuch as harsh, breathy, and hoarse. • Use relaxation techniques to teach relaxation of vocal folds. • Establish “quiet time” to give voice a rest. • Tape record/videotape student’s speech and ask them to describe what they hear (e.g.: too loud, nasal, hoarse, harsh, etc.) • Provide tracking charts to help parents and teachers determine when students are using target voice skills. Texas Speech-Language Hearing Association 2009 www.txsha.org

21. RTI and Stuttering Any RTI program for students who exhibit fluency disorders should include classroom teachers, staff, and whenever possible, parents/ caregivers since fluency disorders tend to vary in severity according to speaking situation and conversational partner(s). Texas Speech-Language Hearing Association 2009 www.txsha.org

22. RTI and Stuttering General Fluency Strategies: • Provide a slower rate of speech, pause frequently, slow down overall pace of conversation. • Allow longer amount of time for student to respond verbally. • Ask questions that can be answered with relatively few words. • Provide preparation time before calling on a student to read (i.e. give advanced notice, “Bobby please read the first page, then I’d like Jimmy to read the second page.” Jimmy is the stutterer.) Consider allowing students to read out loud in pairs (takes pressure off student who stutters and allows him/her to become more confident with practice). Texas Speech-Language Hearing Association 2009 www.txsha.org

23. RTI and Stuttering General Fluency Strategies: Cont. • When possible, allow for quiet practice time before requiring student to verbalize. • Helps all members of the class learn to take turns talking and listening. All students find it easier to talk when there are few interruptions and have the speaker’s attention. • Relaxation techniques may also be helpful if it appears that the fluency difficulties are being exacerbated by excessive stress or tensions or dysfluencies seem to be breathing related. Texas Speech-Language Hearing Association 2009 www.txsha.org

24. Speech Impairment (SI)Guidelines for Eligibility Determination • Federal Guidelines and Texas Register/Commissioner’s Rules School-based speech-language pathologists (SLPs) provide services within the context of public education. Decisions regarding speech-language pathology services, including assessment and evaluation, are made within the framework of the mandates of this social institution. IDEA 2004 defines speech or language impairment as relevant to the context of schooling. Speech or language impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance. [emphasis added, 34 CFR §300.8 (c)(11)]

25. Speech Impairment (SI)Guidelines for Eligibility Determination Texas Commissioner’s Rules for Special Education defer to the federal definition of a speech or language impairment. Speech impairment. A student with a speech impairment is one who has been determined to meet the criteria for speech or language impairment as stated in 34 CFR, §300.8(c)(11). The multidisciplinary team that collects or reviews evaluation data in connection with the determination of a student's eligibility based on a speech impairment must include a certified speech and hearing therapist, a certified speech and language therapist, or a licensed speech/language pathologist. [TAC §89.1040 (10)] Individual evaluations of students suspected of having a disability must be designed for educational relevance. IDEA 2004 provides parameters for the services provided in educational settings, stipulating that the goal of providing services is to help students make progress in the general education curriculum, and/or be successful when integrated in nonacademic settings and extracurricular activities. [34 CFR §300.107(a) (b); §300.117] (ASHA, 2007).

26. Speech Impairment (SI)Guidelines for Eligibility Determination Concerns from teachers, parents, and other school personnel about articulation, phonology, voice, stuttering, swallowing/feeding, language, and social/interpersonal communication need to be examined in relation to school environments—both academic and nonacademic. Speech language pathologists evaluate the student’s communicative competence as well as the language skills needed to meet curriculum expectations in academics. A student is eligible for speech-language pathology services through IDEA 2004 when s/he exhibits a speech impairment that has an adverse effect on educational performance to the degree that specially designed instruction or related services and supports are needed from the SLP to help the student make progress in the general education curriculum. Determination of eligibility for individualized education program (IEP) services with a speech impairment is a three-stage process that involves collecting data to answer: (TSHA Eligibility guideline 2009)

27. HCISD Eligibility Process • The speech and language summary in the Full and Individual Evaluation (FIE) report should include answers to questions Stage I, Stage II and Stage III eligibility for speech impairment (SI). • The answer to all three stages requires a “yes” in order to make an eligibility recommendation for speech impairment.

28. HCISD Eligibility Process • Eligibility Criteria- • Is there a disability condition (i.e. communication disorder) present? • Is there an adverse effect on educational performance (academic achievement and/or functional performance) resulting from the communication disorder? • Is specially designed instruction (Speech Therapy) required for the student to make progress in the general curriculum?

29. Educationalvs. Medical Model Educational Model Medical Model Medical team, which includes family, decides frequency and duration of therapy (or insurance company). Medical therapy services address areas of weakness no matter how severe, which affect performance of daily living. Therapy focuses on treatment to alleviate or cure specific underlying medical pathologies. Services are outpatient setting or home. www.middletownparentmentor.com • Educational team includes parents, educators and Therapists. • Educational therapy services addresses areas of weakness, which impacts educational performance in the schools. • Therapy focuses on intervention to improve the student’s ability to learn and function in the school environment. • Services are provided primarily in the school. www.middletownparentmentor.com

30. Educationalvs. Medical Model Educational Model Medical Model Treatment is generally one-to-one. Payment is fee for service, insurance, Medicaid or other payer source (private pay). Services are provided year-round. Goals are reviewed and updated as needed (i.e. 3 to 6 months). Reevaluations are completed to update levels of performance as needs dictate. Decisions about continuation of services are made by the medical team (or insurance). www.middletownparentmentor.com • Services provided in the student’s educational setting, often in group setting. • Student’s age range is 3-21. • Services are provided at no cost to parents. • Services are provided during the school year. • Goals are reviewed and updated at least every twelve months. • Reevaluations are completed once every three years. • Decisions about intensity or duration of services are team-driven. www.middletownparentmentor.com

31. Service Delivery Models • “Service delivery is a dynamic concept and should change as the needs of the students change. No one service delivery model should be used exclusively during treatment.” (ASHA,1999) • There are five broad categories of service delivery within which students receive services. The arrangement of time, resources, location of service, and collaboration among educators comprise the service delivery model/s that will best meet individual student needs.

32. Service Delivery Models 1. Pull-out Services are provided individually and/or in small groups in the speech therapy room or a setting other than the classroom. This setting is restrictive and needs documentation in the IEP of the rationale for removal from the classroom. Pullout service is by far the most common service delivery model used in Texas schools. 2. Classroom-based Services are provided to students within the classroom and other natural school environments. This model is also known as integrated services, curriculum-based, inclusive services, transdisciplinary or interdisciplinary services. The SLP provides curriculum-based intervention while using materials from the classroom in the least restrictive environment. There are a variety of service delivery configurations included in the classroom-based service delivery model: team teaching, complementary teaching, supportive teaching, parallel teaching, remedial teaching, and station teaching.

33. Service Delivery Models 3. Self-contained The speech-language pathologist is the classroom teacher responsible for providing both instruction of the classroom curriculum and speech-language remediation as listed in the student’s IEP. Preschool speech classes and communication skills labs are the most commonly used self-contained service delivery model. 4. Community-based The speech-language pathologist provides services in the home or community setting for the purpose of maximizing functional communication. This service delivery model may be direct or indirect, depending on the student’s IEP, and is most often utilized as students transition into post high school employment.

34. Service Delivery Models 5. Indirect services The speech-language pathologist performs activities that support the student’s educational program in the least restrictive environment. Indirect services may also be needed to support the provision of direct speech-language therapy services. Indirect services are student-specific activities provided for and on behalf of students with IEPs for speech therapy. Indirect service delivery configurations include: monitor, consultation, collaborative consultation, curriculum support, contextual support, instructional support, and assistive technology/augmentative communication support.

35. Missed Sessions What the 2006 IDEA Part B Final Regulations Say: How to make up missed sessions for speech-language services has been a frequent topic. On November 2, 2006, ASHA wrote to AlexaPosny, Director, Office of Special Education Services (OSEP), U.S. Department of Education (ED), asking for guidance “…on the need to use substitutes and to schedule make-up sessions when speech-language pathology sessions are missed.”

36. Missed Sessions In the response to ASHA on March 8, 2007, ED confirmed that IDEA and the regulations do not address this issue. It noted that “states and local education agencies (LEAs) are required to ensure that all children with disabilities have available to them free appropriate public education (FAPE), consistent with the child’s individualized education program (IEP) (see 34CFR §300.101).” The Department encourages “public agencies to consider the impact of a provider’s absence or a child’s absence on the child’s progress and performance and to determine how to ensure the continued provision of FAPE in order for the child to continue to progress and meet the annual goals of his or her IEP. Whether an interruption of services constitutes a denial of FAPE is an individual determination that must be made on a case-by-case basis.”

37. Missed Sessions Make-up therapy guidelines (Walsh, 2007; Salter, 2009) • OSEP made a state/district issue (34 C.F.R. 300.101) • Student misses therapy (i.e. illness, excused absence)- district not required t make up (letter to Philadelphia School District, 18 IDELR 846 and Letter to Balden (N.C.) County School District, 22 IDELR 2253).

38. Missed Sessions • Prolonged absence or pattern of short-term absences related to disability (Letter to Balkman, 23 IDELR 646, OSEP 1995). Cases related to missed therapy • Long Beach Unified School District – 3.6 days missed during 7 months of school- No Denial of Fape. • Letter to Angleton (TX) – 25 session missed during year; 5 due to student unavailability- Denial of Fape.

39. Frequently Asked Questions About Missed Therapy Sessions • Would therapy sessions be required to be rescheduled when a student is absent from school due to illness or family-initiated activities (i.e. vacations)? No. The general rule is that if the school district makes related services available to the student at the normally scheduled time, the school district is not obligated to make other arrangements to provide services if the student is absent from school at that time. If, however, the student is absent from school for a prolonged period of time, or there is a pattern of repeated short-term absences from school, for reasons associated with the student’s disability, the IEP team should conduct a meeting to review the student’s IEP to determine if his or her current program or placement needs to be modified.

40. Making Up Missed Therapy Sessions In an effort to be in total compliance with IDEA and the student’s IEP, documentation of a “good faith effort” to make up canceled therapy sessions is required. • Asking student/s to come 15 minutes early or stay 15 minutes after student’s scheduled therapy session. • Adding student/s to another scheduled therapy group. *There is no mandated timeline for make-up therapy sessions. Sessions can be made-up throughout the academic year.

41. HCISD Dismissal Criteria A student may be considered for dismissal from speech-language therapy/IEP services, based on a re-evaluation, when one or more of the following conditions exist: • Based on re-evaluation (formal or informal) and therapy data, the student no longer meets the district eligibility criteria for speech-language impairment (document in Eligibility Stage I and Stage II). • The student’s speech/language/communication needs are being addressed through special education services or by other service providers without the need of the speech-language pathologist (document in Eligibility Stage II). • The student’s speech/language/communication skills are commensurate with the level of overall functioning, especially in adaptive skills (document in Eligibility Stage I). • The goals and objectives of treatment have been met and the educational need for services has been mitigated (document in IEP).

42. Dismissal Criteria Continued • The student's communication abilities are comparable to those of the same chronological age, gender, ethnicity, intellectual level, or cultural and linguistic background (document in Eligibility Stage I). • The student who uses an augmentative or alternative communication system has achieved functional communication across environments and communication partners (document in Eligibility Stage II). • The student is unable to tolerate treatment because of a serious medical, psychological, or other condition.* • The student demonstrates behavior that interferes with improvement or participation in treatment (e.g., noncompliance, malingering), providing that efforts to address the interfering behavior have been unsuccessful.* • Speech-language therapy no longer effects change in the student’s communication skills. There does not appear to be any reasonable prognosis for improvement with continued treatment.* When using these as basis for dismissal, the campus SLP should work with the multidisciplinary team to document minimal educational benefit from speech-language therapy services. Source ASHA, (2004). Admission/Discharge Criteria in Speech-Language Pathology: Ad Hoc Committee on Admission/Discharge Criteria in Speech-Language Pathology. Rockville, MD: Author.

43. Dismissal Criteria Continued Speech Services in the Educational Setting (form) Attachment –A Speech Impairment Guidelines – Education Service Center, Region XV

45. Websites • www.speakingofspeech.com • www.teacherspayteachers.com • www.ric.edu/sherlockcenter/lessons.html (adaptive literature and lessons) • www.boardmakershare.com