Low Cognition and SLP: Therapy vs. Babysitting and School Culture

By Pam Marshalla

Q: I am very frustrated working in the public school. I am forced to see very low functioning children 2-4 times per week, and even with this much therapy they are not progressing in vocabulary, phonemes, nothing. Am I doing something wrong?

Let me be very blunt here.

Warning! Those of you who don’t know me need to be warned that I do not speak with political correctness. I find it to be an imposition on our freedom of speech and therefore a violation of the constitution. I will not be held responsible for anyone who is offended by the following comments…

Again… Let me be very blunt here.

I believe that we need a change of school culture.  We are seeing children with very low cognitive skills too much and students with mild speech problems and average intelligence or better too little.  I have a long-term goal to change this back to the common sense procedures that SLPs used to use.

I am teaching today’s SLPs to begin to repeat to their teams the following concept: “A child can speak only as well as he understands.” 

In general––

  • Kids whose cognition is below the 6-month level should be saying no words and they should be making very few sounds.  They should not even be babbling. They should have no “communicative intent” and should not be able to use signs, gestures, or pictures for any meaningful purpose. They should be encouraged to make sound, any sound.
  • Kids whose cognition is at the 6-10 month level are at the stage of “illocution.”  This is still a pre-language level.  They should have no concept of word and thus they should be saying no words.  They should only be making some spontaneous sound, and a few babbling-type noises.  Their sounds should be becoming regular, consistent, and repetitive however. In other words, they should have a few sounds that they say to the exclusion of everything else.  They should be getting good at repeating these sounds and every sound they make should be celebrated.
  • Kids who function at 10-14 months of age should be saying one single word only. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words. These children may have a word or two that pops out occasionally but never on demand.  They should be in situations in which it is likely that they will say the word they have.  For example, if the child can say “keys” he should be encouraged to say keys many times per day. Each time he spontaneously produces the word should be celebrated. “Yeah! David is learning how to say keys!”
  • Kids who function at the 14-18 month cognitive level should be saying 1-10 words at best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words.  They should be using gestures, facial expressions, objects, and pictures, and some vocalizations to begin to communicate their wants and needs. They should not be able to practice words on demand, but words should be popping out here and there. These should be celebrated whenever they occur.
  • Kids who function at the 18–24 month level should be saying 10-25 words (probably fewer), and up to 50 words at the very best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have very few words.  They should be using these words consistently for communication purposes.  The words probably will be very hard to understand due to the dysarthria.  They probably will lock in on an incorrect way to say a word and they will say it that way for many years.  For example, perhaps the child’s name is Kristie, and she calls herself “Tee-Tee.” I would not expect this to change for a very long time.

Kids with very low cognition should not been seen multiple times per week. That is called “Babysitting.”  They do not change fast enough to warrant that much therapy.  Instead, we should be acting as consultants to the team about how to stimulate for a few basic communication routines that are functional for the child at home and at school. It only takes one time per month to do this, at most.

We need school psychologists to step up to the plate again and put cognitive ages on these kids.  In lieu of this information, we need to help the parents and team understand the child’s cognition.  We can help them understand the developmental level of the child’s play, his ability to understand vocabulary words, his ability to follow directions, and his ability to answer questions (with word, sound, gesture, sign, or picture).

Again: A child can speak only as well as he understands.

Add to that:  A child usually says far less that he understands.

One final note: We should not be assigning children with low cognition and neuromuscular disorder with the diagnosis of “apraxia.”  A child with low cognition and neuromuscular has “mental retardation” and “dysarthria.”  Three-to-five days per week of therapy will not change his IQ and therefore it will not change his verbal output.

47 thoughts on “Low Cognition and SLP: Therapy vs. Babysitting and School Culture”

  1. In my district we commonly compare a students IQ to their language scores. You can’t expect that a student with an IQ of 64 will produce language scores within the average range. If their IQ score is commensurate with their language skills and they can communicate functionally they are typically dismissed from therapy. In my district students in this type of situation are typically in a focus program and through consultation with the SLP their needs can be met by their special education teacher.

  2. In our small district we have two site based programs for students with ASD. The nonverbal and significantly cognitively delayed students with ASD are team taught by a special education teacher and SLP. Our other program has students with higher functioning ASD who have a wide range of speech and language skills. I would love to see increased speech-language services for our higher functioning students on the ASD spectrum, but it seems that the nonverbal students are considered more “needy.” Would you consider writing a “politically correct” version of your blog piece? I’d love to share it with other staff and administrators to support increased service for these children. Thanks for all you do for the Speech-Language Community!

    1. Lynn, this is wrong. You and Pam should be treating all kids. Not just those you prefer to treat.

      Once you learn how to treat this population, you’ll find that it is very rewarding because the IDD kids make leaps and bounds in their progress.

      1. Actually, Pam and Lynn are correct. In the ASHA code of ethics there’s a point about only providing services where there is reasonable benefit. If a student is not making progress for a whiledue to low cognition and motivation, or poor behavior – and if you’ve tried and documented a few different strategies/modifications to increase efficacy – then it would make sense to reduce services from direct to consultation based services, and eventually dismissal. It would be nice to help every student; but not everyone who has language needs can gain benefit from therapy. This is true even if you’re the most knowledgeable SLP or have the most motivational kinds of material. Having low language scores or functionally low language skills is only one factor in determining the need for services. One should also determine the attention span, frustration tolerance, and cognitive abilities, and behavior before recommending services.

  3. A major focus for these children should be ALTERNATIVE AND AUGMENTATIVE COMMUNICATON. Try reading books by David R. Beukelman & Pat Mirenda on the management of severe communication disorders. These children “understand” much more than they can “speak” and perhaps always will. Speech Language Pathologists can and should provide direct therapy. Many SLPs do not want to do therapy because they are simply out of ideas or do not understand what to do. Educate yourself.

    1. Well said Sally… FYI, I did not mean to exclude augmentative/alternative in my response. I said, “we should be acting as consultants to the team about how to stimulate for a few basic communication routines that are functional for the child” to include verbal and non-verbal communication.

    2. I believe her point was that a child cannot speak BETTER than they understand, not that they can’t understand more than we realize. Her point, I think, was that if you expect a child’s communicative skills to increase beyond what they can comprehend, you aren’t fully understanding the concept of communication.

    3. Yes! aAC helps especially when it is not merely “functional” and also includes morphology.
      These kids do learn, and become highly proficient communicators!

  4. Thank you! I get a bad wrap in my district for expressing these views! It’s nice to know other professionals agree.

  5. Putting a cognitive age is not all that simple. As a psychologist, I know that it is an unreliable indicator; however, I will often put a range such as 2 to 3 years.

  6. Pam-
    For low IQ students, what types of standardized assessments should we be giving. As I was giving the CELF to one of my students with a cognitive impairment today, I realized how unfair it was to him. Shouldn’t we be testing them against their “IQ” age, not their actual age? I mean he would get a couple questions correct here and there, but overall he bombed (of course) because he really had no chance to begin with… so I’m just “thinking out loud”, and wanted your input.

  7. I understand your point and your frustration, but I have to say that I disagree. Being a school speech path who also works with some mildly cognitively impaired students, it’s important to consider what functional skills they are lacking in the area of communication. We are perhaps the only person in the school who has both knowledge, time, and hopefully desire, to provide these kids with the “life language skills” they will need to be successful in their life. While their future life may not include college, or maybe even a high school diploma, it MAY include a basic job of some sort. At this job, they will need to be able to a) follow basic directions to complete a task, and recognize how to ask for help if they don’t understand the task, b) be able to functionally communicate their needs, ask questions, and participate in social communication, and c) use language skills to complete basic life skills such as making phone calls, asking for help, maybe some life management like banking, etc. For all of these tasks, they need be able to understand basic language concepts (which they are capable of learning), speak in full, complete sentences so that they can convey a message, as well as have some pragmatic language skill (which they can be taught…by an SLP). I think it’s time to start thinking outside of the box as far as your therapy targets. Maybe it’s time to make the shift away from working on the “typical” language objectives and work towards making these kids more functional, and making their lives as valuable and enjoyable as they can be. These kids are some of my favorite kids to work with. They make me laugh every day, they are often loving and kind, honest, and forthright. They DO make progress, despite their cognitive ability. While there ability level may be frozen, they often can gain skills that are above and beyond what their IQ says they should be able to do. This comes from good instruction, repetition, and meaningful experiences where they can practice the skills. Please take a fresh look at what YOU can do as a speech pathologist to enrich these little lives. I believe our role is an important one.

    1. I never mean that we should not work with these kids. I encounter SLPs all over the US and Canada who NO LONGER SERVE kids with mild arctic problems because they cannot. THIS IS WRONG. I am sorry, but I believe that we are very valuable to these mild kids and we should fight to keep them on our caseloads. I do not mean that we have to cut out low functioning kids all together, but I believe our priority should be the higher kids. I am sorry, this is my perspective and I m sticking to it.

      1. I must say that I completely agree. I have been a school-based SLP for close to three decades. Though each student is deserving of therapy, I strongly believe that we must be making decisions based on whether prognosis for improvement with intervention is good or guarded. I have serviced low-cognitive students year after year who absolutely improve, though at a much slower rate. The therapy i provide could easily be provided through consulting with special education teachers and paraprofessionals who work with the students daily throughout the day. We must spend time with our articulation population who require specific and non-duplicated intervention. The quality of their lives are completely impacted by the therapy we provide. It is essential.

      2. I completely disagree.
        It’s disheartening to read what you wrote, Pam. I think you definitely should limit your practice to the types you want to, but the public schools are here and pay tax dollars to fund speech services, not consult only, to ALL.

        Pam, you sound like those who’d not treat cancer patients who are terminal because, why bother.

    2. Yes! wellsaid , this is so true.
      You others should look at how you dont know and have little ability in this area is speech therapy.
      I do this work, and it is beneficial and these kids thrive! You’d be AMAZEd at how much they start talking!

  8. Ribbon Dale— I do not need to care. I cannot stand Political Correctness. It is a direct attack on our freedom of speech. We have guaranteed in the Constitution the right to freedom of expression. We all, including you and me, can say whatever we like.

  9. What is the discrepancy between test score and IQ in order to justify saying their scores are commensurate with their IQ? Are we talking a 10 point difference or 5 point or what? Please provide examples!

  10. I totally agree with Pam. I work with a few students with autism who are adolescents now, with very low IQ, non-verbal, very difficult to engage and no particular interests. They don’t recognise photos or symbols. I feel powerless and “babysitting” and the government says I have to see them 2 times per week in 1-to-1 sessions. As I said before, I feel powerless!

  11. Help! I’m at a junior high school. An 8th grade student with IEP goals only for /r/ at 1x per month came up for re-eval. His IQ is 64 and he is in a life skills classroom. He can correctly repeat his mispronounced sound (which is replaced with w). He has been in speech a long time and this is where he is peaked. I want to dismiss him, but the team rallied against me. They also told me I need to work on his social language. I offered to do a “social language group” for the class. That olive branch was broken and they are trying to get me to test him! I explained there is no test I can give him that wouldn’t show him at achieving commensurate with his ability level. I’m the “hated” now. What should I do?

    1. Ooooooo. Bad situation. I have failed with four R students in my career: One had Aspergers and the other three had IQs in the same range you mentioned for your client. I am sure it is possible to teach R to your client, but it is all about trial and error. I would not assume that I couldn’t do it, but it all comes down to him. An IQ of 64 would make it questionable for me too. I would tell the family/staff that it is worth a shot, but that I could give no guarantees. (Of course we should never give guarantees anyway, with any client…). I would approach R with him the same way I would with any client— Use the Retroflex R because it usually is easier, get to the mirror, get the tongue to curl up and back while it is held in a wide stance. I cannot advise you about the social language part of your question because it is outside of my area of expertise.

    2. I am an audiologist with a daughter who has an IQ of 69. Rs have always been a problem for her, but I thank God that her SLP didn’t give up on her when I insisted she keep trying as a high school sophomore. It is SO important that these people be treated with the respect they deserve, but they won’t if their Rs are produced like Ws. My daughter is doing much better with her Rs, but she still has to think about it to articulate them correctly in certain contexts. Yes, she has cognitive limitations, but she has far surpassed many teachers’ expectations. NEVER put limits on a student! That’s not fair to them and their future.

  12. Mary
    I agree with that article. When children have few words or sounds, a SLP should just be a consultant. It is absurd to see a child like that. But besides telling the IEP teams, we should be explaining this to parents.

    1. Mary, you and Pam are so very wrong! Many Slps in school are just as prejudiced as you and don’t want to treat IDD kids, but that is because these Slps don’t have the capability to work with them — it has nothing or little to do with how much these kids can and DO LEARN!
      If you work for a public school, then you have the duty to see and treat these kids the same as kids you think will make ” more” progress. You don’t know what IDD kids can and will do. I’ve seen kids that you’d write off, and these kids would astound you.

  13. My thoughts on this much-needed discussion (thank you Pam) — I agree with a consult model and that model needs to be developed well and implemented reliably and with good documentation. This is probably an area of need in the realm of SLP continuing ed. When classroom staff are needing more training and education to do a good job in facilitating the communication skills we are recommending / prioritizing for the student (based on developmental information compared to the student’s strengths and needs), then service to the educators needs to happen in order for us to be accountable as consultants to the IEP. Also, there needs to be good strong, reliable and documented parent-school-Speech collaboration and communication. Good discussion!

  14. I see this is an old post so I hope you’re still replying to comments. Similar situation as many others here…6 year old with a 64 IQ with a frontal lisp, substitutions of voiced and voiced TH and /v/. Testing requested by parent accompanied with letters addressed to me from a pediatrician at a well-respected hospital and the home health SLP. Mom wants artic therapy. I have attempted to explain to parent 1) child is functioning at her ability and 2) these sounds are barely appropriate for a typically developing 6 year old. She is irate. I am baffled at the other professionals, especially colleagues in other settings, who are supporting this. It’s a problem I’m seeing more and more…colleagues outside the public school system working on anything and everything the parent desires whether it is appropriate or ethical (I have worked in a multitude of settings and I know professional judgment is still aloud!).I’m tired of feeling like the bad guy for being ethical! I guess I’m hitting on 2 different topics but I would love to hear your take/advice on both. The IEP meeting is tomorrow! Thanks in advance!

  15. As the mother of a low-cognitive functioning child w/ acquired aphasia (due to seizures), I disagree. My child functions at about the 18 to 24 mth level (some areas higher, like self-feeding). Up to age 5 he was able functionally communicate with a vocab of about 50 words and phrases such as “read a book,” “watch a show,” “I need to poop,” “I don’t want,” “I like that.” In other words, he was about to communicate his basic wants and needs. He then lost most of his spoken language, although he still understands and follows directives, and has progressed in other skills, so IQ seems to be the same as before the expressive language regression. Now, without a means to communicate, he has become increasingly agitated and aggressive. My observation of the classroom is that he’s not going to relearn language there – very little is done to encourage him to speak. I believe that speech therapy techniques similar to what would be used with stroke victims may be helpful in getting him back to where he was.

  16. Some children have actual language disorders that artificially deflate their IQ scores. They need actual language therapy. Luckily, there are some SLPs who understand such things. My child’s IQ score went up 23 points in a year after we finally found a skilled SLP who understands language disorders. Unfortunately, we had to go through several therapists who only saw an IQ score before we found one with the right skill set.

  17. On the AAC topic, I work with early childhood (3-5)…if my students don’t understand how to “play” with toys appropriately, have very low language skills, and are basically unaware of communication partners, how do I begin with AAC? My district wants everyone and their brother to use an iPad. We have some switches, but I’ve had very little success with them. I too believe we should not be “overserving” this population.

    1. The ipad may be too advanced. Have you looked into go talk 9+ for functional communication? I work at a NPS(non public school) mild to severe levels students from early childhood to young adults; and have noticed that for the really low functioning GO Talk 9+ works great for them. Its not as challenging as navigating through the Ipad but yet more selections to communicate using one template where you can add up to 12 icons, record using a familiar voice as a voice over.

    1. IQ and language ability are related. There are many, many research articles that you can read that can provide you with more information regarding this topic.

      1. They are related but one does not have to determine the other. It is feasible and suggested by many experts that some children’s language skills can be higher than their IQ. Knowing this, the least harmful assumption IS that they can benefit from language therapy.

  18. Good conversation. I am currently working with low cognitive functioning teens on my caseload, some directly others consult. The teacher would like to see all of her consult kids receiving direct services. Just like so many of you I have informed the teacher that the students are functioning at their potential, they are using AAC (ipad/proloquo program) in their Life Skills program, which I also use with some kids. I am no expert at using the program or how to use it to facilitate expanded language skills. The teacher insists that all these kids can do more and I should be providing more time. They have one teacher and 4 aids for 8-10 kids, they all know the AAC program. I have nothing special to bring to the table, and I feel like I’m being bullied and have to defend my position. Am I so wrong? When does therapy stop being provided?

  19. As stated in other posts, it seems that the goals for the OP’s student might need to be changed. Focusing on improving receptive language skills and introducing alternative methods of communication would, in my view, warrant the number of sessions this particular student is being seen. At some point, however, as Pam stated, there might be a need for consult, but overall, I disagree with the premise of this post. You should never, ever base how much therapy you give on what appears to be a child’s IQ,but on whether the therapy appears to be helping, bearing in mind that you need to look at this over a long period of time. And if it feels like “babysitting”, then it’s up to the SLP to figure out why that is. Good therapy should never feel this way. And as for disliking “political correctness” -well, to me, that term is code for “speaking with tact and sensitivity to others while still trying to get your point across.” Some things should not be said, or said in a more thoughtful way without steamrolling over what for some parents and SLPs is a tough area.

  20. The thought process that says students with significant communication problems due to whatever the factors, do not deserve our time and effort is a disgrace to the profession. I work with this very population and I see progress. Is it slow? Yes. Does it take a lot of time and effort? Yes. Do I reduce their time? No!!! I increase it because it takes a lot of effort to help teach them to live more independent and self sufficient lives. Every one can make progress. If they aren’t making progress, it is your fault. You aren’t meeting them where they are at and you aren’t creating modifications and accommodations to help them achieve much needed skills. You need to do your job and get creative to help them and the team. They deserve your best not your least.

  21. Research has shown that providing 20-25 hours of services a week to persons with ASD in the first 4 years of life can save taxpayers over 1 million dollars in their lifetime. The fact that you are complaining that they are not progressing with phonemes , vocabulary, or linguistic concepts shows that your focus is too narrow and you need to work on functional goals to increase their engagement and functional communication skills like communicating their desire for recurrence, reject, or ask for assistance. Try using sign language or Picture Exchange Communication to bridge their limited verbal abilities. Frequently, using these bridging methods can increase their verbal abilities.

    1. Some readers seem to be missing the original point. The topic is treating severely/profoundly cognitively impaired individuals who do not need the specialized skills of an SLP.

      I have worked directly with students with such cognitive impairments. However, I have advocated for dismissal or consultation especially when historically the students hasn’t made progress and the SLP brings no more to the table because there’s no specialized skill necessary.

      Remember-our Code of Ethics, the definition of therapy, and the ability of a person to self-monitor and motivation/desire to communicate.

      I was in a situation that I was required to directly service students who had no likelihood of improving communication skills. I composed a list for caregivers regarding the person’s methods of communicating needs. The students were very low-functioning so I did an exercise to determine whether the student’s breathing rate changed when different auditory stimuli. I searched for ideas of what I could do with them to enhance their skills or quality of life. Consultation or no service would have been a better use of my time.

      I appreciate and agree with what Pamella wrote for treatment guidelines. The information may be hard to communicate to staff and parents, but needs to be said. Remember-people expect SLP’s to have some “magic” but we can’t turn a stone into a tree. Teachers might wonder why specialists no longer need to be involved with particular students. We have a different role and responsibility. The educational system is as such that the teacher, the generalist, provides services to age 21. Not so for specialists. We need to be honest despite potentially negative repercussions.

      One way to support the teacher is to have specialists provide a group session that is part of the Life Skills program. The service doesn’t need to be on the service delivery grid.

      We need to advocate both for services and no services appropriately. Honor our Code of Ethics!

      1. Linda, thank you for your thoughtful and well-articulated response. Pam is no longer with us in this world and we appreciate those who continue to speak her message and advocate for common sense! Thank you for your contribution to this discussion.

  22. I know this is an old discussion, but I’m very intrigued by the topic. I have been accused of not asking for “the appropriate” amount of services for my MOID, SID, and ASD populations. I had 125 students at three schools last year (2 MoID classes, and ASD classroom, and a MD classroom, and 3 MID classes, and regular students). There just wasn’t enough of me to go around! So, I’m trying to find ways to be more efficient in a shorter service provision time.
    In seminars I’ve attended, articles I’ve read, and talking to my mom (a school psychologist, SpEd Director, and SpEd law teacher for a few universities), there are some problems that I don’t feel are being taken into account:
    1.) IQ tests are not as reliable as many psychologists reliance on them are. Therefore, saying the IQ is 64 based on the test isn’t that accurate. And, I feel all kids deserve at least attempting speech language therapy to see if intervention can help them.
    2.) Then there’s ASHA’s stance to not do cognitive referencing. I agree that we shouldn’t write these students off from services, but I think we need to be realistic too. These students aren’t going to make presidential speeches, but need functional communication and skills. With very low IQ students, using consult in addition to a reasonable service provision amount makes more sense because the teacher and paras are with them all day which could exponentially help the progress. But me giving them 60-90 mins. a week and no one else helping will take a lot longer. If I could get the staff to work on these items in class once they’ve had direct instruction and show some success, then the teacher and paras should be able to support and encourage that skill throughout the day everyday. It should be a team responsibility.

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