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Speech-Language Services in IEPs of Students with Extensive Support and Complex Communication Needs

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Title: Speech-Language Services in IEPs of Students with Extensive Support and Complex Communication Needs
Language: English
Authors: Kathryn E. Dorney (ORCID 0000-0002-2103-9970), Nancy A. Quick, Karen A. Erickson
Source: Exceptional Children. 2026 92(3):305-321.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 17
Publication Date: 2026
Sponsoring Agency: Office of Special Education Programs (OSEP) (ED/OSERS)
Contract Number: H327S140017
H327S160005
Document Type: Journal Articles
Reports - Research
Education Level: Elementary Education
Junior High Schools
Middle Schools
Secondary Education
High Schools
Elementary Secondary Education
Descriptors: Individualized Education Programs, Speech Language Pathology, Multiple Disabilities, Students with Disabilities, Elementary School Students, Middle School Students, High School Students, Grade Level Differences, Autism Spectrum Disorders, Intellectual Disability
Geographic Terms: North Carolina, Florida, Maryland, Pennsylvania, Virginia
DOI: 10.1177/00144029251377056
ISSN: 0014-4029
2163-5560
Abstract: Students with extensive support needs (ESN) are a group of students with multiple disabilities including significant expressive and receptive language impairments that make it difficult for them to access and participate in the general education curriculum, even with quality instruction and appropriate accommodations. Like all students with disabilities, students with ESN typically require related services to benefit from the special education services they receive. The purpose of this descriptive and parametric statistics study was to examine speech-language services in the IEPs of students with ESN (n = 258) across six U.S. states. Specifically, the type and intensity of speech-language services were examined across grade band, the Individuals With Disabilities Education Improvement Act (2004) disability category, and symbolic communication level (i.e., pre-symbolic, symbolic). The relationship between speech-language services and various demographic variables was analyzed using multinomial logistic regression. While no significant relationship was identified between demographic variables and the type of speech-language services students received, some demographic variables (i.e., communication level, grade band) predicted the intensity of speech-language services. Findings are discussed relative to the literature with implications for practice in schools and future research.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1500247
Database: ERIC
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  Value: <anid>AN0192372879;exc01apr.26;2026Mar23.04:45;v2.2.500</anid> <title id="AN0192372879-1">Speech-Language Services in IEPs of Students with Extensive Support and Complex Communication Needs </title> <p>Students with extensive support needs (ESN) are a group of students with multiple disabilities including significant expressive and receptive language impairments that make it difficult for them to access and participate in the general education curriculum, even with quality instruction and appropriate accommodations. Like all students with disabilities, students with ESN typically require related services to benefit from the special education services they receive. The purpose of this descriptive and parametric statistics study was to examine speech-language services in the IEPs of students with ESN (n = 258) across six U.S. states. Specifically, the type and intensity of speech-language services were examined across grade band, the Individuals With Disabilities Education Improvement Act (2004) disability category, and symbolic communication level (i.e., pre-symbolic, symbolic). The relationship between speech-language services and various demographic variables was analyzed using multinomial logistic regression. While no significant relationship was identified between demographic variables and the type of speech-language services students received, some demographic variables (i.e., communication level, grade band) predicted the intensity of speech-language services. Findings are discussed relative to the literature with implications for practice in schools and future research.</p> <p>Keywords: IEPs; augmentative and alternative communication; speech-language services; speech-language therapy; extensive support needs</p> <p>The Individuals With Disabilities Education Improvement Act ([<reflink idref="bib30" id="ref1">30</reflink>]) mandates that specially designed instruction and related services be provided to all students who have disabilities that have an adverse effect on their access to an appropriate education. IDEA and Title II of the Americans with Disabilities Act ([<reflink idref="bib2" id="ref2">2</reflink>]) further require that schools ensure that communication with students with disabilities is as effective as communication with students without disabilities (IDEA, 2004). These laws are especially important for students with extensive support needs (ESN) who have significant receptive and expressive language impairments that are generally described as complex communication needs (CCN; [<reflink idref="bib25" id="ref3">25</reflink>]). Yet, students with ESN with or without CCN have historically received speech and language as a related service less frequently than students with high-incidence disabilities ([<reflink idref="bib20" id="ref4">20</reflink>]; [<reflink idref="bib21" id="ref5">21</reflink>]; [<reflink idref="bib41" id="ref6">41</reflink>]).</p> <hd id="AN0192372879-2">Students with Extensive Support Needs and Complex Communication Needs</hd> <p>Students with ESN receive special education services under a variety of IDEA special education disability categories (e.g., autism, multiple disabilities, intellectual disability) and most are educated in separate special education classrooms or schools ([<reflink idref="bib18" id="ref7">18</reflink>]; [<reflink idref="bib25" id="ref8">25</reflink>]; [<reflink idref="bib33" id="ref9">33</reflink>]). Students with ESN require extensive individualized instruction, consistent support, and substantially adapted materials to acquire, maintain, and generalize learning across settings ([<reflink idref="bib50" id="ref10">50</reflink>]. In accordance with the U.S. Department of Education (DOE), starting in third grade, students with ESN participate in mandated statewide alternate assessments based on alternate achievement standards. These alternate achievement standards are aligned to grade-level standards but reflect less breadth, depth, and/or complexity ([<reflink idref="bib26" id="ref11">26</reflink>]; §1177-24).</p> <p>Many students with ESN struggle with communication. In a large sample of 92,080 students with ESN, approximately 75% were reported to use speech to communicate, but fewer than half of those who use speech were reported to combine three or more words ([<reflink idref="bib18" id="ref12">18</reflink>]). Burns and Clark noted that approximately 25% of the full sample used AAC. Of those students that used AAC, less than 10% combined three or more graphic symbols in the grammatically correct order, and only 25% combined two symbols. In contrast, nearly 66% used only one symbol to communicate. Furthermore, across multiple surveys of students with ESN, many are reported to not have symbolic communication in any modality. Nearly 33% lack any formal symbolic means of communication ([<reflink idref="bib25" id="ref13">25</reflink>]; [<reflink idref="bib32" id="ref14">32</reflink>]; [<reflink idref="bib34" id="ref15">34</reflink>]; [<reflink idref="bib48" id="ref16">48</reflink>], [<reflink idref="bib47" id="ref17">47</reflink>]), and less than 10% have no conventional means of communication ([<reflink idref="bib18" id="ref18">18</reflink>]; [<reflink idref="bib25" id="ref19">25</reflink>]). In sum, slightly more than one-half of students with ESN also have CCN. As a group, students with ESN and CCN require augmentative and alternative communication (AAC), which encompasses communication methods used as an alternative or supplement to speech, and includes unaided (e.g., gestures, body language, and manual signs) and aided (e.g., paper-based communication boards, speech generating devices, apps) forms ([<reflink idref="bib6" id="ref20">6</reflink>]).</p> <hd id="AN0192372879-3">Individual Educational Programs and Speech-Language Services</hd> <p>Practice guidelines from the American-Speech-Language-Hearing Association (ASHA) indicate that speech-language pathologists play a central role in assessing and treating people who require AAC ([<reflink idref="bib8" id="ref21">8</reflink>]). In public schools in the United States, these speech-language pathology services are generally classified as related services that are required to help a student benefit from their education and are designated as part of a student's individual education program (IEP; IDEA, 2004). IEPs are described as the keystone of quality education for students with disabilities in the United States ([<reflink idref="bib51" id="ref22">51</reflink>]). The purposes of an IEP include: (a) documenting the student's educational needs; (b) describing the supports, technologies, and services required to meet those needs; and (c) detailing goals that will help the student make meaningful progress from year to year ([<reflink idref="bib52" id="ref23">52</reflink>]). Students with ESN require a broad range of supports and services that should be documented on their IEPs. Speech-language as a related service is one service that would be expected on the IEPs of students with ESN, especially when they also have CCN ([<reflink idref="bib25" id="ref24">25</reflink>]).</p> <p>As with other related services, designating speech-language pathology as a related service on a student's IEP requires the team to determine the format, frequency, and duration of those services. Services can be provided directly to the student in individual or small group sessions, via an indirect, consulting model, or a combination of these ([<reflink idref="bib7" id="ref25">7</reflink>]). Direct services are often appropriate when the student needs to develop skills and learn new skills. In contrast, consultation services can support the students' ability to increase spontaneous or generalized use of an established skill (ASHA, 2017). In addition to the type of service delivery, the IEP team must determine the frequency and duration of services and the setting in which the services will be provided. Each of these should be determined based on the team's best understanding of what is necessary for the student to make reasonable progress within the IEP period ([<reflink idref="bib53" id="ref26">53</reflink>]).</p> <p>Prior research examining the IEPs of students with ESN has focused on the content of goals ([<reflink idref="bib17" id="ref27">17</reflink>]; [<reflink idref="bib22" id="ref28">22</reflink>]; [<reflink idref="bib36" id="ref29">36</reflink>]) and the quality of IEPs across a variety of educational placements ([<reflink idref="bib37" id="ref30">37</reflink>]) and IDEA disability categories ([<reflink idref="bib29" id="ref31">29</reflink>]; [<reflink idref="bib38" id="ref32">38</reflink>]; [<reflink idref="bib46" id="ref33">46</reflink>]). For example, [<reflink idref="bib17" id="ref34">17</reflink>] found that the goals on the IEPs of students with ESN (<emph>n</emph> = 88) offer limited focus on academic or self-determination skills and focus largely on compliance; however, they did report that nearly 30% of all goals on the IEPs addressed social skills or communication, with 9% specifically designated as goals related to speech-language pathology services. [<reflink idref="bib35" id="ref35">35</reflink>] explored the IEP goals from school entry through middle school for students with ESN who had autism (<emph>n</emph> = 15). They reported that 37% to 40% of the students' IEP goals focused on communication, and they reported that there was no relationship between receipt of speech-language pathology as a related service with grade level or placement (i.e., general education inclusion or separate special education classroom). However, they did not report on the percentage of students who received speech-language pathology as a related service or the form, duration, and frequency of services students received.</p> <hd id="AN0192372879-4">Speech-Language Services and AAC Among Students with ESN/CCN</hd> <p>There is limited research informing decisions regarding the appropriate form, duration, and frequency of speech-language service delivery as documented among IEPs for students with disabilities. In one [<reflink idref="bib5" id="ref36">5</reflink>] survey, speech-language pathologists (SLPs) reported providing a median of 60 min of direct weekly services to students with speech and language needs in school settings, but results were not provided for specific sub-groups of students. In Brandel's 2020 survey of 425 SLPs, 48% (<emph>n</emph> = 204) reported they provided services to students with severe disabilities for 60 min each week, and 22% (<emph>n</emph> = 94) reported that they provided services for more than 60 min weekly. Among respondents, only 1% reported they provided more than 60 min of direct services to students with mild disabilities, and only 6% reported this intensity of services to students with moderate disabilities. Importantly, Brandel did not report the percentage of services that were direct versus indirect, or consult-based. Furthermore, it is important to note that these findings are counter to previous findings that suggest that students with more severe disabilities have access to fewer related services, and less intensity and duration of services than their peers with less severe disabilities ([<reflink idref="bib14" id="ref37">14</reflink>]; [<reflink idref="bib43" id="ref38">43</reflink>]).</p> <p>The decision to provide speech-language services to people with ESN has historically been impacted by a practice known as cognitive referencing ([<reflink idref="bib40" id="ref39">40</reflink>])), which is the practice of using intelligence and receptive language measures as a basis for determining eligibility for speech-language services ([<reflink idref="bib9" id="ref40">9</reflink>]). Cognitive referencing led teams to deny speech-language services when a students' communication skills and intelligence were deemed commensurate ([<reflink idref="bib24" id="ref41">24</reflink>]). This cognitive referencing continued despite evidence that children with cognitive disabilities can make gains with language intervention independent of changes in cognitive ability ([<reflink idref="bib20" id="ref42">20</reflink>]; [<reflink idref="bib42" id="ref43">42</reflink>]; NJC, 2002) and the adoption of policies against cognitive referencing in practice (ASHA, n.d.c; NJC, 2002). It is possible that cognitive referencing may still be impacting IEP teams as they make decisions regarding the designation of speech-language pathology as a related service on the IEPs of students with ESN with and without CCN. It is also possible that students with ESN receive services as very young children, but those services are discontinued because of guidance in many states (ASHA, n.d.d) and from ASHA ([<reflink idref="bib3" id="ref44">3</reflink>]) suggesting that speech-language pathology services can and should be discontinued when "treatment no longer results in measurable benefits [and] there does not appear to be any reasonable prognosis for improvement with continued treatment." (Item 11, para 14).</p> <p>The purpose of the current study was to investigate the IEPs of a group of students with ESN and CCN to determine if speech-language pathology was designated as a related service, and, if it was, to examine the type, frequency, and duration of those services. The relationships between the designation of speech language services and student grade band, IDEA disability category, and symbolic communication level (i.e., presymbolic, symbolic) were also examined. The specific research questions were:</p> <p></p> <ulist> <item> What is the distribution of the type, frequency and duration of speech-language services on the IEPs of students with ESN and CCN?</item> <p></p> <item> What is the relationship between the designation of speech-language services on student IEPs and student grade band, IDEA disability category, and symbolic communication level?</item> <p></p> <item> What is the relationship between the type, frequency, and duration of speech-language services designated on student IEPs and student grade band, IDEA category, and symbolic communication level?</item> </ulist> <hd id="AN0192372879-5">Methods</hd> <p></p> <hd id="AN0192372879-6">Data Source and Participants</hd> <p>A total of 258 IEPs of students with SCD/CCN in Grades 3–12, selected from a larger set of IEPs collected as part of two larger studies (i.e., Project Core and Tar Heel Shared Reader[<reflink idref="bib5" id="ref45">5</reflink>]) were included in the current study. The selected IEPs had to include a specific indication that the IEP team determined that the student was eligible to participate in the states' alternate assessments based on alternate achievement standards (AA-AAS; IDEA, 2004). This provided evidence that the student had SCD. Furthermore, the student's CCN status had to be confirmed through various means. All participants in Project Core had CCN as a condition of their participation in the larger study. As such, all 157 IEPs for students in third grade and higher in Project Core were retained. Not all participants in Tar Heel Shared Reader had ESN and CNN. Therefore, each IEP was carefully examined to identify an indication that the student used some form of AAC (<emph>n</emph> = 70). If there was no reference to AAC on the student's IEP, their scores on the Communication Matrix (Matrix; [<reflink idref="bib45" id="ref46">45</reflink>]) were consulted to determine if the student had CCN. Specifically, students were considered to have CCN if their Matrix profile included no indications of scores at Level 7 (i.e., combines two symbols in a correct syntactical form) for two or more communication purposes (<emph>n</emph> = 148).</p> <hd id="AN0192372879-7">Student Variables</hd> <p></p> <hd id="AN0192372879-8">Demographics</hd> <p>Demographic characteristics of the participants were collected from the IEPs, including age, gender, state of residence, primary IDEA disability category, grade band (i.e., elementary, middle, high), educational placement, reported vision and hearing loss, types of related services (i.e., speech-language therapy, physical therapy [PT], occupational therapy [OT], vision impairment services, etc.), and reported use of aided AAC.</p> <hd id="AN0192372879-9">Speech-language Services</hd> <p>The type of speech-language services, including direct and indirect services, was collected from the IEPs. Given variations in the reporting of the frequency and duration of speech-language sessions across the IEPs, each was converted to reflect the total number of minutes per year based on 36 weeks of instruction to support the planned analysis. This resulted in five intervals of weekly minutes: (<reflink idref="bib1" id="ref47">1</reflink>) none; (<reflink idref="bib2" id="ref48">2</reflink>) low, 1–35 min; (<reflink idref="bib3" id="ref49">3</reflink>) low-medium, 40–54 min; (<reflink idref="bib4" id="ref50">4</reflink>) medium, 60–70 min; and (<reflink idref="bib5" id="ref51">5</reflink>) high, 75 or more minutes.</p> <hd id="AN0192372879-10">Student Communication Level</hd> <p>The highest level of communication reported on each student's Matrix was used to create two groups: symbolic and pre-symbolic communicators. Students who scored at a level of 5 (i.e., concrete symbols) or higher for at least one communication purpose were classified into a <emph>symbolic</emph> communication group (<emph>n</emph> = 130; 50.8%). Students who scored at a Level 4 (conventional non-symbolic communication) or lower for all communication purposes were classified into a <emph>pre-symbolic</emph> group (<emph>n</emph><emph>=</emph> 78; 30.2%).</p> <hd id="AN0192372879-11">Procedures and Reliability</hd> <p>Copies of the original IEPs were examined, transcribed, coded for type, frequency, and duration of speech-language services by the first author. Student demographic information (i.e., gender, state, grade, primary IDEA classification) was transcribed, and each student's participation in their states' AA-AAS was confirmed by the first author.</p> <p>A portion of the IEPs (<emph>n</emph> = 104) were previously transcribed for Project Core with the transcriptions and data entry checked for accuracy as part of the larger study. The procedures for that study mirrored the procedures used in the current study. The remaining IEPs (<emph>n</emph> = 154) were transcribed by the first author, and a graduate research assistant checked the accuracy of the transcription and data entry for each IEP.</p> <hd id="AN0192372879-12">Analyses</hd> <p>Descriptive and parametric analyses were conducted using SPSS (Version 26), with <emph>p</emph> values set at <emph>p</emph> <.05. Descriptive analyses were completed to describe the demographic characteristics of the participants (i.e., age, gender, state of residence, primary IDEA disability category, educational placement, reported vision and hearing loss), types of related services (i.e., speech-language therapy, PT, OT, vision impairment services, etc.), and reported use of aided AAC. Descriptive statistics were also conducted to analyze the type (i.e., direct, indirect, direct/consult) and intensity of speech-language services across grade bands and across IDEA disability categories. Additional descriptive statistics were used to examine the frequency and proportion of speech-language service delivery and intensity across communication levels. Multinomial logistic regression was used to examine if a relationship existed between independent variables (i.e., grade band, IDEA disability categories, and symbolic communication level) and the type of speech-language services, as well as to examine if a relationship existed between independent variables (i.e., communication level, IDEA disability categories, and grade band) and the intensity of speech-language services.</p> <hd id="AN0192372879-13">Results</hd> <p>The 258 IEPs represented students from six U.S. states including North Carolina (44.9%, <emph>n</emph> = 116), Florida (25.9%, <emph>n</emph> = 67), New York (13.2%, <emph>n</emph> = 34), Maryland (10.5%, <emph>n</emph> = 27), Pennsylvania (3.1%, <emph>n</emph> = 8), and Virginia (2.3%, <emph>n</emph> = 6). All suggested that the students spent 60% or more of their school day in separate classrooms (29.1%, <emph>n</emph> = 75) or separate schools (70.9%; <emph>n</emph> = 183). Most participants were male (<emph>n</emph> = 169, 65.5%), and their ages ranged from 8 to 23 years old (<emph>M</emph> = 14.40, <emph>SD</emph><emph>=</emph> 3.3, <emph>Mdn</emph> = 14.0, mode = 12.0). They received special education services in each of eight IDEA disability categories; autism (35.7%, <emph>n</emph> = 92), intellectual disability (32.6%, <emph>n</emph> = 84); multiple disabilities (22.1%, <emph>n</emph> = 57), traumatic brain injury (2.3%, <emph>n</emph> = 6, emotional disturbance (0.39%, <emph>n</emph> = 1), other health impairment (4.26%, <emph>n</emph> = 11), orthopedic impairment (1.16%, <emph>n</emph> = 3), and deafblindness (1.55%, <emph>n</emph> = 4). The five disability categories that included very small numbers of participants (range = 1–11: i.e., traumatic brain injury, emotional disturbance, other health impairment, orthopedic impairment, and deafblindness) were collapsed into a single group—<emph>other</emph>—for analyses.</p> <p>The grade level of participants was fairly evenly dispersed with 28.7% (<emph>n</emph><emph>=</emph> 74) in elementary school (i.e., Grades 3–5), 37.2% (<emph>n</emph><emph>=</emph> 96) in middle school (i.e., Grades 6–8), and 34.1% (<emph>n</emph><emph>=</emph> 88) in high school (i.e., ninth grade or higher). Race and ethnicity are not indicated on IEPs; however, the teachers of 184 participants (71.3%) provided information regarding race and ethnicity. This sub-sample of participants for which data were available included 54.9% (<emph>n</emph> = 101) White/Caucasian, 32.1% (<emph>n</emph> = 59) Black/African American, 5.4% (<emph>n</emph> = 10) Hispanic/Latino, 3.2% (<emph>n</emph> = 6) Asian, 2.7% (<emph>n</emph> = 5) Pacific Islander or Native Hawaiian, and 1.6% (<emph>n</emph> = 3) Multiracial. A sub-sample of 59.7% (<emph>n</emph> = 154) of the IEPs included information about English proficiency. Within this group, a small proportion of the participants (6.5%; <emph>n</emph> = 10) were identified with limited English proficiency.</p> <p>Numerous participants in the current sample were reported to have sensory impairments. Data regarding the presence or absence of sensory impairment were reported on 85.2% (<emph>n</emph> = 220) of the IEPs. Only 8.9% (<emph>n</emph><emph>=</emph> 23) of IEPs indicated that the student had a visual impairment and 5.8% (<emph>n</emph> = 15) indicated a hearing impairment. Four participants were identified as experiencing dual sensory impairment. The need for access to assistive technology (AT) devices or services was specified on 45.9% (<emph>n</emph> = 119) of the IEPs of students for whom a level of symbolic communication was available. The need for AAC was specifically indicated on 59.2% (<emph>n</emph> = 77 of 130) of the IEPs of students with symbolic communication and 58.9% (<emph>n</emph> = 46 of 78) of the IEPs of students with pre-symbolic communication.</p> <hd id="AN0192372879-14">Speech-Language Pathology as Related Services</hd> <p>Speech-language pathology was designated as a related service on 79.1% (<emph>n</emph> = 204) of the IEPs. These services were specified as direct on 42.2% (<emph>n</emph> = 109) and indirect on 37.2% (<emph>n</emph> = 96) of the IEPs. The annual number of minutes of direct speech-language services assigned to the participants ranged from 40 min to 5,400 min (this equates to 2.5 hr of speech services per week), which is an annual mean of 1727.9 min (<emph>SD</emph> = 1609.0; <emph>Mdn</emph> = 1080; Mode = 5,400). This equates to roughly 48 min weekly given 36 weeks in a school year. For the IEPs specifying in services, there was an average of 10 sessions per year (<emph>SD</emph> = 10.5; <emph>Mdn</emph> = 6; modes = 4 & 10), which is slightly more than one session each month during the school year. The bi-modal frequency was 4 (14.02%, <emph>n</emph> = 23) and 10 (14.02%, <emph>n</emph> = 23) sessions each year. The duration of these sessions (i.e., number of minutes) was not specified on 62.4% (<emph>n</emph> = 68) of the IEPs.</p> <hd id="AN0192372879-15">Grade Band and Speech-Language Pathology as a Related Service</hd> <p>Across all IEPs, the number of students assigned speech-language pathology as a related service decreased across grade bands while the provision of indirect versus direct services increased (see Table 1). Specifically, three times as many IEPs for students in the elementary grade band designated direct services than IEPs for students in the high school grade band. When IEPs designated direct-speech-language services, the majority (53.7%, <emph>n</emph> = 121) designated fewer than 35 min weekly, and very few (0.8%, <emph>n</emph> = 10) designated 60–70 weekly minutes.</p> <p>Table 1. Type, Proportion and (Frequency) of Speech-Language Services and Intensity Assigned in IEPs Across Grade Bands (n = 258).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="center" /><col align="center" /><col align="center" /><col align="center" /></colgroup><thead><tr><th align="left">Service Delivery</th><th align="center">All (<italic>n</italic> = 258)</th><th align="center">Elementary (<italic>n</italic> = 74)</th><th align="center">Middle School (<italic>n</italic> = 96)</th><th align="center">High School (<italic>n</italic> = 88)</th></tr></thead><tbody><tr><td>None</td><td align="char" char="(">20.9% (54)</td><td align="char" char="(">5.4% (4)</td><td align="char" char="(">13.5% (13)</td><td align="char" char="(">42.0% (37)</td></tr><tr><td>Direct</td><td align="char" char="(">46.9% (121)</td><td align="char" char="(">70.3% (52)</td><td align="char" char="(">52.1% (45)</td><td align="char" char="(">21.5% (15)</td></tr><tr><td>Consultation</td><td align="char" char="(">31.8% (82)</td><td align="char" char="(">24.3% (18)</td><td align="char" char="(">33.3% (32)</td><td align="char" char="(">36.4% (32)</td></tr><tr><td>Direct/Consultation</td><td align="char" char="(">5.0% (13)</td><td align="char" char="(">4.1% (3)</td><td align="char" char="(">6.3% (6)</td><td align="char" char="(">4.5% (4)</td></tr><tr><td>Total</td><td align="char" char="(">100% (258)</td><td align="char" char="(">100% (74)</td><td align="char" char="(">100% (96)</td><td align="char" char="(">100% (88)</td></tr><tr><td><italic>Level of Intensity of Direct</italic></td><td /><td /><td /><td /></tr><tr><td>Low</td><td align="char" char="(">25.2% (65)</td><td align="char" char="(">37.8% (28)</td><td align="char" char="(">47.9% (46)</td><td align="char" char="(">13.6% (12)</td></tr><tr><td>Low-Medium</td><td align="char" char="(">7.8% (20)</td><td align="char" char="(">14.9% (11)</td><td align="char" char="(">26.0% (25)</td><td align="char" char="(">2.3% (2)</td></tr><tr><td>Medium</td><td align="char" char="(">3.9% (10</td><td align="char" char="(">8.1% (6)</td><td align="char" char="(">7.3% (7)</td><td align="char" char="(">0% (0)</td></tr><tr><td>High</td><td align="char" char="(">10.2 (26)</td><td align="char" char="(">9.5% (7)</td><td align="char" char="(">4.2% (4)</td><td align="char" char="(">5.7% (5)</td></tr><tr><td>Total with Direct Service</td><td align="char" char="(">46.9% (121)</td><td align="char" char="(">70.3% (52)</td><td align="char" char="(">14.6% (14)</td><td align="char" char="(">21.5% (19)</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note.</emph> Weekly minutes, Low = 1.1–35; Low-medium = 40–54; Medium = 60–70; High = 75+.</p> <hd id="AN0192372879-16">IDEA Disability Category and Speech-Language Pathology as a Related Service</hd> <p>As displayed in Table 2, speech-language pathology was designated with varying frequency and duration across IDEA disability categories. IEPs for students in the autism category most frequently designated speech-language pathology as a related service among the IDEA categories, and the duration (i.e., number of minutes per session) was highest for this group as well. Further, the IEPs of students in the autism category most frequently designated speech-language pathology as a direct service and least frequently designated speech-language pathology as a consultation service compared to students in other IDEA disability categories. The disability category with the next highest frequency of speech-language pathology as a related service—both direct and indirect—was multiple disabilities.</p> <p>Table 2. Type, Proportion and (Frequency) of Speech-Language Service Delivery Assigned in IEPs Across IDEA Disability Categories.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="center" /><col align="center" /><col align="center" /><col align="center" /><col align="center" /></colgroup><thead><tr><th align="left">Service Delivery</th><th align="center">All (<italic>n</italic> = 258)</th><th align="center">Autism (<italic>n</italic> = 92)</th><th align="center">Intellectual Disability (<italic>n</italic> = 84)</th><th align="center">Multiple Disabilities (<italic>n</italic> = 57)</th><th align="center">Other (<italic>n</italic> = 25)</th></tr></thead><tbody><tr><td>None</td><td align="char" char="(">20.9% (54)</td><td align="char" char="(">16.3% (15)</td><td align="char" char="(">26.2% (22)</td><td align="char" char="(">17.5% (10)</td><td align="char" char="(">28.0% (7)</td></tr><tr><td>Direct</td><td align="char" char="(">42.2% (109)</td><td align="char" char="(">55.4% (51)</td><td align="char" char="(">36.9% (31)</td><td align="char" char="(">36.8% (21)</td><td align="char" char="(">24.0% (6)</td></tr><tr><td>Consultation</td><td align="char" char="(">31.8% (82)</td><td align="char" char="(">26.1% (24)</td><td align="char" char="(">35.7% (30)</td><td align="char" char="(">29.8% (17)</td><td align="char" char="(">44.0% (11)</td></tr><tr><td>Dir/Con</td><td align="char" char="(">5.0% (13)</td><td align="char" char="(">2.2% (2)</td><td align="char" char="(">1.2% (1)</td><td align="char" char="(">15.8% (9)</td><td align="char" char="(">4.0% (1)</td></tr><tr><td>Total</td><td align="char" char="(">100% (258)</td><td align="char" char="(">100% (92)</td><td align="char" char="(">100% (84)</td><td align="char" char="(">100% (57)</td><td align="char" char="(">100% (25)</td></tr><tr><td colspan="6"><italic>Level of Intensity of Direct Weekly Minutes</italic></td></tr><tr><td>Low</td><td align="char" char="(">25.2% (65)</td><td align="char" char="(">27.2% (25)</td><td align="char" char="(">25.0% (21)</td><td align="char" char="(">28.1% (16)</td><td align="char" char="(">12.0% (2)</td></tr><tr><td>Low-Medium</td><td align="char" char="(">7.8% (20)</td><td align="char" char="(">8.7% (8)</td><td align="char" char="(">7.1% (6)</td><td align="char" char="(">13.0% (5)</td><td align="char" char="(">4.0% (1)</td></tr><tr><td>Medium</td><td align="char" char="(">3.9% (10)</td><td align="char" char="(">8.7% (8)</td><td align="char" char="(">1.2% (1)</td><td align="char" char="(">0% (0)</td><td align="char" char="(">4.0% (1)</td></tr><tr><td>High</td><td align="char" char="(">10.1% (26)</td><td align="char" char="(">13.0% (12)</td><td align="char" char="(">4.8% (4)</td><td align="char" char="(">8.7% (8)</td><td align="char" char="(">8.0% (2)</td></tr><tr><td>Total with Direct Service</td><td align="char" char="(">46.9% (121)</td><td align="char" char="(">57.6% (53)</td><td align="char" char="(">38.1% (32)</td><td align="char" char="(">50.9% (29)</td><td align="char" char="(">24.0% (6)</td></tr></tbody></table> </ephtml> </p> <p>2 <emph>Note</emph>. Dir/Con = Direct and Consultation; Weekly minutes, Low = 1.1–35; Low-medium = 40–54; Medium = 60–70; High = 75+.</p> <p>The IEPs of the participants receiving services in the multiple disabilities and intellectual disability categories designated direct speech-language services more frequently than consultation, although the difference was much smaller than it was for the IEPs of students in the autism category. Most IEPs of the students in the "Other" disability categories (e.g., deaf/blind, orthopedic impairment) indicated speech-language services (72%, <emph>n</emph> = 18). These IEPs infrequently designated direct services, with consultation services more frequently designated than their peers receiving services in the remaining disability categories.</p> <hd id="AN0192372879-17">Symbolic Communication Level and Speech-Language Pathology as a Related Service</hd> <p>As displayed in Table 2, the IEPs of students communicating at a symbolic level had speech-language pathology less frequently designated as a related service. Across symbolic levels, when speech-language pathology was designated as a related service, it was more often designated to be direct than indirect. Unfortunately, more than 20% (<emph>n</emph> = 16) of the IEPs of students who did not use symbolic communication failed to designate speech-language pathology as a related service. In fact, very few students at the pre-symbolic level had direct speech-language pathology designated as a related service on their IEPs. Across all levels of communication, when speech-language pathology was designated as a related service, it was most often provided for 35 min or fewer each week Table 3.</p> <p>Table 3. Frequency and Proportion of Speech-Language Service Delivery and Intensity Assigned in IEPs Between Symbolic Communication Levels (n = 208).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="center" /><col align="center" /><col align="center" /><col align="center" /></colgroup><thead><tr><th align="left" rowspan="2">Service Delivery</th><th align="center" colspan="2">Pre-Symbolic Level (<italic>n</italic> = 78)</th><th align="center" colspan="2">Symbolic Level (<italic>n</italic> = 130)</th></tr><tr><th align="center">Frequency</th><th align="center">Proportion</th><th align="center">Frequency</th><th align="center">Proportion</th></tr></thead><tbody><tr><td>None</td><td align="char" char=".">16</td><td align="char" char=".">20.5%</td><td align="char" char=".">30</td><td align="char" char=".">23.1%</td></tr><tr><td>Direct</td><td align="char" char=".">36</td><td align="char" char=".">46.2%</td><td align="char" char=".">49</td><td align="char" char=".">37.1%</td></tr><tr><td>Consultation</td><td align="char" char=".">25</td><td align="char" char=".">32.1%</td><td align="char" char=".">43</td><td align="char" char=".">33.1%</td></tr><tr><td>Direct/Consultation</td><td align="char" char=".">1</td><td align="char" char=".">1.3%</td><td align="char" char=".">8</td><td align="char" char=".">6.2%</td></tr><tr><td>Total</td><td align="char" char=".">78</td><td align="center">100%</td><td align="char" char=".">130</td><td align="center">100%</td></tr><tr><td colspan="2"><italic>Level of Intensity of Direct</italic></td><td /><td /><td /></tr><tr><td>Low</td><td align="char" char=".">27</td><td align="char" char=".">34.6%</td><td align="char" char=".">23</td><td align="char" char=".">17.7%</td></tr><tr><td>Low-Medium</td><td align="char" char=".">6</td><td align="char" char=".">7.7%</td><td align="char" char=".">12</td><td align="char" char=".">9.2%</td></tr><tr><td>Medium</td><td align="char" char=".">0</td><td align="char" char=".">0%</td><td align="char" char=".">3</td><td align="char" char=".">2.3%</td></tr><tr><td>High</td><td align="char" char=".">3</td><td align="char" char=".">3.8%</td><td align="char" char=".">19</td><td align="char" char=".">14.6%</td></tr><tr><td>Total with Direct Service</td><td align="char" char=".">36</td><td align="char" char=".">46.1%</td><td align="char" char=".">57</td><td align="char" char=".">43.8%</td></tr></tbody></table> </ephtml> </p> <p>3 <emph>Note</emph>. Weekly minutes, Low = 1.1–35; Low-medium = 40–54; Medium = 60–70; High = 75+.</p> <hd id="AN0192372879-18">Other Student Characteristics and Speech-Language Pathology as a Related Service</hd> <p>As displayed in Table 4, multinomial logistic regression revealed no significant relationships between the type of speech-language services designated on the IEP and grade band, IDEA disability categories, and symbolic communication level. However, both communication level and grade band did predict the intensity of speech-language services designated on the IEPs. For these multinomial logistic regressions, the reference categories were: (a) the "Other" disability category (e.g., orthopedic impairment, other health impairment), (b) the high school grade band, and (c) high-level intensity of service delivery (i.e., great than 70 min per week). The model fit was a significant improvement over the null model with large effect sizes, <emph>X</emph><sups>2</sups>(<reflink idref="bib32" id="ref52">32</reflink>) = 255.752, <emph>p</emph> <.0001, <emph>R</emph><sups>2</sups> =.706 (Cox & Snell), <emph>R</emph><sups>2</sups> =.735 (Nagelkerke). Given that the Pearson Chi-Square did not suggest that the model fit well—<emph>X</emph><sups>2</sups>(<reflink idref="bib68" id="ref53">68</reflink>) = 92.476, <emph>p</emph> =.026—and the Deviance Chi-square indicated the model did fit well—<emph>X</emph><sups>2</sups>(<reflink idref="bib68" id="ref54">68</reflink>) = 51.985, <emph>p</emph> =.925—dispersion parameters were calculated (<emph>F</emph> Pearson = 1.35; <emph>F</emph> Deviance = 0.76). This helped to rule out the possibility of overdispersion, and neither result suggests that the data is over-dispersed ([<reflink idref="bib27" id="ref55">27</reflink>]). A summary of these results is provided in Table 4.</p> <p>Table 4. Multinomial Logistic Regression Results of the Type Speech-Language Services Across Grade Band, IDEA Disability Categories, and Symbolic Communication Level.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="(" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" /><th align="left" /><th align="left" /><th align="center" colspan="2">95% CI for Exp. (<italic>B</italic>)</th></tr><tr><th align="center" /><th align="center"><italic>B</italic> (<italic>SE</italic>)</th><th align="center"><italic>OR</italic></th><th align="center">Lower</th><th align="center">Upper</th></tr></thead><tbody><tr><td colspan="2"><italic>No Speech-Language Services</italic></td><td /><td /><td /></tr><tr><td>Pre-symbolic</td><td>12.520 (38.87)</td><td>273685.48</td><td>2.243E-28</td><td>3.340E + 38</td></tr><tr><td>Symbolic</td><td>9.908 (38.84)</td><td>20090.73</td><td>1.729E-29</td><td>2.335E + 37</td></tr><tr><td>Autism</td><td>–7.665 (38.85)</td><td>0.000</td><td>4.027E-37</td><td>5.466E + 29</td></tr><tr><td>Intellectual Disability</td><td>–6.397 (38.85)</td><td>0.002</td><td>1.415E-36</td><td>1.963E + 30</td></tr><tr><td>Multiple Disabilities</td><td>–9.868 (38.85)</td><td>5.179E-5</td><td>4.452E-38</td><td>6.024E + 28</td></tr><tr><td>Elementary School</td><td>6.343 (27.22)</td><td>568.49</td><td>3.849E-21</td><td>8.97E + 25</td></tr><tr><td>Middle School</td><td>–1.755 (0.89)</td><td>0.173</td><td>0.030</td><td>0.989</td></tr><tr><td colspan="2"><italic>Direct Speech-Language Services</italic></td><td /><td /><td /></tr><tr><td>Pre-symbolic</td><td>10.747 (38.87)</td><td>46472.94</td><td>3.801E-29</td><td>5.682E + 37</td></tr><tr><td>Symbolic</td><td>7.889 (38.85)</td><td>2668.76</td><td>2.290E-30</td><td>3.111E + 36</td></tr><tr><td>Autism</td><td>–5.839 (38.85)</td><td>0.00</td><td>2.499E-36</td><td>3.396E + 30</td></tr><tr><td>Intellectual Disability</td><td>–5.484 (38.85)</td><td>0.00</td><td>3.519E-39</td><td>4.899E + 30</td></tr><tr><td>Multiple Disabilities</td><td>–8.945 (38.85)</td><td>0.00</td><td>1.120E-37</td><td>1.51E + 29</td></tr><tr><td>Elementary School</td><td>9.471 (0.12)</td><td>12975.94</td><td>8.836E-20</td><td>1.906E + 27</td></tr><tr><td>Middle School</td><td>–0.021 (0.88)</td><td>0.98</td><td>0.173</td><td>5.546</td></tr><tr><td colspan="3"><italic>Consultation Speech-Language Services</italic></td><td /><td /></tr><tr><td>Pre-symbolic</td><td>12.521 (38.87)</td><td>273971.00</td><td>2.230E-28</td><td>3.337E + 38</td></tr><tr><td>Symbolic</td><td>9.795 (38.85)</td><td>17949.17</td><td>1.547E-29</td><td>3.397E + 26</td></tr><tr><td>Autism</td><td>–7.423 (38.84)</td><td>0.00</td><td>5.141E-37</td><td>6.940E + 29</td></tr><tr><td>Intellectual Disability</td><td>–6.417 (38.85)</td><td>0.00</td><td>1.390E-36</td><td>1.921E + 30</td></tr><tr><td>Multiple Disabilities</td><td>–10.051(38.84)</td><td>4.314E-5</td><td>3.717E-38</td><td>5.007E + 28</td></tr><tr><td>Elementary School</td><td>7.746 (27.22)</td><td>2313.42</td><td>1.575E-20</td><td>3.397E + 26</td></tr><tr><td>Middle School</td><td>3–1.052 (0.87)</td><td>0.35</td><td>0.063</td><td>1.927</td></tr></tbody></table> </ephtml> </p> <hd id="AN0192372879-19">Discussion</hd> <p>The IEPs in this study were developed for school-aged students with ESN and CCN across several U.S. states. As a group, students with ESN and CCN require substantial support to learn language and access the general education curriculum ([<reflink idref="bib10" id="ref56">10</reflink>]). Like more than 90% of students with ESN across the United States ([<reflink idref="bib25" id="ref57">25</reflink>]; [<reflink idref="bib33" id="ref58">33</reflink>]), all the participants in the current study were educated in separate educational settings. Despite these specialized placements, approximately 20% of the IEPs in the current study did not designate speech-language pathology as a related service. This is concerning as the available literature describes students with ESN and CCN as demonstrating significant expressive and receptive language impairments impacting vocabulary, grammar, syntax, and difficulty using abstract language, as well as difficulty understanding complex language ([<reflink idref="bib1" id="ref59">1</reflink>]; [<reflink idref="bib16" id="ref60">16</reflink>]; [<reflink idref="bib19" id="ref61">19</reflink>]; [<reflink idref="bib25" id="ref62">25</reflink>]). It is especially concerning for the students who did not use symbolic communication.</p> <p>Approximately one-third of the IEPs in the sample were created for students who communicated at the pre-symbolic communication level. Given that prior research suggests that approximately one-third of all students with ESN have no formal symbolic means of communication ([<reflink idref="bib25" id="ref63">25</reflink>]; [<reflink idref="bib32" id="ref64">32</reflink>]; [<reflink idref="bib33" id="ref65">33</reflink>]; [<reflink idref="bib48" id="ref66">48</reflink>], [<reflink idref="bib47" id="ref67">47</reflink>]); we would have expected this to be higher. A potential explanation for this difference is the fact that the current investigation used the Communication Matrix ([<reflink idref="bib45" id="ref68">45</reflink>]) to determine whether students were symbolic or pre-symbolic communicators rather than the teacher reports that were used in prior research. Alternatively, it is possible that pre-symbolic communicators were underrepresented in the larger studies for which these IEPs were originally collected. Perhaps the same reasons that lead teams to decide that students with ESN and CCN cannot benefit from speech-language pathology as a related service lead them to decide that they cannot benefit from participation in research targeting literacy and communication.</p> <p>Given that AAC is instrumental for students with CCN, it was expected that more of the IEPs would specify the use of AAC in the accommodations, AT devices and services, statements of present levels of academic achievement and functional performance, or goals. Fewer than half of the IEPs reflected AAC use. Results of the Communication Matrix revealed a group of nearly 150 students who were unable to combine symbols to communicate. These same students had no record of AAC access or use reported on their IEP. Of equal concern is the fact that almost a quarter of the IEPs for students communicating at the pre-symbolic level indicated that AT, which includes aided AAC, was <emph>not</emph> required. Neglecting a need for AT is concerning but specifically considering AT and then deciding that a student in Grade 3–12 with no formal means of symbolic communication does not require AT is even more disturbing. Clearly there is a need for more of the kinds of supports and services that the U.S. DOE described in its guidance regarding AT devices and services for students with disabilities (https://sites.ed.gov/idea/idea-files/at-guidance/).</p> <p>Although slightly more than half of the IEPs of students communicating at the symbolic level indicated that access to AT for communication was required, this is also lower than would be expected, given that the inclusion criteria for the study Table 5. Students were recruited because they were not able to use speech to meet their communication needs and could use no more than single symbols when communicating for a range of purposes. Yet, there is no evidence that they had access to AAC to support them when needed. It is possible that these students had access to AAC, but it was not indicated on their IEPs. It is also possible that the teams made the decision to exclude AAC because of the commonly held misunderstanding that AAC use can interfere with the development of spoken language ([<reflink idref="bib39" id="ref69">39</reflink>]). Whatever the reason, there is a clear need to provide information regarding the importance of AAC and speech-language pathology as a related service to the IEP teams of students with ESN and CCN.</p> <p>Table 5. Multinomial Logistic Regression of Weekly Direct Speech-Language Minutes in IEPs Across Symbolic Communication Level, IDEA Disability Categories, and Grade Band (n = 258).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" /><th align="left" /><th align="left" /><th colspan="2">95% CI for Exp. (<italic>B</italic>)</th></tr><tr><th align="left" /><th align="center"><italic>B</italic> (<italic>SE</italic>)</th><th align="center"><italic>OR</italic></th><th>Lower</th><th>Upper</th></tr></thead><tbody><tr><td colspan="5"><italic>No Weekly Minutes (0 min.)</italic></td></tr><tr><td>Pre-symbolic</td><td>5.579 (1.38)*</td><td>264.91</td><td>17.527</td><td>1.672E + 66</td></tr><tr><td>Symbolic</td><td>3.741 (1.17)*</td><td>42.30</td><td>4.282</td><td>417.816</td></tr><tr><td>Autism</td><td>−1.873 (1.13)</td><td>0.15</td><td>0.017</td><td>1.401</td></tr><tr><td>Intellectual Disability</td><td>−0.537 (1.18)</td><td>0.58</td><td>0.058</td><td>5.871</td></tr><tr><td>Multiple Disabilities</td><td>−2.502 (1.16)</td><td>0.03</td><td>0.008</td><td>0.799</td></tr><tr><td>Elementary School</td><td>−1.330 (0.73)</td><td>0.26</td><td>0.063</td><td>1.108</td></tr><tr><td>Middle School</td><td>−2.502 (1.16)*</td><td>0.08</td><td>0.008</td><td>0.799</td></tr><tr><td colspan="5"><italic>Low Minutes per Week (.1–35 min.)</italic></td></tr><tr><td>Pre-symbolic</td><td>3.201(4.52)*</td><td>24.57</td><td>1.285</td><td>469.619</td></tr><tr><td>Symbolic</td><td>0.758 (0.33)</td><td>2.13</td><td>0.160</td><td>28.426</td></tr><tr><td>Autism</td><td>–0.337 (0.07)</td><td>0.79</td><td>0.060</td><td>8.488</td></tr><tr><td>Intellectual Disability</td><td>0.487 (0.14)</td><td>1.63</td><td>0.124</td><td>21.400</td></tr><tr><td>Multiple Disabilities</td><td>–1.602 (0.98)</td><td>0.841</td><td>0.123</td><td>5.748</td></tr><tr><td>Elementary School</td><td>0.432 (0.78)</td><td>1.54</td><td>0.332</td><td>7.127</td></tr><tr><td>Middle School</td><td>–0.780 (1.25)</td><td>0.20</td><td>0.015</td><td>2.623</td></tr><tr><td colspan="5"><italic>Low-Medium Minutes per Week (40–54 min.)</italic></td></tr><tr><td>Pre-symbolic</td><td>–7.111 (0.03)</td><td>0.00</td><td>1.074E-41</td><td>6.201E + 34</td></tr><tr><td>Symbolic</td><td>–8.467 (0.04)</td><td>0.00</td><td>2.809E-42</td><td>1.573E + 34</td></tr><tr><td>Autism</td><td>7.520 (0.29)</td><td>1844.49</td><td>2.489E-35</td><td>1.367E + 41</td></tr><tr><td>Intellectual Disability</td><td>8.213 (0.34)</td><td>3689.25</td><td>4.962E-35</td><td>2.743E + 41</td></tr><tr><td>Multiple Disabilities</td><td>6.678 (0.23)</td><td>794.82</td><td>1.070E-35</td><td>5.905E + 40</td></tr><tr><td>Elementary School</td><td>1.683 (2.73)</td><td>5.38</td><td>0.731</td><td>39.607</td></tr><tr><td>Middle School</td><td>–0.211 (0.04)</td><td>0.81</td><td>0.112</td><td>5.870</td></tr><tr><td colspan="5"><italic>Medium Minutes per Week (60–70 min.)</italic></td></tr><tr><td>Pre-symbolic</td><td>–10.708 (0.12)</td><td>2.237E-5</td><td>1.145E-31</td><td>4.371E + 21</td></tr><tr><td>Symbolic</td><td>–6.200 (0.12)</td><td>2.237E-5</td><td>1.145E-31</td><td>4.371E + 21</td></tr><tr><td>Autism</td><td>–1.188(0.53)</td><td>0.30</td><td>0.013</td><td>7.396</td></tr><tr><td>Intellectual Disability</td><td>–7.286 (20.434)</td><td>0.00</td><td>2.767E-21</td><td>1.695E + 14</td></tr><tr><td>Multiple Disabilities</td><td>–7.847 (0.14)</td><td>0.30</td><td>0.013</td><td>7.396</td></tr><tr><td>Elementary School</td><td>6.726 (0.06)</td><td>834.05</td><td>1.083E-19</td><td>6.425E + 24</td></tr><tr><td>Middle School</td><td>6.155 (0.05)</td><td>471.19</td><td>6.292E-20</td><td>3.529E + 24</td></tr></tbody></table> </ephtml> </p> <p>4 <emph>*</emph><emph>=</emph><emph>p</emph> <.05.</p> <hd id="AN0192372879-20">Frequency and Duration of Speech-Language Pathology Services</hd> <p>Many of the IEPs in the current study designated indirect rather than direct speech-language pathology as a related service. On average, these indirect services were designated at a rate of 3–4 monthly sessions during the IEP period. This does not reflect the guidance offered to school-based SLPs by ASHA. In fact, ASHA (2017) specifies that direct services from an SLP are required to teach skills, while indirect, consultation services are used to support the generalization of skills that have already been acquired. The inclusion criteria for the current study confirm that the students whose IEPs were included in the current study have not acquired all the speech and language skills they require to benefit from their educational program, yet they received no intervention intended to teach new skills delivered by a SLP.</p> <p>The problem is even greater for the students whose IEPs did not indicate any speech-language pathology services. Speech and language interventions should be contextually based, educationally relevant, and collaboratively delivered by members of the IEP team ([<reflink idref="bib49" id="ref70">49</reflink>]). Educators need experts like SLPs to help them learn to successfully implement communication instruction with students with ESN/CCN ([<reflink idref="bib12" id="ref71">12</reflink>]; [<reflink idref="bib13" id="ref72">13</reflink>]). Students with ESN/CCN cannot get all the support they require when they do not receive speech-language pathology as a related service, and it is unlikely they will get enough when the services they require are indirect and infrequent.</p> <p>The findings regarding decreasing services across the grade bands and low intensity of services for students communicating pre-symbolically corroborate other studies that have previously documented lower-intensity services for students with more significant disabilities ([<reflink idref="bib14" id="ref73">14</reflink>]). However, they contradict direct reports from SLPs that suggest that the national average is 60 min per week of direct services (ASHA, 2018; [<reflink idref="bib15" id="ref74">15</reflink>]). The results do suggest that teams may be reducing or discontinuing services for students in response to guidance that supports these decisions when students do not make measurable progress over time (ASHA, n.d.d). Further research is needed to understand the contradiction and the reasons why students are less likely to receive direct speech-language pathology services as they age, even when they continue to demonstrate only pre-symbolic or early symbolic communication skills. Older students with ESN and CCN can make meaningful progress in their language and communication skills ([<reflink idref="bib44" id="ref75">44</reflink>]). In fact, progress is possible into adult years ([<reflink idref="bib11" id="ref76">11</reflink>]; [<reflink idref="bib31" id="ref77">31</reflink>]). Nevertheless, the findings of this study confirm prior research suggesting that practices and educational priorities shift as students age, and that age appears to influence IEP development ([<reflink idref="bib23" id="ref78">23</reflink>]; [<reflink idref="bib35" id="ref79">35</reflink>]). The findings also supports previous investigations identifying problematic IEP quality for this student population (Kurth et al., 2022).</p> <p>Although ASHA and several states have issued statements against the use of cognitive referencing (ASHA, n.d.b; [<reflink idref="bib4" id="ref80">4</reflink>]), guidance continues to emphasize a lack of measurable progress as a rationale for discontinuing services. The results of this study suggest that one or both play a role in the decisions IEP teams make regarding the designation of speech-language pathology as a related service, as 20% of IEPs for students who communicate pre-symbolically did not designate any form of speech-language pathology services, and approximately 32% of IEPs of all students designated only indirect services. Future studies might explore the specific rationale teams apply when they make decisions about the delivery of speech-language pathology as a related service.</p> <hd id="AN0192372879-21">Implications</hd> <p>The results of this study have numerous implications. First, the study provides disconcerting evidence that students with ESN and CCN are not receiving related services from SLPs at a rate and intensity level that matches their needs. Although there is no current research that would offer guidance regarding minimum levels of frequency and duration required, the combination of ESN and CNN suggests that all these students require at least some direct speech-language intervention to benefit from their education. Furthermore, it seems they would require at least the 60 min per week that SLPs report as their average (ASHA, 2018). Of course, if teams have not made a shift to IEPs designed to support progress in the general education curriculum, they may not see the need to support communication. However, success in making progress in academic instruction aligned with the general education curriculum requires ongoing attention to communication ([<reflink idref="bib12" id="ref81">12</reflink>]).</p> <p>The number of IEPs (<emph>n</emph> = 148) that did not reference access to personal AAC for students who are unable to use speech to meet their communication needs is also alarming. People with ESN and CCN can all benefit from AAC in some form ([<reflink idref="bib12" id="ref82">12</reflink>]; NJC, 2002). Although SLPs often report that they feel unprepared to deliver AAC services ([<reflink idref="bib28" id="ref83">28</reflink>]), they should at least be knowledgeable regarding the benefits of AAC given that it is part of their scope of practice (ASHA, n.d.a). However, SLPs would only be present at an IEP meeting if speech-language pathology was being considered as a related service. If SLPs are not participating in IEP meetings for all students with ESN and CCN, teams may not have access to this critical information regarding the potential of AAC. One solution would be to require an SLP to be part of the IEP team for all students with ESN and CCN, whether or not their services are designated on the IEP.</p> <p>Whether the lower than expected rates of speech-language pathology services are the result of cognitive referencing, discontinuation rules based on evidence of measurable progress, or something else, it is important for all IEP team members to reflect on their personal biases. It is also important for them to understand the impact of state and local guidelines that could be perpetuating reduced access to speech-language pathology as a related service for students with ESN and CCN. More so, there is a need for administrators and funding mechanisms to consider the difference between caseload and workload for SLPs to ensure they have the time needed to provide the necessary interventions students with ESN/CCN require to make measurable progress. Use of a workload framework would consider the additional support needed to: (a) evaluate and obtain the necessary funding for an AAC systems; (b) support the programming and maintenance of the AAC system; (c) provide the intensity of direct interventions the students require to acquire new skills; and (d) train and support classroom staff in promoting communication and language skills outside of direct intervention with the SLP. Consistent with the recommendations of [<reflink idref="bib54" id="ref84">54</reflink>], this work could help teams learn to use the IEP process and the services it ensures to maximize outcomes for students with ESN and CCN.</p> <hd id="AN0192372879-22">Limitations and Future Directions</hd> <p>A strength of this study was the large sample of 258 IEPs from students with a combination of ESN and CCN. This is very unusual with this low-incidence population. Unfortunately, the procedures did not result in an equal distribution of students across any of the grouping variables; this was especially true for the groups of students using pre-symbolic and symbolic forms of communication and IDEA category. Furthermore, the design of the study failed to account for the fact that some IEPs came from the same teacher, school, school system, or state. Each would formally and informally impact the development of IEPs. Unfortunately, the unequal distributions and inconsistency in IEP format across states precluded multi-level modeling that could have addressed the nested nature of the results.</p> <p>The fact that the IEPs were selected from two larger studies, including one that purposefully recruited students with ESN with CCN, presents further limitations because it resulted in a sample that is not representative of the population of students with ESN. The sample also failed to include any students who spent more than 60% of the school day in a general education setting. Though more than 90% of students with ESN are educated in separate settings ([<reflink idref="bib18" id="ref85">18</reflink>]; [<reflink idref="bib25" id="ref86">25</reflink>]), it is important to understand the relationship between placement and all aspects of education, including the content of student IEPs and their access to related services. Unfortunately, the design of the current study precluded this.</p> <hd id="AN0192372879-23">Future Directions in Research</hd> <p>Future research should investigate the impact of SLP workloads, training, and experience on the decisions they make when they are included in IEP meetings and decisions regarding the designation of services. Further, future research should investigate the ways teams make decisions about the inclusion/exclusion of speech-language pathology as a related service, and the decision to provide AT devices and services. In particular, valuable insight could be gained by examining the relationship between characteristics of school districts and the speech-language services provided to this population of students. The current study suggests that many students who would consistently be expected to require these services to benefit from their education are not receiving them. Understanding why they are not receiving these services is critical if the problem is to be addressed effectively in the future.</p> <p>Beyond understanding why teams do and do not include these services on IEPs, research is needed to help inform decisions regarding the appropriate frequency and duration of services. In the absence of this information, teams are deciding that minimal levels of direct services, infrequent indirect services, or no services at all are appropriate. Given the profiles of students with ESN and CCN ([<reflink idref="bib18" id="ref87">18</reflink>]; [<reflink idref="bib25" id="ref88">25</reflink>]), these decisions are unlikely to support meaningful access to the general education curriculum and progress over time.</p> <hd id="AN0192372879-24">Conclusion</hd> <p>In the United States, IEPs are largely regarded as the keystone of special education (U.S. DOE, 2018). They are central to documenting each student's educational needs, describing the supports, technologies, and services they need, and detailing goals that will help ensure meaningful progress from year to year (U.S. DOE, 2024). Given the language and communication profiles of students with ESN and CCN, it is reasonable to assume that they would receive high levels of speech-language pathology as a related service. It is also reasonable to expect that they would receive AT devices in the form of AAC and AT services to support them in learning and using their AAC devices. Yet, the current study suggests that many students with ESN and CCN are not receiving speech-language pathology as a related service, and many others are not receiving it as the direct services they likely require to learn new skills (ASHA, 2017). When the IEPs did include speech-language pathology as a related service with direct services to the student, they were offered at a level that appears to be below the levels reported by school-based SLPs for the general population of students with disabilities they serve (ASHA, 2018). 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D., Ireland M. C., Murphy K. A., Sparks Lancaster H. (2024). Go beyond compliance: Use individualized education programs to answer strategic questions and improve programs. Language, Speech, and Hearing Services in Schools, 55(2), 249–258. https://doi.org/10.1044/2023_LSHSS-23-00084</bibtext> </blist> </ref> <ref id="AN0192372879-26"> <title> Footnotes </title> <blist> <bibtext> The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> This research was approved by the Human Subjects Review Board at the University of North Carolina at Chapel Hill and, where required, the local education agencies where the work was conducted. Written consent was secured from the caregivers of all participants.</bibtext> </blist> <blist> <bibtext> The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the U.S. Department of Education, Office of Special Education Programs, (H327S140017, H327S160005). The views expressed herein do not necessailty represent the positions or policies of the Department of Education. No official endorsement by the U.S. Department of Education of any product, commodity, service, or enterprise mentioned in this publication is intended or should be inferred.</bibtext> </blist> <blist> <bibtext> Kathryn E. Dorney https://orcid.org/0000-0002-2103-9970</bibtext> </blist> <blist> <bibtext> Project Core (H327S140017; <ulink href="http://project-core.com">http://project-core.com</ulink>) and Tar Heel Shared Reader (H327S160005; <ulink href="http://sharedreader.org">http://sharedreader.org</ulink>) are Stepping Up Technology Implementation projects funded by the U.S. Department of Education, Office of Special Education Programs.</bibtext> </blist> </ref> <aug> <p>By Kathryn E. Dorney; Nancy A. Quick and Karen A. Erickson</p> <p>Reported by Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib30" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib25" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib20" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib21" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib41" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib18" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib33" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib50" firstref="ref10"></nolink> <nolink nlid="nl9" bibid="bib26" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib32" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib34" firstref="ref15"></nolink> <nolink nlid="nl12" bibid="bib48" firstref="ref16"></nolink> <nolink nlid="nl13" bibid="bib47" firstref="ref17"></nolink> <nolink nlid="nl14" bibid="bib51" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib52" firstref="ref23"></nolink> <nolink nlid="nl16" bibid="bib53" firstref="ref26"></nolink> <nolink nlid="nl17" bibid="bib17" firstref="ref27"></nolink> <nolink nlid="nl18" bibid="bib22" firstref="ref28"></nolink> <nolink nlid="nl19" bibid="bib36" firstref="ref29"></nolink> <nolink nlid="nl20" bibid="bib37" firstref="ref30"></nolink> <nolink nlid="nl21" bibid="bib29" firstref="ref31"></nolink> <nolink nlid="nl22" bibid="bib38" firstref="ref32"></nolink> <nolink nlid="nl23" bibid="bib46" firstref="ref33"></nolink> <nolink nlid="nl24" bibid="bib35" firstref="ref35"></nolink> <nolink nlid="nl25" bibid="bib14" firstref="ref37"></nolink> <nolink nlid="nl26" bibid="bib43" firstref="ref38"></nolink> <nolink nlid="nl27" bibid="bib40" firstref="ref39"></nolink> <nolink nlid="nl28" bibid="bib24" firstref="ref41"></nolink> <nolink nlid="nl29" bibid="bib42" firstref="ref43"></nolink> <nolink nlid="nl30" bibid="bib45" firstref="ref46"></nolink> <nolink nlid="nl31" bibid="bib68" firstref="ref53"></nolink> <nolink nlid="nl32" bibid="bib27" firstref="ref55"></nolink> <nolink nlid="nl33" bibid="bib10" firstref="ref56"></nolink> <nolink nlid="nl34" bibid="bib16" firstref="ref60"></nolink> <nolink nlid="nl35" bibid="bib19" firstref="ref61"></nolink> <nolink nlid="nl36" bibid="bib39" firstref="ref69"></nolink> <nolink nlid="nl37" bibid="bib49" firstref="ref70"></nolink> <nolink nlid="nl38" bibid="bib12" firstref="ref71"></nolink> <nolink nlid="nl39" bibid="bib13" firstref="ref72"></nolink> <nolink nlid="nl40" bibid="bib15" firstref="ref74"></nolink> <nolink nlid="nl41" bibid="bib44" firstref="ref75"></nolink> <nolink nlid="nl42" bibid="bib11" firstref="ref76"></nolink> <nolink nlid="nl43" bibid="bib31" firstref="ref77"></nolink> <nolink nlid="nl44" bibid="bib23" firstref="ref78"></nolink> <nolink nlid="nl45" bibid="bib28" firstref="ref83"></nolink> <nolink nlid="nl46" bibid="bib54" firstref="ref84"></nolink>
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Speech-Language Services in IEPs of Students with Extensive Support and Complex Communication Needs
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Kathryn+E%2E+Dorney%22">Kathryn E. Dorney</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-2103-9970">0000-0002-2103-9970</externalLink>)<br /><searchLink fieldCode="AR" term="%22Nancy+A%2E+Quick%22">Nancy A. Quick</searchLink><br /><searchLink fieldCode="AR" term="%22Karen+A%2E+Erickson%22">Karen A. Erickson</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Exceptional+Children%22"><i>Exceptional Children</i></searchLink>. 2026 92(3):305-321.
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  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 17
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2026
– Name: SourceSuprt
  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: Office of Special Education Programs (OSEP) (ED/OSERS)
– Name: NumberContract
  Label: Contract Number
  Group: NumCntrct
  Data: H327S140017<br />H327S160005
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink><br /><searchLink fieldCode="EL" term="%22Junior+High+Schools%22">Junior High Schools</searchLink><br /><searchLink fieldCode="EL" term="%22Middle+Schools%22">Middle Schools</searchLink><br /><searchLink fieldCode="EL" term="%22Secondary+Education%22">Secondary Education</searchLink><br /><searchLink fieldCode="EL" term="%22High+Schools%22">High Schools</searchLink><br /><searchLink fieldCode="EL" term="%22Elementary+Secondary+Education%22">Elementary Secondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Individualized+Education+Programs%22">Individualized Education Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Speech+Language+Pathology%22">Speech Language Pathology</searchLink><br /><searchLink fieldCode="DE" term="%22Multiple+Disabilities%22">Multiple Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Students+with+Disabilities%22">Students with Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Elementary+School+Students%22">Elementary School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Middle+School+Students%22">Middle School Students</searchLink><br /><searchLink fieldCode="DE" term="%22High+School+Students%22">High School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Grade+Level+Differences%22">Grade Level Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Intellectual+Disability%22">Intellectual Disability</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22North+Carolina%22">North Carolina</searchLink><br /><searchLink fieldCode="DE" term="%22Florida%22">Florida</searchLink><br /><searchLink fieldCode="DE" term="%22Maryland%22">Maryland</searchLink><br /><searchLink fieldCode="DE" term="%22Pennsylvania%22">Pennsylvania</searchLink><br /><searchLink fieldCode="DE" term="%22Virginia%22">Virginia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/00144029251377056
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0014-4029<br />2163-5560
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Students with extensive support needs (ESN) are a group of students with multiple disabilities including significant expressive and receptive language impairments that make it difficult for them to access and participate in the general education curriculum, even with quality instruction and appropriate accommodations. Like all students with disabilities, students with ESN typically require related services to benefit from the special education services they receive. The purpose of this descriptive and parametric statistics study was to examine speech-language services in the IEPs of students with ESN (n = 258) across six U.S. states. Specifically, the type and intensity of speech-language services were examined across grade band, the Individuals With Disabilities Education Improvement Act (2004) disability category, and symbolic communication level (i.e., pre-symbolic, symbolic). The relationship between speech-language services and various demographic variables was analyzed using multinomial logistic regression. While no significant relationship was identified between demographic variables and the type of speech-language services students received, some demographic variables (i.e., communication level, grade band) predicted the intensity of speech-language services. Findings are discussed relative to the literature with implications for practice in schools and future research.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1500247
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1500247
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/00144029251377056
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 17
        StartPage: 305
    Subjects:
      – SubjectFull: Individualized Education Programs
        Type: general
      – SubjectFull: Speech Language Pathology
        Type: general
      – SubjectFull: Multiple Disabilities
        Type: general
      – SubjectFull: Students with Disabilities
        Type: general
      – SubjectFull: Elementary School Students
        Type: general
      – SubjectFull: Middle School Students
        Type: general
      – SubjectFull: High School Students
        Type: general
      – SubjectFull: Grade Level Differences
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Intellectual Disability
        Type: general
      – SubjectFull: North Carolina
        Type: general
      – SubjectFull: Florida
        Type: general
      – SubjectFull: Maryland
        Type: general
      – SubjectFull: Pennsylvania
        Type: general
      – SubjectFull: Virginia
        Type: general
    Titles:
      – TitleFull: Speech-Language Services in IEPs of Students with Extensive Support and Complex Communication Needs
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            NameFull: Kathryn E. Dorney
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            NameFull: Nancy A. Quick
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            NameFull: Karen A. Erickson
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              M: 04
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-print
              Value: 0014-4029
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              Value: 2163-5560
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              Value: 92
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            – TitleFull: Exceptional Children
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