School-Based Speech-Language Pathology Must Change

The Confession

Dear School-Based SLP,

I need to apologize to each of you.  I often find myself standing in front of you and telling you all that it is going to be okay.  You will be okay, SLP, and your efforts are always worth it.  You come up to me after presentations, your eyes wet, and tell me that I convinced you not to quit. We hug, and I’m grateful we kept another great SLP in the profession.   You email me about your caseload of almost 100 students, and I help you problem-solve how to talk to your special education director.  You thank me, and I’m hopeful that you will have a reprieve from your daily profession efforts, soon.  You write to me and ask if it is worthwhile to switch to the profession of speech-language pathology.  I write back and tell you about the meaningful outcomes of my profession, and you tell me that you will work hard to join the SLP ranks.  In the last few months, the quiet whisperings of “this is not right,” “how am I suppose to do this” and “is it really worth it?” has been getting resoundingly louder.  So, we need to talk.

The Arithmetic Does Not Add Up, SLPs

In junior high and high school, I used to compete in math.  Let’s remove some of my mathematical cobwebs and apply my skills to school-based speech-language pathology.  Let’s say, we are given a 40 hour work week.  School-based SLP, I know that you are all laughing at a mere 40 hour work week; however, humor me.   As an SLP who has served in many districts, I am going to ballpark that most SLPs have a caseload of 65 students.  I am currently providing support on a campus that has 71 students receiving speech/language services.  Those services are usually provided by one full-time SLP.  Last year, I worked in a district alongside an SLP-Intern who was serving almost 90 students across 6 campuses, and I just spoke to an SLP who supports one SLP-Assistant with an anticipated caseload of 100+ for the 2019-2020 school year.

Time Given Per Student

Okay, let’s recap.  We have a full-time SLP at one campus with 65 students. Let’s see how much time it would take to provide our students speech-language therapy in one week.  Let’s say each student is seen twice a week for 30 minutes per session.  In other words, it would take one hour of speech-language therapy per student.   I fully acknowledge that this is a pattern of service delivery, and that is illegal.  For the sake of my point, let’s allow this.  Now, in a clinical setting, I must acknowledge that it would take me 65 hours to get this done, and the kid would get 60 minutes of my undivided attention.  In a school setting, I use my creative grouping powers to get this done because this is how the structure of speech-language pathology has been set up.   Let’s say I put the students in groups of 3.  So, now I have 22 groups, and this means 22 of my 40 work hours are dedicated to direct therapy.  Not bad, right?  I still have so much time left over during my work week.

Let’s dig a little deeper.  This also means that each student’s time, in theory, is now divided by three.  A group of one student in a 30 minute session means that the student gets 30 minutes of intervention.  A group of three means that my school-based SLP attention will be divided, and my work is not as rich as one-one-one therapy.*  (Hmmmm, I wonder if this will have an impact on how long the student will be in speech-language therapy?  I digress, and the answer is YES, YES, YES! )  Then, I realize that three of my students need to be seen individually.  So, I am going to add three more hours of therapy into my week.  We have now used up 25 hours.

*I whole-heartedly acknowledge that there are MANY benefits to group therapy:  students serve as models for one another, mutual understanding that we all have individualized needs, tackling social skills with peers and much more.  Here is a post I wrote about group therapy.  Please know that I use this example to convey that it’s not okay to keep adding students to groups because we do not have the available time in our schedule.

I.E.Puh-lease!

No worries because I still have 15 hours of the work week left.  However, I have 3 IEP meetings this week.  On average, it takes me 30 minutes to prep each student (I’m really good at prepping), 60 minutes to run the meeting and about 45 minutes following the meeting to wrap up, make copies, get accommodation/modification info out to teachers and send the paperwork home.  Now, I am down to an entire 9.75 hours left in my week! I am surely sitting in the SLP-lap-of-luxury.

I forgot!  Since I had 3 IEP meetings, I missed therapy for 18 students.  According to our laws, I must make this up.  What does this look like?  Well, I already have a schedule in place.  So, this typically looks like doubling up on my groups.  Remember my group of 3 students?  Just like that, I now have a group of 6 students.  My 30 minute session looks differently.  (I also want to acknowledge that other educational professionals have substitutes when they are sick or go to training.  This does not happen for SLPs, and we are expected to make-up the therapy on top of our current schedule.   I’ll say it–this sole fact compromises our professional integrity.)

But, wait.  I have an evaluation due in a week.  So, I test my student.   It’s a test that I use frequently.  So, I don’t need to take a few hours to read through it.  SLP-smart, I am.  She is a student with concerns in the area of receptive language, expressive language and articulation.  The testing takes me 2.75 hours.  I will acknowledge that in the clinic, my evaluation usually take 45 minutes for articulation concerns, 60 minutes for fluency concerns and 1.5 hours for a language assessment (in two languages).  In the schools, it always takes longer.  Factors include finding time to pull the student in truncated episodes and gathering the paperwork from the family and the teachers.  We are now at 7 hours left in my week.  This is awesome because it takes me 7.5 hours to gather the paperwork, score the tests, analyze the results, and write up the report, and I am only 30 minutes in the red.  Again, I must acknowledge that report writing takes longer in the schools.  Integrating the information from the parent forms, the teacher forms, the observations across settings and, at times, the content from outside evaluations takes time.  Sitting down for 20-30 minute chunks to write the report requires added time to rethink, remember and rework the content that you completed a few days prior makes the process longer.  This is our truth.

Spending an additional half an hour one evening a week doesn’t sound too bad, right?  Except I have not completed my Medicaid billing.  This takes me another 1.5 hours on a different evening.  Whew!  It’s been a great week!  Let’s remember:  lunch is overrated, I only had to stay up late to work 2 evenings, planning and collaborating are a luxury and I only had one evaluation due.  As an SLP, I look at the glass-half-full.  Since we are friends, though, I’d like to tell you what a not-so-good week looks like.

Here’s 99 Problems

Here’s 99 problems and compliance is surely one, school-based SLP.  I acknowledge that there are many holes in my example above; however, I need for us to acknowledge that there is a problem right now for school-based speech-language therapy.  This was a fabricated example, and the outcomes are insignificant.  The real life scenarios of caseloads I’ve covered and the whispered confessions of my SLP peers are atrocious and sad.  And, dearest SLPs, this is not a “people problem.”  This is not YOU.  This is a “systems problem.”  Our school systems are not set up in a manner that 1) yields optimal progress for students (a.k.a. service delivery problem), 2) compliancy for school districts and 3) emotional health and safety for my speech-language pathologists.   Brené Brown, a research professor, talks about how “being kind” is “being clear.”  Right now, I want to be VERY clear.   We need to make changes to the system.  Now.  If you don’t believe me, here are true examples of what is happening:

  • SLPs recommend 30 minutes of speech-language therapy weekly because they cannot physically see the students for more time
  • SLPs are compliant on IEP and evaluation deadlines.  Therapy minutes are secondary because it’s not tracked by school district personnel
  • SLPs dismiss students once they get to the secondary level because there are not enough SLPs
  • SLPs do not have time to conduct an evaluation and write up a report to dismiss students.  So, they keep and keep and keep staying on the caseload
  • SLPs tell their teachers, “I don’t have time.  Just pick the worse student in your class.”
  • SLPs are told they CANNOT recommend more than one 30-minute session
  • SLPs do not qualify students
  • SLPs are quitting

Again, I need my SLPs to whole-heartedly know that I do not blame them for these errors.  This is the direct result of what has been placed on our very full speechy plates.  It is not a “people problem.”  It is an “exhaustion” problem.  You are all tired, and you are barely staying afloat.  This is not okay.  This is not okay.  You got it, SLP?  This is not okay.

What’s Next?

So, what’s an SLP to do?  I have already acknowledged that you do not have any more time.  So, SLPs, I need for you to sit out on this paragraph. I am now going to address school district leaders, state organizations, state legislators and, finally, the American Speech-Language-Hearing Association.   SLPs, you need to understand that your school district hires you.  This means that hiring is mandated by your state’s School Board Association.  School districts, here is information you need to know about your SLPs:  Staffing Considerations for SLPs.   And, I cannot go without acknowledging that SLPs serve the largest numbers in special education, and we also support the efforts that provide Medicaid reimbursements for school districts.  We surely do not support our students and families for the money; however, it goes without saying that our efforts are considerable and vast.  Then, state organizations needs to acknowledge this problem.  I have heard from SLPs across the country, and this is an epidemic.  You are the link to the work that needs to be done.  For example, in my state of Texas, the joint Texas Speech-Language-Hearing Association (TSHA)/Texas Council of Administrators of Special Education (TCASE) Joint Committee is talking about ways to address this big problem.  Third, our legislators need to know that school-based speech-language pathologists are a part of instructional personnel.  I fully acknowledge that our public school system needs are great, and SLPs need to be a part of the discussion that takes place at the state level.  Last, let’s talk about ASHA.  I’ll be honest.  I am not sure ASHA can give direct guidance on caseload numbers.  From my perspective, the needs are too diverse across the nation based on what I see when I visit school districts and when I speak to you all.  ASHA, however, has given input on  workload versus caseload, and this is a worthwhile consideration.

The Reality

As I conclude my heated rant, I need to bring it back home–this is you, SLP.  I have spent the last few months thinking often and deeply of your daily woes.  You tell me that you got into this profession to support the communication journeys of your students and their families.  Know that you are.  It’s amazing.  As you talk to me about your caseloads, inundations of evaluations and reports and Medicaid billing, you start sharing success stories of your students.  You talk about how he started putting together a sentence.  You talk about the creative ways you use science experiments in speech-language therapy.  You talk about the scholar that started using her communication board to request for her favorite breakfast.  Here’s the thing.  Despite EVERYTHING that is happening against you, you show up.  You show up, and you work hard.

Now, it’s time for others to show up for you.  It’s TIME.

Written by: phuonglienpalafox

23 Comments on “School-Based Speech-Language Pathology Must Change”

  1. April 5, 2019 at 6:12 am #

    Excellent article! I wonder how the situation differs in states that have unions!

    • April 5, 2019 at 7:24 am #

      Monica,

      You bring up an important point. We have presented in states with unions, and the needs are different. I would love to hear input from SLPs from states with unions. Thank you.

  2. April 5, 2019 at 6:52 am #

    The district I currently work in has implemented the 3:1 model. I honestly can’t imagine working as a school-based SLP without the 3:1 model. I hope that this model is implemented around the nation, as it allows us time to complete paperwork, evaluations, make-up sessions, and collaborate with teachers and other IEP members during our workday.

    More information found here:
    https://www.asha.org/uploadedFiles/0914Handouts.pdf

    • April 5, 2019 at 7:34 am #

      Hi Elyssa,

      You bring up a valuable point with service delivery models. I supported a larger district the year we implemented the 3:1 model, and I appreciate 3:1 for its ability to 1) align our SLP content to the general education curriculum, 2) tracked time in our schedule of service to meet with teachers, reach out to parents, program devices, make materials and 3) provide a true representation of our prime duties (therapy AND testing AND report writing AND Medicaid billing AND AAC/AT AND aligning to curriculum, etc.) I agree with you–I whole-heartedly believe that considerations to service delivery is part of the answer for our workload. I will also say that the purpose of 3:1 is to 1) generalize the skills to home and classrooms and 2) alignment of the curriculum. It is also one service delivery model, and this should also be individualized to the student needs, as well. Thank you for bringing up this important consideration, Elyssa.

    • April 5, 2019 at 8:35 am #

      I implemented the 3:1 model a few years for the majority of my students a few years ago and I will never go back! It legitimately provides time for all the “extras”. In addition, as a district, we are filling in the Workload/Caseload spreadsheet on ASHA to get a better idea how to distribute caseloads more evenly. With the new response regarding Dr. Zirkel’s letter (Jan 29, 2019) from the US Dept of Ed, our responsibilities can no longer include RTI or MTSS which should help…however this may mean more evaluations and collaboration time with regular educators.

      • April 5, 2019 at 9:15 am #

        Heather,

        The intent of the 3:1 model was to support the comprehensive efforts of SLPs and to provide opportunities to align to the curriculum and generalize skills. It’s also one of many service delivery options that needs to be individualized. Sadly, you are right. The intent of the model has shifted due to the initial reasons why I wrote this post—-the workload is too much.

        I’m so glad you brought up ASHA’s caseload/workload model. In the district I used to support, we used a workload model. It helped us determine assignments. The following was accounted for: Meidicaid billing, student needs, bilingual responsibilities, caseload, specialized units, etc. I do believe in the workload model. In saying that, I acknowledge that districts using the workload model have seen significant increases in workload in the last decade. For us in Texas, there was a significant change when our state budge was cut in 2011. Oh, I could go on.

        Thank you, Heather, for your input. You bring up valuable points to consider.

  3. April 5, 2019 at 7:34 am #

    Phenomenal article! Thank you for your advocacy and speaking our truth!!!

  4. April 5, 2019 at 8:18 am #

    All I can say is thank you, thank you, thank you, thank you for “doing the math.” As an SLP I have to say most of the time I feel inadequate. I feel like I’m spinning my wheels and I’m never enough, therapy is never enough, I don’t have time to make cute “Spring themed activities” my reports should be done faster, my IEP’s should be more dynamic. Why? This is why. Thank you for asking the RIGHT question. The question has always be, “Why can’t the SLP do this?” “What does he/she need to do differently?” What we should be asking is, “What is wrong with this system?” “How can we change the role of the school based SLP?” Mind blown!

    • April 5, 2019 at 12:31 pm #

      Christina,

      This is it. We need to stop reprimanding SLPs for what “X, Y or Z” that is not happening. Instead, we need to ask, “Why is the system not set up to support our speech-language pathologists?” I get to meet many SLPs, and, at times, I feel like I just see a sea of crying professionals. For me, tears mean that something is important, and I KNOW that we all value our students, clients and our families. When things don’t happen, we need to think about the breakdown in the system. Perhaps she missed therapy because her caseload has increased by 10% this year?

      And, finally, the part that makes me the saddest is that SLPs feel like they are not doing a good job. This is unfair. Last week, I had a group of 8 kindergarteners in one group. I had two ARD/IEP meetings that day, and it was one way to not miss my minutes. The group went well, and I was proud of myself for getting the job done. Then, when a fellow SLP said, “Ugh, I need to be better at that,” I realized what I was doing. My dear SLP friend does not need to berate herself for not yet putting 8 kids into one group. This is not normal and expected. However, it’s what we are doing to make it work. So, instead of feeding the system, I am going to speak our truths.

      Thanks for reaching out, Christina. Here’s to a productive end-of-year and love to Region 4.

  5. April 5, 2019 at 8:35 am #

    I’m fortunate to have approximately 50 students on my caseload at the moment and am on a 3:1 model as well. Even this, sadly, is too much, especially considering additional responsibilities–i.e., lunch break, recess duty, cafeteria duty, prep time, team meetings during prep time, etc. Because of my smaller caseload, it’s possible for me to see more students individually. Each of these students receives much more intensive intervention and I feel receives adequate “group” time with their typical peers the remainder of their day. My concern with the 3:1 model is that the 1 part is not held sacred, and is seen as an opportunity to schedule mandatory SLP meetings, trainings, etc.

    • April 5, 2019 at 9:08 am #

      Trevor,

      You are right. I see this, as well. The intent of this model is to 1) support alignment of curriculum and 2) generalize skills. I strongly caution SLPs to 1) NOT use this model for all students (this goes back to pattern of service delivery) and 2) as an avenue for completing our work outside of direct service. Again, this goes back to my initial sentiments—-we need more help, and this system is not working. I also agree with your efforts in seeing students individually and in a group. We need to give them the time they need, and I’m glad you have the opportunity to do that. What’s not okay is that this luxury should be a “status quo.” Thank you for your thoughtful input and SLP-efforts.

  6. April 5, 2019 at 9:37 am #

    Personally, I believe in order to be effective, ethical service providers, we must know our limits and prioritize the students we serve. I cannot help but feel that ASHA is about “job security” by proclaiming our need to be involved in every type of possible communication disorder. There are other service providers who can and should be the first contact when dealing with students with selective mutism (an ANXIETY disorder) or severe/profound disorders in which daily language stimulation is needed.
    I am not saying that SLPs cannot provide a supporting role in these cases, but in my experience, there is NOT a team approach. The SLP IS the team, and ASHA adds to the pressure and watering down of our services with the idea that every single child can communicate, and all can benefit for our services. I know I’m likely overgeneralizing, but I am beat down by the system and feeling a bit pissy. I started the year with a caseload of 65, later to find out that THIRTY of the students were in the Severe and Profound classes, and ALL had AT/AAC needs that were not in place. And the students who I truly feel would benefit most get pushed to the side while I spend the majority of my time attending staffings and ARDs and attempting to developing assistive technology for students who either aren’t benefiting from my service and/or whose parents/teachers refuse to let go or to assist in the process.

    • April 5, 2019 at 12:20 pm #

      Hi Brandi,

      Your bring up some really good points. The specialized skills of a speech-language pathologist are unique, and I agree that, at times, our educational peers do not understand the scope of our practice. For me, it’s helpful to do a brief staff training once the campus knows and trusts my efforts. I also agree that a team approach is best. I have been at campuses where interdisciplinary work reigned. Collectively, we were able to use each of our skills to address the students’ comprehensive needs! It was awesome. I have also been on campuses where this did not happen, and our efforts were reduplicated and less effective. From my experience, I feel like part of this is attributed to available time. The ASHA Schools Survey always asks for challenges in the field, and SLPs talk about lack of time for collaboration.

      Wow, having almost half of your caseload of 65 with severe and profound needs is significant. I can surely testify to the amount of time and work it takes to set up our students on with their AAC/AT supports. This sounds hard, Brandi. As for feeling frustrated, it makes sense to me. I’m hopeful the post will serve as an opportunity for conversation. We can’t change things unless we acknowledge the truth. And, the truth is that we are having a hard time. Thank you for sharing your truths.

      Take care,
      Phuong

  7. April 5, 2019 at 9:45 am #

    I think it is very important to enlist the help of the teacher’s union. I’ve been paying teacher union dues for years, but with my new district I feel like I’m finally being heard. I tried my best to help them understand my situation, by using teacher situations. For example, how would they feel if they 30-50% more students in their classrooms fully knowing that their cap is 25-35 students. So just imagine having 40-50 kindergartners in a class!

    • April 5, 2019 at 12:11 pm #

      Thank you for this perspective, Olga. I am glad there are proactive ways for you to convey your needs in the school. It sounds like there is still a gap in understanding between general education and special education (US!) needs. I really like how you communicated what our needs “look like” if we were classroom teachers. Thank you for advocating, and thank you for being a part of our field.

  8. April 5, 2019 at 12:15 pm #

    Thank you for discussing this. While the financial decisions do lie with the legislature etc.. I think we as SLPs need to make some decisions about how we choose to work in our field. I left the schools when I first entered the profession (25 years ago) because I had 3 schools and a caseload of 70. I felt like I was putting a bandaid on an artery wound. As a female dominated profession we are waaaay too accommodating. If you look at male dominated professions they would not put in all those extra hours without compensation. We need to speak up, union up, and or leave the work setting when it is intolerable. I have a son with special needs and understand that we feel like we are abandoning our students but we are doing them no favors by providing less than adequate services because we are overloaded. I am now back in the schools because it suites my family life, but I have caseload limits that keep me busy but not much more than when I was running my own practice. I encourage everyone with a colossal caseload to team up with the SLPs, OTs, PTs in your district and present to the powers that be as a group. The schools need us as much as we need the work. We can’t forget this. GO TEAM SLP!

    • April 5, 2019 at 12:40 pm #

      Kathleen! YES! YES! Your words resonate deeply with me. When something happens, I usually let it go. When something happens repeatedly, I know that I am a part of the problem. Without diving too deeply (which I CAN!) into the gender differences in job roles, responsibilities and compensation, we are accommodating this big problem when we put in the extra time and hours. I recall talking to one of my former SLPs in a large district. She was crying because she was going home each night after 7pm, and she was exhausted. As her lead SLP, I had no idea this was happening. When we make accommodations within our day and outside the boundaries of our self-preservation, we are letting others know that we are okay and getting it done. We all know it’s NOT OKAY.

      And, you’re so right, Kathleen. Gather your teams, SLPs. Garner your frustrations and speak up and speak out. As communication experts, I know we can do this. At this point, there is not another option.

  9. April 5, 2019 at 4:04 pm #

    I really want to respond to this with a more thoughtful note. However, after 29 years in a school and school district I have loved, for the first time the word “retirement” has entered my thoughts over and over this school year. I simply can’t sustain the workload nor reconcile it with my ethical standards. You know me, Bilinguistic peeps, and you know that I am passionate about my work so this is a tough realization. In our district, we do use a workload approach, have complete autonomy and flexibility in how we deliver our services and have the most supportive and proactive boss but even those things can’t fix the problem. Then, the state senators (SB3) decided we weren’t worthy of being included in the big pay raise they want to give teachers. At least all but one of house representatives (HB3) felt we were worthy and passed a bill to include us in the raises. That gave me the strength to continue another day. Another year? Probably will do that too.

    • April 8, 2019 at 7:53 am #

      Oh, Gina. You said it, “I simply can’t sustain the workload nor reconcile it with my ethical standards.” There are so many layers to your words, and you are right on all accounts. I’m with you–I work alongside a supportive team within a profession that I love so very much, AND something is not right. This crescendo of mishap has been building for the last 7-8 years, and we need help. Thank you for being honest. And, I will keep saying it loudly, “Our SLPs are so worthy of so much more.”

      SLP in solidarity,
      Phuong

  10. April 5, 2019 at 4:19 pm #

    This was a terrific read, thank you. I am a school SLP in Canada, and this is my first year on the job. We don’t have caseload caps here, and I currently have 100+ kids on my caseload at three different schools in a small, remote city.

    I have described the job in a similar way to a commenter above, as putting a bandaid on a bleeding wound. I’ve felt like I was failing my kids because I don’t have time to provide adequate therapy, much less collaborate with educational assistants, teachers, other therapies OR prepare materials. I try to share with teachers and admin about the workload, and I’m happy to say most have been supportive and understand we are not superhuman (even though we try to be).

    This article was a great read, and provided some real info on the profession. Thank you so much!

    • April 8, 2019 at 7:49 am #

      Hi Gabby,

      Most states in the US do not have caseload caps either. From experience, I know that serving students across different schools adds a whole other layer of complexities. Thank you for being a part of this profession–I know it’s so hard. The part that makes my heart ache the most is you saying “I was failing my kids.” This is the part that is not okay. SLP are doing their best, including you, and this is what I continually see. It’s not YOU. It’s a system that needs to change. Thinking of you as we continue to speak our truth and potentially make some meaningful change.

      Take care,
      Phuong

  11. April 9, 2019 at 3:41 pm #

    Thank you for saying everything you said.

    • April 10, 2019 at 3:10 pm #

      You are very welcome, Christina.

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