WSHA Response on day 43

December 22, 2009

Teresa Canjar, Executive Assistant

Special Education Unit

Wyoming Department of Education

Hathaway Building, 2^nd Floor

2300 Capitol Avenue

Cheyenne, WY 82002

Dear Ms. Canjar,

The Wyoming Speech-Language Hearing Association (WSHA) is a state chapter of the American Speech-Language Hearing Association. (ASHA). ASHA is the national professional, credentialing, and scientific organization for speech-language pathologists and audiologists. The vast majority of speech-language pathologists practicing in Wyoming, including school SLPs, are members of WSHA and/or ASHA.

WSHA has reviewed the proposed permanent Chapter 7, Services For Children with Disabilities Rules and Regulations, which were promulgated on November 13, 2009, and wishes to voice the following serious objections regarding the proposed speech/language eligibility criteria:

Objection #1: The proposed voice impairment eligibility criteria omit the previous requirement of the 2007 Chapter 7 Rules that “a physician’s statement [be obtained] documenting that voice therapy is not contraindicated.” (2007 Chapter 7 Services for Children with Disabilities Part 4 Section 11 (e)(i)(C)). WSHA strongly believes that this omission is not only contrary to the ASHA recommended practice guidelines for Speech-Language Pathologists, but it also endangers Wyoming children who may have an undiagnosed and potentially life-threatening medical condition.

Dr. David Jones, Professor, University of Wyoming Division of Communications Disorders and Interim Associate Dean for Academic Affairs, College of Health Sciences, previously informed the Wyoming Department of Education (WDE) of these concerns during the stakeholder input period. In his letter dated October 12, 2009 Dr. Jones presented the following facts:

The ASHA Preferred Practice Guidelines (2004) state that:

All patients/clients with voice disorders are examined by a physician, preferably in a discipline appropriate to the presenting compliant. The physician’s examination may occur before or after the voice evaluation by the speech-language pathologist.

· Laryngeal examination by an otolaryngologist is necessary to determine the etiology of a suspected voice disorder. A dysphonic voice may be due to an organic disease process such as laryngeal papillomatosis or an anatomic abnormality such as a laryngeal web, which require medical treatment rather than voice therapy. It is therefore in the best interest of the child with a suspected voice disorder to be examined by a physician in order to rule out the presence of a condition that is life threatening and/or requires medical treatment.

· The majority of school-based Speech-Language Pathologists practicing in the state of Wyoming are ASHA-certified and thus bound by the ASHA Code of Ethics to follow the recommended practice of referring all individuals with suspected voice disorders to a physician. There are, however, school SLPs practicing in Wyoming who are not certified by ASHA and thus not bound by ASHA policy. If a school SLP and the multidisciplinary evaluation team do not refer a child with a suspected voice disorder to an otolaryngologist, this could not only endanger the health of the child, but also increase the liability of the SLP and the school district should the child’s health be compromised and the child’s parents seek damages. Dr. Jones cites an example of a student in another state who was not referred for a physician’s examination by his school SLP and subsequently died of airway obstruction secondary to laryngeal papillomatosis.

The WDE response to these stakeholder concerns regarding the proposed voice impairment eligibility criteria was to add the following language to the Chapter 7 Section 4 requirements that govern all Initial Evaluations of children with suspected disabilities:

Section 4(b)(i)(C): A comprehensive evaluation shall include, as needed, evaluative services provided by a licensed physician to determine a child’s medically related disability that results in the child’s need for special education and related services. [See 34 C.F.R. 300.34(c)(5)].

While WSHA commends WDE’s addition of this paragraph to the general requirements for any initial evaluation, WSHA feels that this change is insufficient to insure that evaluation and treatment of a child with a suspected voice disorder is conducted in accordance with SLP professional practice guidelines and in a manner that does not endanger the health or life of the child. Section 4(b)(i)(C) requires only that inclusion of a physician’s examination in an initial evaluation be determined on an “as needed” basis. WSHA believes that when a child’s suspected disability is a voice disorder, a physician’s examination should not be optional and determined on an “as needed” basis by the multidisciplinary evaluation team, but should be mandatory. While the WDE may argue that the need for a physician’s evaluation in the case of a child’s voice disorder is implicit in Section 4(b)(i)(C), WSHA believes that this requirement should be made explicit in the voice impairment eligibility criteria.

WSHA strongly urges the WDE to restore the previous requirement of the 2007 Chapter 7 Rules eligibility criteria that evaluation of a child with a suspected voice disorder include examination by a physician and procurement of a physician’s statement that voice therapy is not contraindicated.

Objection #2: The proposed Chapter 7 Rules list only two criteria that must be met in determining that a child has a language impairment:

Section 4 (d)(xi)(A)(III)(1.):

a. The child demonstrates on standardized measures an understanding and use of morphologic, syntactic, semantic, or pragmatic patterns at 1.5 standard deviations below the mean for the child’s chronological age; and

b. Documentation that receptive or expressive language interferes with the child’s oral communication or primary mode of communication.

Additional criteria, which were part of the previous 2007 Chapter 7 Rules, have been omitted:

Part 4 Section 11 (d)(i)(B): If the standardized measures do not accurately or sufficiently reflect that the child’s language is impaired in the use of morphologic, syntactic, semantic, or pragmatic patterns the team must be allowed to establish eligibility based on a preponderance of the information presented and that other measures may be used to determine eligibility such as observations, criterion referenced measures, clinical judgment and other clinically accepted practices.

WSHA believes that the omission of these additional criteria excessively narrows the scope of a language evaluation, and results in overreliance on standardized language test performance alone to determine if a child has a language disability. WSHA believes that the proposed speech/language eligibility criteria thus violate the IDEA Part B requirement that:

34 C.F.R. 300304(b): In conducting the evaluation, the public agency must:

(1) Use a variety of assessment tools and strategies to gather relevant functional, developmental, and academic information about the child…

(2) Not use any single measure or assessment as the sole criterion for determining whether a child is a child with a disability and for determining an appropriate educational program for the child; and

(3) Use technically sound instruments that may assess the relative contribution of cognitive and behavioral factors, in addition to physical or developmental factors.

The WDE justified the omission of Section 4(d)(xi)(A)(III)(1.) in its Comparison Summary of 2007 Wyoming Chapter 7 Rules, 2009 Emergency Chapter 7 Rules, and the Federal Regulations (9/6/09). In that document, the WDE stated that the 2009 speech/language eligibility criteria “deleted use of clinical judgment to override ineligibility in all subcategories” of speech or language impairment. WSHA feels that this statement by WDE reflects a distorted and erroneous interpretation of the 2007 Chapter 7 speech/language eligibility criteria. WSHA does not believe that the intention of the Part 4 Section 11(d)(i)(B) of the 2007 Chapter 7 Rules was to allow “the use of clinical judgment to override ineligibility.” Rather clinical judgment was included as one of several clinically accepted practices—in addition to observation, criterion-referenced measures and standardized measures--that could be used to determine eligibility.

In stating that the 2007 Chapter 7 Rules allowed “the use of clinical judgment to override ineligibility,” the WDE is implying that eligibility can be determined based upon standardized measures alone, and that a child who does not score 1.5 standard deviations below the mean on a standardized language test is considered ineligible for a speech/language impairment. In making this argument, WDE is in direct violation of Federal Regulation 34 C.F.R. 300304(b)(2) (cited above) which states that no single measure be used to determine eligibility. Rather WSHA believes—and Federal Regulation 34 C.F.R. 30004(b)(1) (cited above) requires--that a determination of eligibility should not be made until the

multidisciplinary team has considered ALL the evidence gathered as part of a comprehensive speech/language evaluation: not only standardized test scores, but also information gathered from multiple sources such as: observation of the child, collection of a representative speech/language sample, parent and/or teacher interview, criterion-referenced measures of the child’s ability to meet the communication demands of the classroom and the curriculum, and performance on district and state assessments.

The WDE was informed of WSHA’s concerns regarding the proposed changes to the language eligibility criteria during the October 13, 2009 WSHA Stakeholder meeting facilitated by Carol Hvidston. In addition, the Department Chairman and two additional faculty members of the University of Wyoming Communication Disorders Department submitted written comments to WDE voicing their concerns regarding the language impairment eligibility criteria: Professor and Chairman Teresa Ukrainetz, Professor Melissa Allen and Professor Douglas Petersen. WSHA would like to reiterate several of the points made by Drs. Ukrainetz, Allen and Petersen:

· Norm-referenced (standardized) language tests do not reveal a child’s language performance in the classroom or in the context of the curriculum.

· Norm-referenced tests typically require short, structured responses and thus are often inadequate for assessing language production--sentence formulation, vocabulary use, discourse organization, etc

· Norm-referenced tests are not a valid measure of language use (pragmatics)—one of the areas of language impairment specified in the Chapter 7 eligibility criteria.

· Norm-referenced tests can be culturally- and linguistically-biased, and therefore are not always a valid or appropriate measure of child’s language abilities. School-based SLPs must be able to use alternative assessment methods, including criterion-referenced measures, processing tasks, and dynamic assessment, when evaluating culturally and linguistically diverse children.

In sum, standardized language tests can provide valuable information, but they do not provide a complete or necessarily accurate picture of a child’s functional language abilities. Given these recognized short-comings of standardized language tests, WSHA would like to point out that the WDE proposed permanent Chapter 7 Rules reliance on standardized test scores to determine a child’s eligibility violates the requirements of Federal Regulation 34 C.F.R. 300304(b) (cited above) that “each public agency… use a variety of assessment tools and strategies to gather relevant functional… and academic information about the child;… and use technically sound instruments that may assess the relative contribution of… behavioral factors….”

WSHA strongly urges the WDE to restore language to the 2009 Chapter 7 language eligibility criteria allowing the use of a variety of assessment tools and strategies to assess a child’s eligibility as language impaired. While WSHA believes that standardized test measures should be part of a comprehensive evaluation, they should not be the sole determining factor. Rather the multidisciplinary team should be permitted to follow the IDEA Part B mandate to use a variety of assessment tools and strategies to gather relevant functional, academic and behavioral information about the child in order to make a determination of eligibility.

Objection #3: WSHA would like to express disappointment and frustration with the process WDE followed in promulgating new Chapter 7 speech/language eligibility criteria. To WSHA’s knowledge, the WDE did not seek input from members of the speech-language pathology profession practicing in Wyoming, from the professional organizations--WSHA and ASHA—which represent SLPs, or from the University of Wyoming Communications Department when drafting the speech/language eligibility criteria included in the May 2009 proposed Chapter 7 Rules or the August 2009 Emergency Rules. Nor did WDE make any changes to the proposed speech/language eligibility criteria as a result of stakeholder input submitted by WSHA and the UW Communications Disorders Department in October 2009.

The Chapter 7 speech/language eligibility criteria have an enormous impact on how school SLPs in Wyoming perform their professional duties: they define and regulate what children SLPs may serve, what speech/language disorders they may treat, and what methods SLPs may use in evaluating children for suspected speech/language disabilities. Promulgation or revision of these criteria should not be undertaken arbitrarily or without a thorough understanding of communication disorders. That knowledge can best be provided by certified members of the profession and scholars familiar with current speech/language pathology research and practice.

Wyoming is very fortunate to have an excellent Communication Disorders Department in the College of Health Sciences at the University of Wyoming. The Communication Disorders Department not only offers undergraduate and graduate courses as preparation for the Speech-Language Pathology profession, but is also actively engaged in research in the various areas of speech/language disorders, including articulation/phonology, craniofacial disorders, childhood language development, deaf education, fluency, multicultural language and education, and voice disorders. WSHA recommends that any effort by the WDE to promulgate or revise the Chapter 7 speech/language eligibility criteria include input from appropriate UW faculty members.

WSHA urges the WDE to suspend promulgation of the proposed Chapter 7 speech/ language eligibility criteria and to initiate a joint effort by the WDE, WSHA and UW Communication Disorders Department to draft speech/language eligibility criteria which are (1) in compliance with IDEA and the IDEA Part B regulations, and (2) based upon current research and ASHA recommended practice guidelines for the identification and treatment of speech/language disorders.

WSHA would like to point out that other state Departments of Education (DOE) have developed successful mechanisms for communicating and collaborating with school SLPs. Rhode Island worked directly with state ASHA representatives in promulgating their new eligibility criteria in 2008. Nevada has a speech pathology consultant who works with the Nevada DOE and functions as a liaison with the Nevada Speech and Hearing Association. The Connecticut DOE recently established an advisory committee of speech-language pathologists to help them address current issues. WSHA would like the proposed joint effort by the WDE, WSHA and UW Communication Disorders Department to be a first step in facilitating better communication and collaboration to ensure that Wyoming children with disabilities receive the services to which they are entitled under IDEA.

Respectfully submitted,

Donna G. Shippen, M.S., CCC-SLP

ASHA State Education Advocacy Leader for Wyoming

dshippen@park6.k12.wy.us

Anna Anderson, M.S., CCC-SLP

2009 WSHA President

Anna_L_Anderson@yahoo.com

Emily Trujillo, M.S., CCC-SLP

2009 WSHA President-Elect

Emily_Trujillo@ncsd.k12.wy.us

Christiane Dechert, M.A., CCC-SLP

2009 WSHA Past-President

cdechert@uwyo.edu

Kim Lewis, M.S., CCC-SLP

WSHA Treasurer

miklew@tctwest.net

Cindy Greenwald, M.S., CCC-SLP

WSHA Secretary

cgreenwald@acsd1.org

Carolyn Wood-Helling, M.S., CCC-SLP

WSHA Professional-at-Large

hellingc@acsd1.org

Michael Murdock, M.S., CCC-SLP

ASHA Advisory Councilor for Speech-Language Pathology

Michaelm2@bresnan.net

Cindy Payler, M.S., CCC-SLP

2010 President-Elect

cpayler@gmail.com

Cc: Dr. Jim McBride, Superintendent of Public Instruction

Wyoming Department of Education

The Honorable Dave Freudenthal

Governor, State of Wyoming

The members of the Education Committee of the Senate and House of the State of Wyoming:

Senator Henry H.R. "Hank" Coe
Senator Kit Jennings
Senator Mike Massie
Senator Kathryn Sessions
Senator Michael Von Flatern
Representative Del McOmie

Representative Bob Brechtel

Representative Cathy Connolly
Representative Bernadine Craft
Representative Ross Diercks
Representative Allen M. Jaggi
Representative Thomas E. Lubnau, II
Representative Robert M. McKim
Representative Matt Teeters

The legislative leadership of the Senate and House of the State of Wyoming:

President of the Senate Senator John J. Hines
Senate Majority Floor Leader Senator Jim Anderson
Senate Vice President Senator Tony Ross
Senate Minority Floor Leader Senator Kathryn Sessions
Senate Minority Whip Senator Mike Massie
Senate Minority Caucus Chairman Senator John M. Hastert
Speaker of the House Representative Colin M. Simpson
House Majority Floor Leader Representative Edward A. Buchanan
House Speaker Pro Tempore Representative Frank Philp
House Majority Whip Representative Lorraine K. Quarberg
House Minority Floor Leader Representative W. Patrick Goggles
House Minority Whip Representative Mary Throne
House Minority Caucus Chairman Representative Lori Millin

Opportunities for public comment

MEMORANDUM

TO: Chapter 7 Stakeholders

FROM: Peg Brown-Clark, State Director of Special Education

DATE: November 20, 2009

SUBJECT: Proposed Permanent Rules, Chapter 7, Services of Children with Disabilities

The Wyoming Department of Education (Department) began permanent rule promulgation of the Chapter 7, Services for Children with Disabilities Rules and Regulations on November 13, 2009. A copy of the proposed rules is attached.

The public comment period began November, 13, 2009 and will end at 5:00 p.m. on Dec. 28, 2009. All comments are to be submitted to Teresa Canjar, Executive Assistant, via email at tcanja@educ.state.wy.us or in hard copy to 2300 Capitol Avenue Hathaway Building, 2^nd Floor, Cheyenne, WY 82002.

In addition to written comments, the Department has scheduled the following public hearings via the WEN to accept public comment on the noted rules:

· Dec. 1, 2009 (5:00 – 6:30 PM)

o Riverton High School, 2001 W. Sunset, Riverton;

o Central High School, 5500 Education Drive, Cheyenne;

o Sheridan High School, 1056 Long Drive, Sheridan;

o Casper College, 125 College Drive, Casper;

o Laramie High School, 1275 North 11^th, Laramie; and

o Rock Springs High School, 1375 James Drive, Rock Springs.

· Dec. 3, 2009 (5:00 – 6:30 PM)

o Riverton High School, 2001 W. Sunset, Riverton;

o Central High School, 5500 Education Drive, Cheyenne;

o Evanston High School, 701 West Cheyenne Drive, Evanston;

o Casper College, 125 College Drive, Casper; and

o Gillette High School, 1000 Camel Drive, Gillette.

· Dec. 7, 2009 (5:00 – 6:30 PM)

o Riverton High School, 2001 W. Sunset, Riverton;

o Central High School, 5500 Education Drive, Cheyenne;

o Sheridan High School, 1056 Long Drive, Sheridan;

o Shoshone Learning Center, 140 North Ferris, Powell; and

o Laramie High School, 1275 North 11^th, Laramie.

In addition to the required rulemaking documents, the Department has prepared a Supplemental Packet which outlines the stakeholder input undertaken in revision of the rules and includes a strike and underscore copy of Chapter 7 which compares the previously proposed permanent rules to those currently proposed for adoption. A copy of this document is also attached.

Thank you.

Attachments: (2)

Dr. Teresa A. Ukrainetz

The proposed WDE Eligibility Changes to Section 11: Speech or Language Impairment are not valid for multiple reasons. I focus on the language impairment (III) criteria here, although there are serious problems with the other parts of this section too. If the WDE proposed/emergency rules stand, we will be using these as examples of invalid and inappropriate practices in our university courses.

The rules require both:

1. The child is -1.5sd on standardized tests of morphologic, syntactic, semantic, or pragmatic patterns

2. Documentation that the receptive or expressive language interferes with the child’s oral communication or primary mode of communication.

Problems:

1. NORM-REFERENCED SCORES DO NOT REVEAL ACTUAL PERFORMANCE. There is little correspondence between a particular level of standard score on a test of discrete skills and actual performance in academic activities. Low scores generally correspond to low academic performance, but children can struggle in school due to language problems that are not manifest in extremely low scores.

2. Norm-referenced tests are NOT GOOD at testing language production. The responses are short and structured to allow for quick, easy, and reliable administration and scoring. However very little productive language is elicited. These tests do not demonstrate difficulty in sentence formulation, vocabulary use, or narrative and expository discourse organization.

3. Norm-referenced tests ARE NOT GOOD AT TESTING PRAGMATICS. Pragmatics is a stated area of eligibility, but the appropriate use of language in different contexts cannot be determined by standardized, norm-referenced tests. Pragmatic problems, which do affect academic problems, can only be determined through language sampling, observation, interview, and response-to-learning data.

4. ORAL COMMUNICATION DEFICITS ARE REQUIRED BUT CANNOT BE DEMONSTRATED. The second eligibility requirement is not operationalized. As previously explained, norm-referenced tests do not demonstrate use of language. Clinicians must use some other measure, such as observation, language sampling, or work products to meet the second eligibility requirement. So additional measures are implied, but the lack of explicit requirement/permission will lead to variable and confusing enactment.

5. DEFICITS IN ORAL LANGUAGE AFFECT WRITTEN LANGUAGE. Children should be tested through oral language tests because these avoid the problem of poor decoding/encoding (word reading and spelling) interfering with demonstration of language skills. However, receptive or expressive language problems may interfere with the child’s performance with written language tasks to a greater degree than with oral conversational language.

6. RESPONSE TO INTERVENTION IS NOT INCLUDED IN THE ELIGIBILITY STANDARDS. Federal requirements now allow RTI judgments for reading disabilities. Language (and speech) impairment also fit well within this model. Children can be seen for short periods of intensive intervention with minimal paperwork to quickly and efficiently correct their learning trajectories so they do not need long-term services or, alternatively, to determine if serious underlying language problems are present. If clinicians were supported in investigating ways of using RTI, caseloads could be reduced and limited only to those who really need special education services. (See Ukrainetz, 2006 for further information on RTI and speech-language eligibility)

Recommendations:

1. Keep the conservative level of -1.5 standard deviations (7%ile) on norm-referenced tests to control caseload size.

2. Operationalize the second requirement as involving some measure of actual life performance.

3. Modify the second requirement so that either oral or written language performance is included.

4. Require investigation and documentation of performance, especially that of expressive language and pragmatics, beyond norm-referenced tests. Possible avenues include language sampling, observation, or work products.

5. Allow clinical judgment to bring together the evidence for a determination of eligibility.

6. Include eligibility language that allows use of RTI as part of determination of eligibility.

Ukrainetz, T.A. (2006). EBP, RTI, and the Implications for SLPs. Language, Speech, and Hearing Services in Schools, 37, 298-303.

Teresa A. Ukrainetz, Ph.D.

Director and Professor

Division of Communication Disorders

University of Wyoming

Douglas B. Petersen

The population in the United States is becoming more and more culturally and linguistically diverse. The state of Wyoming will likely not be an exception to this trend. For example, approximately 7% of the population in the state of Wyoming is Hispanic, and in some counties of the state, the percentage is much higher (e.g. nearly 14% of the population were Hispanic in Carbon County in the year 2000). It has been projected that by 2050 the Hispanic population will be the majority ethnic group in the U.S. As this diversity increases, speech-language pathologists will encounter a greater number of children who are from cultural and linguistic backgrounds different from their own.

The American Speech-Language-Hearing Association (ASHA) has had a longstanding position on multicultural considerations of the assessment of language. ASHA has made it clear that no social dialect of English is a disorder (e.g. African American English), and that speech-language pathologists must be competent in distinguishing between a language difference and a language disorder. In fact, this mandate transcends language and applies to all facets of communication.

It has been well established that the use of standardized norm-referenced assessments to evaluate language impairment in culturally and linguistically diverse children can be inappropriate (please see Kamhi, Pollock, and Harris, 1996; Taylor and Payne, 1983; Vaughn-Cooke, 1983, 1986). Standardized norm-referenced assessments are often replete with content bias, linguistic bias, and are typically based on a normative sample that does not include culturally and linguistically diverse populations. This test bias can (and often does) lead to the overidentification of language impairment. If a child were administered a standardized norm-referenced language assessment in a language in which they were not fluent, that child would invariably receive scores well below the norm. Under the Wyoming Department of Education (WDE) Emergency Chapter 7 Rules, almost every child who is culturally and linguistically diverse, and for which there is no valid or reliable standardized norm-referenced assessment based on their specific population, would qualify for language services.

Fortunately, language assessment methods have emerged that are typically more culturally and linguistically sensitive over norm-referenced assessments. These alternative assessment methods have strong evidence of reliably and validly. Processing-dependent methods such as non-word repetition tasks (Campbell, Dollaghan, Needlemen, & Janosky, 1997; Rodekohr & Haynes, 2001) and dynamic assessment procedures (Gutierrez-Clellen & Peña, 2001; Miller, Gillam, & Peña, 2001) have been shown to validly differentiate children who have a language impairment instead of a language difference. Speech language pathologists must be able to use alternative assessment methods including criterion-referenced measures, processing tasks, and dynamic assessment to determine whether a child has a language disorder or a language difference due to cultural or linguistic factors.

Section 612(a)(6)(B) of the Individuals with Disabilities Education Act (2004) states that:

Procedures to ensure that testing and evaluation materials and procedures utilized for the purposes of evaluation and placement of children with disabilities for services under this title will be selected and administered so as not to be racially or culturally discriminatory. Such materials or procedures shall be provided and administered in the child’s native language or mode of communication, unless it clearly is not feasible to do so, and no single procedure shall be the sole criterion for determining an appropriate educational program for a child.

It is my understanding that the Wyoming Department of Education has implemented policy contrary to Federal law by mandating that language impairment be diagnosed using a standardized norm-referenced assessment. Apart from any legal concerns, it is clear that the use of standardized norm-referenced assessments can be discriminatory and unethical. As the instructor of the course on assessment and diagnosis of communication disorders at the University of Wyoming, I stand firm in saying that at no time will the students enrolled in the Communication Disorders Program at the University of Wyoming be taught that a language impairment must be diagnosed using standardized norm-referenced assessments.

I strongly urge the Wyoming Department of Education to consider alternative wording in the proposed regulations that align with a more valid, accurate, and ethical approach to the assessment of language. Several states, including the neighboring state of Utah mandates that “multiple measures (formal and informal) are required for a student suspected of having a speech or language impairment (primary disability or requiring related services).” The WDE would be well served to follow the lead of those who have acknowledged the importance of alternative assessment procedures in the diagnosis of language impairment.

Respectfully,

Douglas B. Petersen PhC, CCC-SLP

Division of Communication Disorders

College of Health Sciences

University of Wyoming

Dr. David Jones

October 12, 2009

Wyoming Department of Education

RE: Voice Impairment eligibility criteria

To Whom It May Concern:

The purpose of this letter is to challenge the implementation of the Wyoming Department of Education (WDE) Emergency Chapter 7 Rules as it pertains to eligibility criteria for students with voice impairment. The WDE is proposing that for students who exhibit voice impairment, it is no longer required to have a physician’s statement documenting that voice therapy is not contraindicated. Although I do not know the motivation for this change, it is possible that the State’s position is economic in nature. Specifically, if the state does not require documentation from a physician, then the school SLP is not required to refer to a physician, and the school will not be responsible for the expenses incurred from a physician’s evaluation. Although this may not be the WDE’s motivation, it is important to point out that the school SLP is bound by the American Speech-Language-Hearing Association (ASHA) to refer all voice cases to a physician if the student has not had a laryngeal examination by a physician.

According to ASHA:

“All students with voice disorders must be examined by a physician,

preferably in a specialty appropriate to the presenting complaint. The examination may occur before or after the voice evaluation by the speech-language pathologist” (ASHA, 1997)

The reasoning behind ASHA’s mandate is simple. A perceptual assessment alone cannot confirm the etiology of a voice disorder. A dysphonic voice can be due to a benign condition such as vocal fold nodules; this diagnosis is appropriate for voice therapy. Alternatively, a dysphonic voice can also be due to an organic disease process such as laryngeal papillomatosis or an anatomic abnormality such as a laryngeal web. If the etiology is organic in nature, then surgery may be warranted, and voice therapy is not indicated. The question as to whether voice therapy is indicated cannot be determined without having a physician confirm a diagnosis.

It can be argued that even without the SLP being bound professionally, a physician referral is in the best interest of the student. Equally important, it is in the best interest of the SLP, the school district, and the state of Wyoming from a liability standpoint. Without the safeguard of a physician’s confirming diagnosis, it is conceivable that a school SLP could initiate voice therapy with a student and continue with therapy for weeks or months, only to discover that the dysphonia was due to a progressive disease. This is not a hypothetical scenario; I know of a case in another state where this occurred, and the student died of airway obstruction secondary to laryngeal papillomatosis mainly because the school SLP did not seek a physician’s evaluation. If this were to happen in Wyoming, it is likely that upon discovering that the WDE had reversed its mandate regarding a physician’s examination, the parents of the student would be certain to seek damages against the school district and the State of Wyoming.

It is possible that the WDE is fully aware that school SLPs will continue to refer voice impairment cases for medical evaluations whether the State mandates it or not. The State may feel confident in knowing that its students will still receive the care that is required without having to cover the expenses involved. It should be noted, however, that there are school SLPs in the state who are not certified by ASHA. Therefore, they are not bound by ASHA policy. In cases such as these, without a mandated physician referral, it is likely that the liability for school district and the State would increase dramatically. Regardless of whether the school SLP is bound by a mandate from ASHA or not, it will be interesting to see if the WDE’s position can withstand a legal challenge from a parent in the event that a child’s health is compromised due to this change in policy.

I urge the Wyoming Department of Education to reinstate the criterion that a student with a voice impairment must have a physician’s statement documenting that voice therapy is not contraindicated.

Respectfully submitted,

David L. Jones, PhD

Professor

Division of Communication Disorders

Interim Associate Dean for Academic Affairs

College of Health Sciences

University of Wyoming

WSHA member Dr. Melissa Allen

Speech/Language-Language. Research (Aram, Morris & Hall, 1993; Gilliam & Gilliam, 2006) supports using clinical judgment as an evidence-based practice for determining eligibility. Additionally, norm-referenced assessments do not take into account context and language usage. In regards to context, most norm-referenced measures require no words (investigating comprehension) or few words. Children with typically developing language speak using sentences. You may have a child who provides a target in an appropriate one-word response, but fails to use the target in a larger linguistic context (i.e., a sentence). In addition, children use language to get what they need and to share information. Norm-referenced tests do not investigate the difference between child-adult and child-child interactions nor do they consider the settings in which they occur. The lack of reliable and valid norm-referenced measures of pragmatics (language usage) eliminates the identification a group of language-disabled students because there are no-norm referenced tools available to use to apply the eligibility criteria. The lack of norm-referenced measures of pragmatics (language use) was emphasized. How can the criteria be applied if there is an area of disability that does not have a valid measure to assess it? The valid measures include language sampling and observations.

I do have one additional comment in response to a remark that Carol Hvidston made during the conference call on 10/13/2009. Carol stated that only the speech-language section had included the need for clinician judgment when the other areas did not. She followed that remark with a second stating that there is an assumption that clinical judgment is assumed. I would make the argument that the suggested eligibility criteria for Autism, Cognitive disability, Emotional disability, Orthopedic impairment, Other health impaired, and Learning disability have an observation component. I see how Carol can make the statement that clinical judgment is assumed since there is an observation component. Observation and all other measures have been removed from the suggested Speech-language AND Developmental delay eligibility criteria,. Due to this removal, the assumption that clinical judgment is assumed cannot be made. If the eligibility criteria are going to be aligned, then observations should be included for the speech-language and developmental delay criteria.

As an aside, the WDE Eligibility Criteria Side-by-Side Comparison form used the term standardized measures. It should be noted that standardized measures are not the same as norm-referenced measures. I can create and use standardized observation and criterion-referenced measures. The inclusion of 1.5 standard deviations below the mean implies that a norm-referenced measure is being used, but it does not guarantee this. I can create a mean and standard deviation for a standardized observation.

Thank you for considering these comments.

Sincerely,

Melissa M. Allen, Ph.D., CCC-SLP

Assistant Professor of Speech-Language Pathology
Division of Communication Disorders
(307) 766-6098
mallen20@uwyo.edu

2009 WSHA Convention

Attendees at the 2009 WSHA Convention, October 1 & 2, 2009 in Casper, WY were asked to share their experience with the new WDE Eligibility Rules for SLP/Aud services.

1. A 2 year 11 months old child who cannot qualify for part B because her language score (on 2 year old norms) is "only" -1.4 SD, but on 3 year norms would be -1.68 SD and would qualify.

2. Very frustrated about omitted "professional judgment" qualifications. (Multiple "dittos")

3. A 3 year 4 months old with 73% receptive, 10% expressive, articulation 10% can't qualify. He needs services badly, can't understand his conversational speech.

Donna Shippen

Donna Shippen of Cody, WY is the new SEAL representative for the State of Wyoming. She will coordinate WSHA's efforts with regard to the WDE's Emergency Rules, adopted 8/26/2009.