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Interview with Claudia Dunaway and Jennifer Taps.

Stunning improvements in speech and language service delivery in schools have enabled speech-language pathologists (SLP) to be more effective and more enthusiastic about how they fit into the general education plans at their schools. I recently visited a school in San Diego City School District to observe a wonderful example of what we can do to provide evidence-based interventions for students with articulation or sound errors. The approach described in this interview has reconfigured the speech and language services in a very large, urban, culturally diverse school district. Claudia Dunaway, MA, CCC-SLP, Lead SLP for San Diego City Schools, and Jennifer Taps, MA, CCC-SLP, Articulation Resource Center Coordinator, are the creators of this program.

Q: I have been very impressed with the speech improvement classes that you have created in your district schools. What prompted the SLPs in your district to focus on improving the way they provided services to students with speech-sound errors?

A: Many of our SLPs expressed dissatisfaction with the way they were serving students with single-sound articulation disorders. Most students were seen 30 to 60 minutes a week in small groups, and progress was reportedly slow. Students stayed on caseloads for a district average of 3 years. Many students were still receiving services in middle and high school. SLPs complained that it was difficult to show the educational impact required by the California Education Code and they railed against the excessive amount of paperwork needed to qualify and dismiss a student. In 2003-2004 we surveyed the staff and discovered that 821 students with single-sound differences or disorders had Individualized Education Programs (IEPs), most of them for 30 minutes each week. Not surprisingly, the average intervention time was 50 to l00 hours. At 55 students per caseload, this number was equivalent to 14 full-time SLPs.

The California Education Code has three eligibility criteria for articulation treatment: 1) significant impact on intelligibility, 2) adverse attention from adults or peers, and 3) educational impact. Many SLPs did not adhere to these criteria. They believed that these speech differences mattered and, understandably, wanted to serve the identified students. So, they developed IEPs that skirted the educational impact issue. This was a problem for our district when we were audited by the California Department of Education. Something needed to be done.

We created a short-term general education class (usually 20 hours in length) to help students with single-sound differences. The Speech Improvement class (SI class) is taught by an SLP and provides high-quality, evidence-based instruction to correct single-sound differences. Thanks to the input from our SLPs, the district shifted its thinking. Students who have single-sound differences that do not significantly affect educational progress still get services. No IEP is required. The teacher completes a questionnaire that provides documentation about educational performance. The SLP determines need and, after the parent gives permission, the student is enrolled in the class.

Q: What is the size and location of your district? How many schools do you have, and how many SLPs are working there? Do you also employ speech-language pathology assistants (SLPAs)?

A: San Diego City Schools is the second largest district in California and the eighth largest urban district in the country, covering more than 200 square miles. Approximately 133,000 students are enrolled at 216 educational facilities. The district's demographics are diverse: 43.4% Hispanic, 25.6% White, 16.6% Asian, and 13.9% African American. More than 50 languages are spoken, and 27.5% of students are English language learners. Two hundred SLPs serve 7,500 students with speech and language impairments, preschool through Grade 12. The average SLP caseload size is 55 students. Nine SLPAs support the SLPs who serve students with intensive speech and language needs. They also maintain our Systematic Analysis of Language Transcription laboratory.

Q: What process did you use to develop the manual and Procedures for this approach? What evidence from research or the literature did you find most helpful?

A: We were very careful to develop our policies and procedures. We knew that this shift in thinking would come under considerable scrutiny from the local and professional community and we wanted a defensible product. We also wanted to address the problem of these students lingering on caseloads for too many years. We knew that we would have to support our staff with high-quality professional development. Claudia wrote the Articulation Differences and Disorders Manual (available online at http://www.csha.org/ResourceCenter/ CSHAArticulationManual.pdf) as our first step. It incorporates current principles of motor learning, evidence-based methodologies, and findings from ASHA's NOMS project (American Speech-Language-Hearing Association's National Outcome Measurement System). The NOMS data and a study by Jacoby, Lee, Kummer, Levin & Creaghead (2002) suggested that 17 to 20 hours is sufficient to remediate a single sound. SLPs also use the principles of motor learning, including mixed practice, separation of prepractice and practice phases, randomization, delayed feedback, early introduction of self-monitoring skills, subvocalization, and mass practice (Skelton, 2004a, 2004b). We've also incorporated complexity principles, such as targeting nonstimulable, phonetically complex and later developing sounds (Gierut, 2001). These principles and other research were the foundation of the Articulation Manual, which we provided for all staff members.

To support SLPs in implementing the SI class format, the district also established the Articulation Resource Center (ARC). As the ARC Coordinator, I (Jennifer Taps) educate district SLPs about workload management and efficacious assessment and intervention methodologies. I also offer large-and small-group workshops, consult by telephone and e-malls, provide opportunities for demonstration observations, and coach individual SLPs at their sites. In fact, I've made 30 site visits so far this school year.

Q: Did you need support from administrators? If so, how did you get it?

A: Support from special education program managers and from site principals was vital to the success of this approach. Claudia approached me (Jennifer) with this idea after analyzing the survey. She developed a proposal and presented it to our Transdisciplinary Services Program Manager and to our Special Education Director. They understood that the cost to provide treatment to these students was significant, that these students were losing valuable literacy time because they were remaining on caseloads for too long, and that our staff was frustrated. They took the idea to our superintendent, who endorsed it wholeheartedly. After we had their full support, we presented to all of the SLPs at our annual fall seminar. We gave them the manual, forms, and other resources to implement the course at some point during the school year. In addition, each SLP was encouraged to discuss this new program with principals and staff at their respective sites. We also gave them a PowerPoint presentation that they could share with their principals and teachers. We said that we were available to go to sites if the administrators had any questions about the program, but this never happened. Adoption has been amazingly smooth.

Q: Explain how students are selected for the Speech Improvement Class.

A: Teachers refer a student and complete a questionnaire that provides us with the documentation I described before. Ideally, we look for students who are in first or second grade who make errors and are nonstimulable for one or two target sounds. This ensures that these students have had sufficient time for development. However, it's still early enough to remediate these sounds prior to the speech normalization boundary of 8 years 5 months (Shriberg, Gruber, & Kwiatkowski, 1994), after which it is much more difficult to learn a new sound. We enroll students older than the speech normalization boundary if they are motivated to improve and will take responsibility for applying what they learn. These SI classes have been implemented at elementary, middle, and high schools throughout our district.

We've also provided guidelines for what to do with students who come to our district with an IEP already in place. If the student does not meet our criteria, we offer the SI class as an alternative service and dismiss the child from his or her IEP. In most cases, parents have been very happy with the process and have reported that they prefer this general education option to enrolling their child in special education.

We also encourage SLPs to require daily home practice. If a student does not complete homework, we do not continue with the service. We enroll the next student on the waitlist because daily practice is critical for full generalization. This is a community service, and we need to ensure that all enrolled students are receiving the full benefit of the course. Parent involvement has increased dramatically. These types of stipulations to continue or discontinue service can be made routinely in general education programs.

Q: What happens in a typical session?

A: We maximize production opportunities and use evidence-based procedures. This is how we are shortening treatment time. During a given session, the children practice target sounds at different levels of complexity (i.e., single sounds, syllables, words, phrases, sentences, stories, conversation). Students tally their productions. Several SLPs have purchased metal tally counters (the kind one might find at an amusement park entrance) and they report that students love seeing how many items or sentences they have completed in a given session. A good Web site for the counters is www.tallycounterstore.com. Sometimes, I ask my students to spread out to various "centers" because I want to create a familiar general education activity. At one center, one student might sit on a pillow and practice at the sentence level. At the same time, another student might practice the sound in isolation by writing words on the board, and another child is saying words while putting manipulatives in a cup. I call "switch" at random intervals so they get practice at different levels in a given session. This requires them to be independent and allows them to get well beyond the recommended 150 correct productions of the target sound per session. We utilize both real and nonsense words in a story format so the students can also practice at a higher level.

In addition, during sessions when all students are sitting at the table together, the students use subvocalization for the extra motor practice when it is not their turn. From all of this, they have developed excellent self-monitoring skills. From the beginning, the students understand that speech improvement is their responsibility. It is important for them to have at least 150 productions of the sound during the session; equally important, however, is developing the feedback loop for self-monitoring beyond the speech-language room.

Q: Do you have some preliminary data on effectiveness?

A: Yes. Erin Kenney, the district's evaluation research consultant, is studying the project's efficacy. Her preliminary data indicates that SLPs, teachers, administrators, and parents are very satisfied with this change in service. SLPs report that it has made their workload more manageable. We also believe that the professional development has resulted in more efficacious treatment, although we can't demonstrate that adequately yet. We can say that there are fewer students with single sounds on our caseloads this year than a year ago. Our SLPs tell us that this reduction is due to students who are dismissed with corrected sounds. As of November 2005, only 147 students had an IEP for single sounds (a significant decrease from 821 in 2004). Another 273 students received short-term services for speech-sound errors in our SI classes. In July 2004, a matched pairs analysis showed an average of 7.2 students per SLP. This figure dropped in November 2005 to 1.3 students with an IEP and 2 students in the SI class. Further, 75% of the SLPs reported changing the way they treat students with single-sound differences, and 92% indicated that they have made changes in their treatment practice, such as varying stimulus and practice levels, target randomization, more target productions per session, and increased emphasis on home practice. All groups would like more flexibility in scheduling and the district is studying the feasibility of offering classes beyond the school day to meet this need.

Q: Can you share a success story from a particular student who benefited from this approach? Did parents or teachers react as well?

A: One student in particular comes to mind. I had assessed him the year before we offered the SI class and he did not qualify for services. His grandmother requested a home program, which I provided, but his lisp was still prominent. As a result, he often assumed the role of class clown, something he confided to me during the evaluation. When we started offering the class, he was the first student I enrolled. He attended regularly and participated with great enthusiasm. Throughout the course, his speech improved dramatically and his confidence soared. His teacher and his grandmother also noticed this transformation as his speech improved and were thrilled with his increased maturity.

Q: Do you think this approach would work in other districts or schools?

A: Absolutely. I think this could work in any district. Most SLPs, administrators, teachers, and parents fully support this short-term, intensive therapy. Research about perception of peers with single-sound errors bears this out. Crowe-Hall (1991) found that peers have a significantly more negative view of fourth- and sixth-grade classmates who make speech errors. Whatever we can do to remediate these sounds will benefit these kids socially and emotionally. All students are worth this time investment, and SLPs have reported that the experience has been rewarding.

Q: I think this service delivery model has many elements of Responsiveness to Intervention (RTI). Do you agree or not? Could it be used that way?

A: I think it shares many principles of RTI, especially at Tier II. With this approach, SLPs can go straight to intervention and provide strategies to the students. Teachers benefit from the modeling and some are taking on the job of coaching our students in the classroom. Perhaps over time this can also be a Tier I intervention. The speech improvement concept just makes sense. It is much more efficient and practical than going through the whole referral process only to find out that the child does not meet the criteria and cannot receive services.

For example, this year, I reduced the number of students with single-sound errors on my caseload, which made more time in my schedule for students who might benefit from RTI. To some extent, the success of the SI class has inspired me to try other RTI models for students with a range of speech and language needs.

Right now our program builds a half day a week for SI classes into our site allocations. We encourage our staff to offer one group (4 students) during that time. This leaves the remaining 2 hours for classroom consultation. Hopefully, this innovative speech approach will create more time, in general, for SLPs to go into classrooms for short-term assistance. When the state adopts RTI, we will be ready.

Q: What are first steps for school districts to begin this highly effective way to assist students with sound errors?

A: Our suggestions align with the work of Staskowski and Rivera (2005). Specifically, it is critical to prioritize time for the SLPs to implement this new course. In our district, SLPs can count up to 5 students from SI classes on their respective caseloads. It's also very important to have the full support of special education and general education administrators as well as site principals.

Finally, a well-organized set of procedures will facilitate the process. This should be provided in the form of a procedures manual, applicable forms (such as permission to enroll and a teacher checklist), intervention activities, and homework packets. This type of support cuts down on paperwork significantly. SLPs need this programmatic support to increase their effectiveness and to integrate the SI classes into their existing schedules.

REFERENCES

Crowe-Hall, B. (1991). Attitudes of fourth and sixth graders toward peers with mild articulation disorders. Language, Speech, and Hearing Services in Schools, 22, 334-340.

Gierut, J. A. (2001). Complexity in phonological treatment: Clinical factors. Language, Speech, and Hearing Services in Schools, 32, 229-241.

Jacoby, G., Lee, L., Kummer, A. W., Levin, L., & Creaghead, N. (2002). The number of individual treatment units necessary to facilitate functional communication improvements in the speech and language of young children. American Journal of Speech-Language Pathology, 11, 370-380.

Shriberg, L. D., Gruber, F. A., & Kwiatkowski, J. (1994). Developmental phonological disorders III: Long-term speech-sound normalization. Journal of Speech and Hearing Research, 37, 1151-1177.

Skelton, S. (2004a). Concurrent task sequencing in single-phoneme phonologic treatment and generalization. Journal of Communication Disorders, 37, 131-155.

Skelton, S. (2004b). Motor-skill learning approach to the treatment of speech-sound disorders. CSHA Magazine, Summer, 8-9.

Staskowski, M., & Rivera, E. (2005). Speech-language pathologists' involvement in responsiveness to intervention activities: A complement to curriculum-relevant practice. Topics in Language Disorders, 25(2), 132-147.

From the Field connects you with clinicians and practitioners in speech-language pathology. Each issue you will meet a professional selected for an in-depth interview on a highly practical topic. The interviews are conducted by the editor of From the Field, Judy K. Montgomery, PhD, CCC-SLP, at Chapman University in Orange, California. Suggestions for future interviews should be sent to Kathy Coufal, CDQ Editor, Wichita State University, 401A Ahlberg Hall, 1845 Fairmont St., Wichita, KS, 67260; e-mail: kathy.coufal@wichita.edu
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Author:Montgomery, Judy K.
Publication:Communication Disorders Quarterly
Article Type:Interview
Geographic Code:1USA
Date:Sep 22, 2005
Words:2873
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