This advice-column-style blog for SLPs was authored by Pam Marshalla from 2006 to 2015, the archives of which can be explored here. Use the extensive keywords list found in the right-hand column (on mobile: at the bottom of the page) to browse specific topics, or use the search feature to locate specific words or phrases throughout the entire blog.
Q: I serve a female client with Down syndrome in school. She is bright and has done quite well in articulation therapy, but she cannot produce CH due to a severe underbite. This is her last articulation error. Her inability to say the sound is not due to poor oral control or cognitive issues. She simply cannot make this phoneme correctly because of the occlusal problem, but she is not going to receive orthodontia or oral surgery. The parents have pushed for her to continue to receive weekly therapy despite lack of progress. Several SLP’s in the district have looked at this child and we all agree that there is nothing we can do for her given her oral structure. My colleagues and I are frustrated over this situation and don’t know what to do. We feel we are wasting our time and the child’s time.
Your situation brings up the topic of exit criteria for speech-language therapy. Speech-language pathologists in the schools tend to have excellent entrance criteria, but we tend to have lousy or non-existent exit criteria. This situation does not occur as much in the private sector. A private practice therapist simply can say, “I don’t think I can help your child. The insurance won’t pay for it, and you do not want to pay for this yourself unnecessarily.”
But school therapy seems “free” to most parents so they are not concerned about the cost. Parents often blame lack of progress in school therapy on the therapist and not the student himself. Parents tend to think that if you just worked hard enough, or longer, or if you just got your act together and somehow magically became a better therapist, that their kid would progress. But lack of progress sometimes cannot be avoided due to problems in oral structure, cognitive deficit, lack of motivation, and other variables outside of a therapist’s control.
We should not be serving clients that we cannot help. This is an ethical problem. ASHA’s Rule of Ethics #7 states: “Individuals shall evaluate the effectiveness of services rendered…and shall provide services…only when benefit can reasonably be expected.”
School therapists need a way to determine when enough is enough, and they should develop a set of “Exit Criteria” just like they usually have a list of “Entrance Criteria.” This is only fair to therapists, children and taxpayers. Therapists should not be burdened with children they cannot help, children should not be pulled out of class for services they cannot use, and school district budgets should not support therapy that is of no benefit. Also, public school clinicians need a predetermined formal exit plan so that individual children and their parents do not feel picked on, excluded, or discriminated against.
Each therapist, school, school district, special education co-op, or state department of education should study the problem and design a set of criteria. A district-wide plan seems best to me because it is small enough to manage and it can be designed with local circumstances in mind. The plan can be built into an RTI program if one exists.
The essential plan is one of determining the number of weeks that can pass without the child showing measurable gain before he is dismissed. For example, it seems reasonable to set 6 weeks as the criteria in articulation therapy. A child is dismissed from treatment if he shows no measurable change on the specific skill in six weeks.
Setting a pre-determined number of weeks to demonstrate progress allows SLP’s to dismiss children who do not change due to any number of reasons including structural anomalies, cognitive impairment, lack of motivation, simple lack of ability, and so forth. This is not a new idea. Therapists have been making these types of decisions on their own for a century. But today’s school therapists are more beholden to the demands of parents, and the new environment requires that this process be made formal.
I realize that some of what I have written here may sound cruel to some readers. But I think I know the heart of SLP’s. Most SLP’s would do just about anything to help their clients change. It is in our very nature to help and we usually do whatever it takes to keep kids in treatment. We keep up with the research, we attend continuing education programs, and we ask other therapists for their opinions and ideas. But there are children we simply cannot help. Common sense dictates that these children be dismissed from our caseloads.
There must be a plan in place to help us avoid situations where we merely end up babysitting clients as suggested in the situation described above. We are not babysitters. We are professional speech-language pathologists who are trained to help certain types of people with certain types of problems. We need to face this within ourselves, and we need to re-organize our practices accordingly. We simply should not be serving children we cannot help.
Pam has written about exit criteria in only one of her books: Carryover Techniques in Articulation and Phonological Therapy.