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