Exit Criteria: Getting Kids Off the School Caseload

By Pam Marshalla

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.

5 thoughts on “Exit Criteria: Getting Kids Off the School Caseload”

  1. This profession needs to hear what you have said–you have said it brilliantly, thoughtfully, and with great empathy. Thank you, Pam. I am proud to call you colleague, friend, and inspiration!
    Donna Ridley

  2. I read your answer to the exit criteria question and I agree with your point of view. However, I have an issue with dismissing a client because you cannot help them anymore. When a student has had therapy with the same therapist for 4 to 5 years and no progress has been met, some of the error may be with the therapist. I work at a middle school and I receive students who have had the same therapist throughout their k – 4 years and when they reach 5th or 5th grade two things may happen:
    1. the new therapist has a better approach, or new ideas to help
    2. the student is motivated because of their age and peers
    Don’t be too hasty to dismiss because your techniques fail. If a student has errors that they have to live with, please, make referrals by offerring another chance at therapy with a different therapist.

  3. Maxine-
    I agree with you.
    In private practice, a family always can switch to another therapist if things aren’t going so well.
    But in the schools there usually is not this option.
    A family is stuck with who they get.
    What is the solution to this?
    A therapist who cannot help still cannot help.

    The blog was intended to address children who cannot be helped because they have been taken as far as they can go.
    This usually is a problem with kids who have cognitive deficit.

  4. Pam,
    I have some very demanding parents who are saying that quote “the ball is in my court” to get the student motivated and make progress. (This mom is very much a bully and brags about making a school psychologist cry and leave the room during an IEP). How do you explain that it in fact is a team effort, and that we are doing all that we can to service you child. I feel no appreciation for all of the tireless hours spent researching, preparing and implementing therapy.
    How have you found to explain this to extremely demanding, bully-like, parents 🙁 Especially when trying to either reduce or dismiss cases.. I have found this extremely challenging. The parents literally tell me “no”.

    p.s. thank you for you sight! Life saver!! And I’m learning so much that I never learned in grad school (it’s so true about what you say about speech-language programs these days) being new in the field I feel SO unprepared and totally out of my league.

  5. Students having exit criteria in the school setting is one of the most important, and often contentious area as a SLP. I too have worked with students with ASD and other disabilities in schools and private practice who do no make reasonable progress due to a mixture of a lack of motivation, severe inattention, cognitive deficits, or very low frustration tolerance when given a non-preferred task. Often-times, these students with severe behavioral, inattention, low frustration tolerance achieve the lowest standard scores of usually 50 on language assessments because their behavior/inattention/ cognitive deficits render them unable to look at the test item, let alone point to a target picture or manipulative. It seems that when a student gets a low standard score both the school ese team and private practice SLP’s think, “Ok, lowest score achieved; I must recommend maximum services!” Then they proceed to input 120-150 minutes per week of language therapy. These students then typically have goals that address requesting, following 1-step directions, responding to their name, etc which they think can be achieved in structured play, or through flash cards as a push-in or pull-out service delivery model. After several weeks of therapy, no progress or very inconsistent progress is achieved because they are not able to: remain seated, look at the pictures/manipulatives, or tantrum when given a non-preferred activity. I’ve tried different strategies and that whole antecedent, behavior, consequence taught in grad school. I’ve tried a visual schedule, first-then board, visual timer, breaks/reinforcement at different intervals, etc and I am still just managing behavior the entire therapy session. I don’t think these students should have been referred for speech/ language therapy with so many minutes per week because they do not have the attentional/ behavioral capacity to make gains. My work then becomes 90% behavior management. Sure, there is behavioral management expected when working with students who have special needs… but what if the majority of the session for several weeks is behavior management? Is it really appropriate to have goals of “will remain seated for x minutes” or “ will refrain from throwing objects” “refrain from negative behaviors for x minutes”? Does this really fall within the realm of pragmatic language? I don’t believe so. I believe they should be put on consultation therapy and referred out for behavioral therapy. I might be wrong, but I can’t understand a referral for speech/language therapy regardless of the standard score, if the student cannot attend to a picture for at least 30 seconds, cannot make an association despite multiple attempts and different material, becomes consistently frustrated/ tantrums the entire session when given a non-preferred task- or cannot handle doing intervaled non-preferred tasks between longer preferred task/ activity. There needs to be a base minimum level of behavior/ attentional/ imitation ability demonstrated before recommending services. I certainly didn’t go to grad school to be spending my day being a baby-sitter. We need to start recommending services where reasonable benefit can be gained on more than just test scores, and we need to not be afraid of parents/ staff demands or pressure to keep servicing students who don’t make gains. You should not listen to a bosses’s demands to keep a student for maximum services just because they cause a company to earn more profit. We have to be ready to be severely disliked, or called out for doing the right thing.

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