When It’s Time for Goodbye When a student is ready to “graduate” from services, how do you handle resistance from parents? Features
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Features  |   September 01, 2016
When It’s Time for Goodbye
Author Notes
  • Lesley Sylvan, EdD, CCC-SLP, has provided services in New York City and San Francisco public school districts. She is currently in private practice in Seattle. lesley.sylvan@gmail.com
    Lesley Sylvan, EdD, CCC-SLP, has provided services in New York City and San Francisco public school districts. She is currently in private practice in Seattle. lesley.sylvan@gmail.com×
Article Information
Speech, Voice & Prosodic Disorders / School-Based Settings / Features
Features   |   September 01, 2016
When It’s Time for Goodbye
The ASHA Leader, September 2016, Vol. 21, 44-48. doi:10.1044/leader.FTR1.21092016.44
The ASHA Leader, September 2016, Vol. 21, 44-48. doi:10.1044/leader.FTR1.21092016.44
If you’ve ever recommended that a student discontinue speech-language services—which you probably have if you work in the schools—you’ve likely encountered opposition. Parents almost always insist that services by speech-language pathologists continue.
Do the following two scenarios sound familiar?
Scenario one: When David still wasn’t talking by age 3, he received an autism spectrum diagnosis and has received speech-language treatment ever since. Now in fourth grade, David attends a specialized public school program for students with moderate to severe disabilities. He remains nonverbal, has poor attention skills and communicates primarily through vocalizations and gestures. At his triennial IEP meeting, the school psychologist notes David’s cognitive skills approximate those of an 18-month-old child; his SLP notes his language skills are also in the 18-month-old range.
The SLP recommends terminating speech-language services because David is in a language-rich classroom, and functional communication is part of the curriculum. David’s parents object to the SLP’s recommendation, arguing that David’s continuing communication difficulties warrant more speech-language intervention.
Scenario two: When Mary was in kindergarten, her teachers noticed she often needed directions repeated and her vocabulary was limited. So they referred her for speech-language services. Now an eighth-grade student, Mary is passing her general education classes but scores approximately two standard deviations below average on comprehensive standardized language assessments.
During Mary’s annual IEP meeting, Mary’s SLP recommends that she discontinue speech-language treatment because she is performing at grade level academically. Mary, who’s at the meeting, says she is “tired” of treatment and feels like she’s been doing it “forever.” However, Mary’s parents worry that without these services, Mary may fall behind academically, particularly as she transitions to high school. They advocate for treatment to continue.
These are just two examples of the types of challenging discussions SLPs often have with parents about how and when to discontinue speech-language services. Let’s take a closer look at why these conversations about exiting a student from services are so challenging—and what SLPs can do to help reach consensus with parents.

If a teacher has been regularly partnering with an SLP, that teacher can better reassure parents of continued support for their child’s language development in an SLP’s absence.

The challenges
Much of the difficulty with exit conversations stems from a combination of tough-to-interpret criteria for receiving services, limited resources and a litigious special-education climate. More specifically:
Eligibility criteria are complex. When making eligibility decisions in public school settings, SLPs need to rely on their knowledge of the eligibility criteria stated in the Individuals With Disabilities Education Act (IDEA). For a student to be eligible—or continue to be found eligible—for speech-language services, all three of the following criteria must apply:
  • The student has a speech or language impairment.

  • The student’s speech or language impairment has an adverse effect on the student’s educational performance.

  • Specially designed instruction is necessary for the student to progress in the curriculum.

Although these three criteria may seem fairly straightforward, they are actually quite complex. That’s why school districts rely heavily on SLPs to interpret the eligibility criteria based on their clinical knowledge. Embedded in each criterion is a host of related questions SLPs need to consider: How can one differentiate a language impairment from a language difference? What are the educational consequences of speech-language disorders and how do these consequences change as a student advances through school? Which student needs can be addressed only through speech-language intervention and which needs are better addressed by other educators? How can one tell when a student is truly benefitting from speech-language interventions?
SLPs must draw on their broad knowledge of language development, human cognition and education in making eligibility decisions. The complexity and subjectivity of the eligibility criteria is part of why explaining recommendations to parents can be difficult.
Each decision is individual. The law is clear that limiting access to speech-language services, based on any particular categorical factor such as a student’s age or diagnosis, is not consistent with IDEA, because IDEA requires that a free and appropriate education be provided based on a student’s individual needs. Given this requirement, SLPs cannot use age, grade, student placement or any other a priori criterion as a main factor for recommending exiting a student from services, nor can school districts advise SLPs to follow certain exiting patterns or pathways (such as discontinuing speech treatment for students with mild-moderate impairments in high school). Instead, SLPs must consider each student on a case-by-case basis.
Special education is litigious. Parents have the right to seek mediation, due process hearings or litigation if an agreement cannot be reached at an IEP meeting. There are many examples of major special-education–related lawsuits that have resulted in significant financial costs to school districts. One of these is Corey H. v. Board of Education of City of Chicago, in which it was found that the school district had failed to provide essential services to help children with disabilities succeed in mainstream classrooms.
Although lawsuits involving failure to provide services typically involve school districts—rather than individual SLPs—obviously we want to keep disagreements with parents from escalating to legal action. (And SLPs in private practice are at risk for being sued personally.) Fear of litigation only adds to the challenge of advocating that a student exit services. The fact that school services are free also makes it hard to convince parents that discontinuing services is in the best interests of their child.

How can SLPs help defuse the difficulty of exit conversations? Their efforts need to be ongoing and not just limited to the conversation itself.

Possible strategies
Given such challenges, how can SLPs help defuse the difficulty of exit conversations? Their efforts need to be ongoing and not just limited to the conversation itself. More specifically, SLPs can:
Continually educate others about the nature of speech-language disabilities. As experts on language development and disorders, it is critical that SLPs talk to school staff and parents about the nature and duration of speech-language disorders. SLPs also understand that many language disorders have a long-term impact and that most interventions, while hugely helpful, cannot “cure” disabilities. Educating parents and other members of the educational team about the nature of speech-language disorders and the limitations of treatment should be a key, ongoing part of any school-based SLP’s job.
As early as the initial IEP meeting, it is important for SLPs to communicate expectations about how and when services will end with parents and educators. Having an ongoing discussion about discontinuing services may help avoid a situation in which parents are caught off-guard or on the defensive when the recommendation is made to discontinue services.
Collaborate closely with other educators. SLPs should work with other educators on a student’s team to ensure that each student’s speech-language goals are addressed across settings. Partnering with other service providers enables SLPs to serve students most effectively. It also clearly shows parents that students’ language needs are being met in multiple settings. If a teacher has been regularly partnering with an SLP, that teacher can better reassure parents of continued support for their child’s language development in an SLP’s absence. Through this type of partnership, teachers can also help SLPs advocate for dismissing a student from services, as appropriate.
Avoid an all-or-nothing approach. It’s also useful to consider the middle ground between the current level of services and no services at all. As a student gets closer to discontinuing speech-language services, the frequency of services, the length of treatment sessions and the location of services could be revised rather than eliminated.In one model, for example, an SLP may collaborate with the classroom teacher to co-teach language-based lessons for a student who no longer needs individual or small-group services. Another possibility is consulting with classroom teachers about strategies to support a student’s language needs rather than providing direct services. It is important to closely monitor a student when a service delivery model is changed and collect data on how the change affects their progress.

An SLP may consider collaborating with the classroom teacher to co-teach language-based lessons for a student who no longer needs individual or small-group services.

Celebrate success but be prepared for some hard conversations. When possible, frame discontinuation of services as a positive step for a student. Point out that a student has benefitted from speech-language services but is now ready to be more independent. Celebrating success and progress may help ease the conversation.
But the conversations may still be difficult. Parenting, especially parenting a child with a disability, is hard emotional work. It’s understandable that parents may experience concern when a helpful service is discontinued. It reminds them that their child is growing older and may raise difficult feelings about their child’s disability. Remind yourself that when parents fight discontinuation of your services, it reflects how much parents value those services.
Back to Mary and David
Returning to those stalled IEP meetings we opened with, let’s consider how the SLP in each case can resolve the sticking points.
For David, the nonverbal fourth-grader with autism, his SLP and classroom teacher give his parents examples of how educators address functional communication in the classroom. The teacher notes that the SLP will revise the IEP to provide a specific amount of service in the classroom, which involves providing direct and indirect services. David’s parents don’t immediately agree to this plan but schedule a follow-up IEP meeting to discuss it after further consideration. The educational team will collect data to share with the parents that may help to demonstrate the appropriateness of this service delivery model.
For Mary—the eighth-grader who’s mostly caught up to her peers in language—the SLP proposes adding a monthly 30-minute speech-language consultative session to Mary’s IEP. During this session, she will mostly serve Mary indirectly, primarily monitoring for any regression in academic progress due to the fading of services. The SLP will also use the session to consult with teachers on classroom strategies to best meet Mary’s learning needs. The SLP says this service will likely be faded next year unless Mary’s academic performance declines notably and the IEP will be revised accordingly. Mary’s parents agree to this plan, and she is on her way to successfully graduating from speech-language services.
1 Comment
October 8, 2016
Karen George
Lesley - Thanks for your thoughts!
I am an SLP who has worked in various settings over the last 10 years. I now run a private practice and a therapeutic day program offering speech, OT and ABA therapy. It is very common for parents to resist discontinuing services, even when a child is age-appropriate. As you described, the situation is common in which parents and clinicians may differ on a child’s discharge date, or how much therapy they will need. In addition, I have found that it can also be emotionally challenging for parents (and therapists’ alike) to let go of that bond formed over several months or years of therapy. When parents do resist your recommendation if a child is ready to be discharged, you should first realize that this is a compliment to you as a clinician! Often times the bond formed and the guidance you have provided the parent is not something they want to lose. I handle this by (1) assuring the parent that I am just a call, email, or text away and (2) Letting them know that we can always restart services if it is warranted. By doing this, and periodically keeping in touch with mom or dad, it has been easier to say “goodbye”.
Karen
www.ChicagoTherapeuticPreschool.com
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September 2016
Volume 21, Issue 9