From the Editor...
A recently published article (Brandel & Loeb, 2012) indicates that the service delivery model most commonly employed by speech-language pathologists (SLPs) in the public schools today is the "pull-out" model. With this model, which reportedly has been in use for over 100 years, children typically receive 20- or 30-min treatment sessions once or twice a week individually or in small groups outside the regular classroom. As the authors report, this model is routinely employed regardless of the type or severity of a child's communication disorder despite the progress that has occurred in our profession in understanding the need to employ different service delivery models for children with different types of disorders, and legal mandates that services be individualized for every child with a communication disorder. The authors then express doubts about the effectiveness of speech-language intervention when it is delivered using this model with all children, regardless of the type or severity of their communication disorder.
In this editorial, I underscore the seriousness of this situation, pointing out some long-term implications for individuals and for society when communication disorders, particularly language disorders, are not remediated when children are young, before they begin to experience significant school failure. I then offer some suggestions for how to address this problem.
To begin, it must be stated that the pull-out model may be an appropriate choice under some circumstances. For example, it may offer unique advantages for the treatment of certain communication disorders—such as stuttering, articulation, or voice—especially when children are first learning how to implement specific techniques (e.g., easy onset, slowed rate) or produce difficult sounds (e.g., s, r, l) at the syllable or word level, or when children are developing awareness of their own patterns of healthful versus harmful vocal use. Intervention that targets these sorts of skills may be quite successful when children are able to work with an SLP individually or in a small group setting that is free of the noise and distractions of a typical public school classroom.
However, when language is the primary disorder, a different treatment model may be required because of the inherent and substantial links between language competence and academic, social, and vocational success. Longitudinal research indicates that many children who are diagnosed with language disorders in kindergarten continue to lag behind their typically developing peers in spoken and written language development throughout the school-age years (Tomblin & Nippold, 2012) and that many of them, as adolescents, experience poorer academic outcomes, weaker social competence, and higher rates of rule-breaking behavior compared to their typically developing peers (Tomblin, 2008). Other longitudinal research has shown that, compared to their peers with typical language development, young adults with a history of early language impairment are less likely to complete high school or attend college, and that when they do obtain employment, it is often at a substantially lower salary (Johnson, Beitchman, & Brownlie, 2010). Another distressing finding is that many young people who are juvenile offenders have developmental language disorders that are reflected in poor narrative discourse that limits their ability to tell about events that happened to themselves or to others, as when speaking to a police officer, judge, or other authority figure; hence, they are unable to defend themselves adequately (Snow & Powell, 2005, 2008). Further, many adolescents and adults who are incarcerated have language and literacy deficits that make it difficult for them to benefit from verbally mediated rehabilitation programs (e.g., anger management) (Bryan, 2004).
These findings from research provide convincing evidence that language and literacy disorders can have extremely negative consequences for children, adolescents, and adults, and for society as a whole, when potentially productive citizens are unable to support themselves and their families, contribute to the tax base as stable employees, or participate positively in the civic life of their communities. Given this information, what can be done to rectify the situation?
Some Possible Solutions
On the positive side, research has shown that language disorders in school-age children can be treated successfully when certain conditions are in place. As reported by Gillam and Loeb (2010), it is important that language intervention be frequent and intense (i.e., that it be delivered on a daily basis for a sustained period of time); that it promote children's active attention; and that children receive corrective feedback on their responses and praise for their efforts and successes. Similarly, research has shown that reading deficits can be treated successfully in school-age children when intervention is intense, explicit, and systematic; children have multiple opportunities to practice their newly learned skills; and teachers and other adults provide them with appropriate amounts of corrective feedback, positive reinforcement, emotional support, and encouragement (Carnine, Silbert, Kame'enui, & Tarver, 2004; Foorman & Al Otaiba, 2009; Torgesen, Al Otaiba, & Grek, 2005; Vaughn & Klingner, 2004). Given the need for frequent, intense, explicit, and systematic intervention, it is clear that school-age children with spoken and written language disorders require a different approach from the traditional pull-out model.
Research has also indicated that, to prevent or reduce the severity of language and literacy deficits, children should receive effective intervention when they are young, preferably during the preschool, kindergarten, or early elementary years (Justice, 2006). Moreover, to ensure its relevance, intervention should focus on the language demands of the regular classroom (Nippold, 2010). For this to happen, SLPs must work closely with classroom teachers and other school professionals, including special education teachers and counselors, so that students' different learning needs are met. To illustrate these points, I present a passage from a third-grade social studies text that is used to teach students about European immigrants sailing to America. Written in the narrative genre, the passage is an excerpt from a young girl's diary, describing her observations.
Hannah's Journal: November 6, 1901In order to comprehend this passage, children must be able to quickly and accurately read and understand many words that are morphologically complex (e.g., magnificent, goddess, approached, ferried), abstract (e.g., liberty, freedom, education, immigration), and multisyllabic (America, promising, excitedly, passengers). They also must be able to parse complex sentences containing multiple subordinate clauses (e.g., All I could tell was that the men boarded the steamship, names were called, people rushed around, and when the hubbub was over, all the first- and second-class passengers were gone, ferried over to America) and draw inferences concerning the main character's hopes, fears, and joys. It is also the case that in many third-grade classrooms, teachers ask students to retell the passages they have read, using narrative discourse that is clear, accurate, and properly sequenced (e.g., Oregon Department of Education, 2010).
A most magnificent day! We're here at last, in America! Our first sight was of the statue everyone talks about – a giant green goddess raising high the torch of Liberty, promising freedom to all who reach her shores. And her other arm holds a book – is it a sign I will get the education I've dreamed of? Everyone crowded on deck to see her. Men cheered. Women waved their kerchiefs. Children clapped excitedly... As we stood at the rails, a ferry approached our ship. I wished I knew English and could understand what was going on. All I could tell was that the men boarded the steamship, names were called, people rushed around, and when the hubbub was over, all the first- and second-class passengers were gone, ferried over to America. Samuel said we must wait for our own ferry, but we wouldn't be taken to America, not yet. First we had to go to an immigration station on Ellis Island. (Viola et al., 2005, p. 178).
This example illustrates that, by third grade, the language demands of the classroom are already quite high, and unfortunately, many school-age children have difficulty meeting these expectations. For example, many children with a history of language disorders identified in kindergarten have difficulty in all key areas—word reading, reading comprehension, vocabulary, syntax, and narrative discourse (Tomblin & Nippold, 2012). Thus, it is not surprising that they often experience intense frustration as they struggle to succeed in school. For this reason, as students' individual weaknesses in any or all of these areas are identified, they will need to be addressed during language–literacy intervention that is carried out in an integrative fashion that involves all factors that research has shown to be important for success (i.e., that it be intense, frequent, responsive, encouraging, supportive of students' attention, etc.). And, to maximize the chances of effective remediation, SLPs must work closely with other school professionals, such as special educators, who often have considerable expertise in remediating reading deficits, and with counselors who can help students learn positive strategies for coping with frustration.
As discussed above, however, many students do not receive this type of intervention. Consider the case of Jeff, a third-grade boy who struggles to understand spoken and written language, and whose narrative language sample has revealed a preponderance of short, simple utterances, lingering grammatical errors, imprecise articulation, numerous false starts and hesitations, and the use of vague words and repetitive phrases (e.g., uh... uh... round thing, lots a stuff, I mean, I mean). The SLP at Jeff's school provides him with only 30 min of intervention once a week in a group with three other children, explaining that her district expects her to serve over 60 other students with diverse communication needs. Thus, in addition to children with language and literacy disorders, her caseload includes children with autism, traumatic brain injury, motor speech disorders, hearing impairment, stuttering, voice disorders, speech sound disorders, cerebral palsy, cleft palate, and dysphagia, all of which require highly specialized knowledge. Given the frequency of this scenario in the public schools, it is not surprising to learn that the existence of large and diverse caseloads, limited time for planning and implementing treatment, and weak administrative support are factors that can cause high levels of dissatisfaction, stress, and burnout for school-based SLPs (Edgar & Rosa-Lugo, 2007; Harris, Prater, Dyches, & Heath, 2009).
If SLPs feel overwhelmed, stressed, and burned out because of their working conditions, which include large and diverse caseloads and insufficient time for planning and implementing quality treatment, it is time to take action. Thus, in addition to employing different service delivery models for different disorders, intervening with children as early as possible, ensuring relevance by focusing on the language demands of the classroom, and working closely with other school professionals, it may be time to allow for greater specialization, recognizing just how much our field has changed since its infancy when "speech teachers," as they were called in the early 1900s, addressed fewer types of disorders (e.g., stuttering, voice, articulation) (Duchan, 2010). As the knowledge base of the profession continues to expand in depth and breadth, perhaps SLPs in the schools should have the freedom to specialize in one or more areas (e.g., language and literacy, autism, traumatic brain injury) and not be expected to demonstrate expert-level skills in all areas. Indeed, the American Speech-Language-Hearing Association's Specialty Recognition Program could be expanded to assist us to move in this progressive direction, acknowledging the vast complexity of each communication disorder and the need to keep up with the constant flow of newly published research in order to deliver the highest quality evidence-based treatment to our clients.
To conclude, current research suggests that in order to meet our legal obligations to the children we serve, we will need to make some changes in our methods of service delivery. As we consider making these changes, it is wise to remember that there is strength in numbers and that complex problems can be solved through reasoned discourse that involves articulate speaking and genuine listening. As SLPs work cooperatively with each other and with other school professionals to build greater awareness of the links between language, literacy, and life success, they will find creative ways to meet the needs of students more efficiently and effectively. When SLPs have greater flexibility to employ different service delivery models for different communication disorders and the freedom to become experts in areas that most interest them, they will be empowered to work with greater passion, vitality, and success in the schools.