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.