"More Therapy" versus "Relationship of Delivery to Outcome"

More Therapy versus Relationship of Delivery to Outcome

The outcome of therapy relies on more than the amount of therapy minutes provided. “More therapy” versus “relationship of delivery to outcome” has been a popular topic on social media professional discussion groups. Regrettably, this is a dilemma that comes up often in school based practices. During IEP meetings, parents and special education teams can sometimes have misunderstandings related to determining service intensity, frequency, and setting. These altering perspectives can lead to disputes. It is frustrating to parents when school staff insist on their traditional set times and delivery methods. It is stressful to school staff when parents demand more therapy or 1:1 intervention.  Such disagreements create a divide on the IEP team and rarely are resolved in a satisfactory manner to all.  In addition, the both sides of this argument may be disregarding the most important factor--the outcome of therapy.

But what if there was a preventative way to resolve this dispute before it begins? IEP teams can use a structured 5 step process to assist with understanding the outcome of therapy. Consequently, resolutions can be achieved as part of the process rather than through disputes.  This is working S.M.A.R.T.E.R., not harder.

Outcome Decisions on therapy delivery can be made by reviewing these 5 steps:

• Previous assessments and progress reports
• Legal mandates
• The evidence-base in research literature
• Parent input
• Professional judgment

Most often, we ask, “Does my child/student need more therapy minutes?”.  Instead, teams should be asking themselves, “What is the relationship of service delivery to the student outcome?”.

Relationship of therapy delivery and student outcomes means that teams should look back at the IEP goal. The IEP goal IS the desired outcome (or should be).  This is addressed in our S.M.A.R.T.E.R. Step method of writing specific goals.  Specific goals address the underlying discrete skill set needed for student success.

Step 1:  Review of a Child’s Previous Assessments and Progress Reports:

First, teams should review assessment and progress data related to the specific skill set or behavior. This information will provide valuable information as well as a rough estimate of what outcome a student can accomplish annually. For example, if a child progressed from 50% baseline to 70% in a skill set with one hour of therapy per week, then there is evidence that this child can progress about 20% in 36 hours of intervention (based on 36 weeks of school). So, with other goals in that skill set range, it would be reasonable to expect a 20% improvement in 36 hours. If that is the desired outcome, then this would be an adequate level to set in a goal.

Rule of thumb:  Most schools have 36 weeks of school. One hour of therapy a week is 36 hours. Therefore, ask yourselves:  What outcome can be reasonably accomplished in 36 hours for this child?  Also, keep in mind that if the delivery model is pull-out method, then the child is missing 36 hours of instruction in the classroom. Therefore, a balance of academic and therapeutic needs should be considered.

Step 2:  Review of Legal Mandates:

1. If the child is making adequate progress on his/her goals, then the intensity, frequency, and setting are probably appropriate to meet the desired outcome. IF the child has unmet goals at the end of the IEP cycle, then the therapy delivery should be reviewed or the goals may need to be revised. SLPs may need to increase in minutes, or the minutes may need to be provided in shorter duration but more frequently in the week.
2. The least restrictive environment must be considered. School-based therapy is federally mandated to offer the general education curriculum with non-disabled peers to the maximum extent possible.  Outcomes must be pointed towards functioning in the classroom setting and all other educational environments.  Schools are under pressure to do this by law or they can risk losing federal funding.

Rule of Thumb:  If you see that a child is not progressing in a goal by the fist reporting period, it would be wise to review the underlying reasons and address those sooner rather than later.  School staff set themselves up for a bad situation at the end of the IEP cycle when they present a series of unmet goals to the team. Parents can be extremely upset when a lack of progress is reported at the end of the IEP cycle.  Teams can prevent this however, by creating a red flag list in the first reporting period and discussing it with parents at that time.

Step 3:  Review of the Evidence-Base in Research:

In 2010, the ASHA NOMS survey (published 2011) was conducted to determine functional outcomes for students related to service delivery.  Grades pre-K through 12 were reviewed.  There were 2,016 pre-k students’ data submitted by 179 SLPs from 47 school systems across 25 states.  There were 14,000 k-12 students’ data submitted by 597 SLPs surveyed from 106 school districts in 37 states.

This article highlights an example using “speech services”.  http://lshss.pubs.asha.org/article.aspx?articleid=1782699&resultClick=3

The SLPs used a functional communication measure scale for pre-testing and post-testing students over the school year. This allowed them to measure progress in a consistent way across all the groups.  The predominant delivery model was 2 times per week for an average of 21-30 minutes in small group pull-out therapy (average of 30 hours per year).

The outcomes of this service delivery model were calculated for the three most common areas of the SLP caseload:  1. Speech Sound Production; 2. Spoken Language Comprehension; 3. Spoken Language Production.

Results indicated that 25% of students with speech sound production did not progress. 40% of students with spoken language comprehension did not progress.  Likewise, 40% of students with spoken language production did not progress.  The concern here is that ¼ to 2/5 of the caseload were not achieving progress with this service delivery model.  So, SLPs need to examine this model closely if they see that a student is not progressing within the first reporting period. This allows the team to make changes as soon as possible to improve outcomes.  The data show that certain students will NOT progress with this model although the survey research did not provide detailed information on demographics or other reasons as to why these students were not progressing.

Other pertinent research that shows alternatives to consider to the typical two times a week for 30-minute small group pull-out model:

http://www.hanen.org/Helpful-Info/Articles/Parents-as--Speech-Therapists--What-a-New-Study-S.aspx

Preschoolers with language delay received Speech Language therapy 26 hours for intervention with a parent training program component. This model resulted in progression and positive outcomes for preschool children.  Parent and/or teacher training can significantly improve outcomes by enhancing carry-over throughout the child’s day and across language settings.

http://www.apraxia-kids.org/library/speech-therapy-for-apraxia-frequency-intensity-11/

CAS Speech Therapy:  Childhood Apraxia of Speech.  Research from Thomas Campbell on 1:1 therapy hours revealed that min-moderately impaired children with CAS needed an average of 21.75 hours of 1:1 therapy in a year.  This was an average of 29 sessions of 45 minutes which totals 1,305 minutes to affect change in benchmarks and increase overall intelligibility.

For severely impaired CAS (nonverbal to minimally verbal) students, an average of 151 sessions of 45 minutes was needed to show improvements. This totals 131.25 hours of 1:1 therapy. This would be difficult to implement solely in a school setting due to the hours of instruction needed. That would be a lot of missed classroom time. One way of addressing the needed hours would be through a team approach utilizing coordinated efforts between outside therapists, paras, SLPs or assistants, volunteers, etc.

Session Length factors:

Sessions should be long enough to allow for the amount of practice needed for the individual child’s ability and goal targets (Rose, 1997, Schmidt, 1988, 1991).  Professionals should consider such factors as:  attention span, age, developmental ability or expectations.

Distributed vs. mass practice for motor learning:

Fletcher (1992) discussed that “distributed practice” will yield better results for speech motor learning.  This means that children benefit from frequently distributed, shorter bursts of practice over the school week rather than longer “mass practice” sessions only 1-2 times per week.

So in summary, children with CAS would most likely benefit from 1:1 therapy for about 10-15 minutes 4-5 times per week.  Additionally, they would benefit from some carry-over practice of these skills into smaller group or large group therapy 1-2 times per week in order to work toward least restrictive environment (LRE).

Rule of Thumb:  Certain diagnoses such as CAS, ASD, Down Syndrome, Cranio-facial anomalies, Cerebral Palsy, Rare incident/low incident genetic differences will all most likely require a different type of service delivery model than the traditional 2/week for 30 minute sessions in small group pull-out.

Step 4:  Parent Input:

Parents have unique knowledge of their child and can share valuable information about “what works” and “what does not work” for their child. They are privy to preferences and triggers that can save us valuable time and effort. School staff should validate and review parental input with seriousness and sincerity.  At the same time, parents should understand that increasing direct speech language therapy minutes does not necessarily result in better outcomes or faster goal attainment.  The team needs to determine collaboratively: 1. If an appropriate goal has been established; 2. If the interventions can be reasonably addressed without the student losing time in the LRE; 3.  If indirect services would be of benefit to add to the IEP (teacher in-services, para training, parent training, etc.); 4. If accommodations and modifications can assist with areas of need rather than an increase in direct minutes.

Rule of Thumb:  Parents need to be validated. Carefully considering parent requests and input can improve the overall outcomes of your students.

Step 5:  Professional Judgment: 

SLPs have experience and knowledge about typical progression and what is reasonable to expect.  Also, SLPs can take other factors into consideration to discuss such as: chronic absences or lack of motivation.  Increasing therapy minutes on the IEP is not going to help a child who is chronically absent have better outcomes.  Students who lack motivation are not going to miraculously do better on their goals by increasing therapy minutes.  The motivation and chronic absences will need to be addressed and resolved.  SLPs have specific knowledge about different diagnoses and recognize that certain speech and language impairments are more severe and persistent in nature.  They know that these students may need more frequent practice of shorter intervals over the week.  So five 10 minute sessions instead of two 25 minute sessions may improve that student’s outcomes by the end of the IEP cycle.

Rule of Thumb:  Attendance, motivation, severity of disability, cognitive disability, attention span, developmental expectations, and health status are important factors that the SLP has expertise to consider when determining service delivery options.

Remember: “Keeping track of the client’s functional outcomes, instead of reporting more trivial changes in discrete communication skills or comparing scaled scores on a pre- and post-test, demonstrates that the speech language pathologist is using resources wisely”, Moore and Montgomery, (2008).

Kelly Ott, MEd, MHS, CCC-SLP Co-Owner, SMARTER Steps:  With over 20 years experience as a licensed Speech Language Pathologist, consultant, educator and administrator, Kelly has served children and adults with a diverse range of speech, language, swallowing, learning, and communication needs. She has provided direct speech pathology services, specialized tutoring services, educator professional development training, business communication and presentation training. Kelly is dedicated to providing students, educators, and parents with specialized strategies for achievement.

Lara Wakefield, MHS, PhD, CCC-SLP Co-Owner, SMARTER Steps: Lara has over 20 years of experience as a Speech-Language Pathologist and Parent Advocate with a focus on children with special needs being socially competent with their peers. Lara has conducted research in the areas of educator collaboration for classroom-based services. Lara assists families and professionals with exploring the research behind evidence-based practices and determining the various educational options available for each child.