Inclusive Practices for Children and Youths With Communication Disorders

Education Reform and Inclusion

In recent years, the topic of education reform has received national attention (NASDSE, 1994, Goals 2000). With the passage of the Goals 2000: Educate America Act, and the Americans with Disabilities Act, emphasis has been placed on high standards for all students, including those with disabilities. A major component of the education reform movement is the effort to create inclusive education environments for all children (Lipsky & Gartner, 1989; Peck, Odom, & Bricker, 1993; Sailor, 1991; Will, 1986; Wolery & Wilbers, 1994). This trend represents the most recent shift in education practices for children and youths with disabilities.

At present, the profession is moving toward intervention practices that merge speech, language, and hearing services with general education programming. This shift reflects a general but not pervasive movement; current perspectives propose an array of service delivery options based on a commitment to serving all children in the environment that best fits their individual needs. This view holds that although inclusive service delivery is the broad goal, it should not be incompatible with continued recognition of the individual service needs of particular children and families. Consequently, in the delivery of speech, language, and hearing services in schools, the term inclusive practices, rather than inclusion, best describes the services that should be offered.

Inclusive practices are defined as intervention services that are based on the unique and specific needs of the individual, provided in a setting that is least restrictive. Factors that contribute to the determination of the individual's need include the child's age and type of disability, communication goals, academic performance, social skills, family and teacher concerns, and the student's own attitudes about speech, language, or hearing services. Inclusive practices may involve utilizing the natural environment as an intervention context, framing services in a manner that integrates classroom content and curriculum activities, and collaborating with families, educators, and other personnel.

Inclusive practices are well suited to the needs of students with communication disorders. For purposes of this technical report, communication disorders refer to speech, language, and/or hearing impairments that involve one or more of the following communication processes: hearing, language, articulation, voice, and fluency (Boone & Plante, 1993). Students with communication disorders may have a primary disability in the area of communication, as well as communication problems that are secondary to other disabilities. This includes individuals (age birth to 21 years) who are enrolled in early intervention, preschool, elementary, secondary, and postsecondary education. These individuals may demonstrate disabilities ranging from mild to severe/profound that adversely affect their educational performance and their ability to communicate in the important contexts of their lives (e.g., home, school, community, workplace). Also included are students who have limited English proficiency with accompanying speech, language, and/or hearing disabilities.

In addition to students with communication disorders, there is a significant population of children and youths with communication differences, such as limited English proficiency, dialectal differences, or children at risk for academic and/or language-learning difficulties. Although these children are not eligible for intervention services under IDEA, they may benefit indirectly from inclusive practices.

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Historical Perspective

To fully understand the concept of inclusive practices, there is a need to recognize the historical evolution of inclusion. In the 1950s and 1960s, children with disabilities were served in segregated programs. In the late 1960s and the 1970s, mainstreaming programs were implemented. At present, curriculum access and integration of exceptional students into general education is emphasized (Lipp, 1991). The term most often associated with this programming is inclusion: “…a state-of-the-art term that refers to placing children with disabilities in integrated sites, [which] … means bringing support services to the child rather than moving the child to a segregated setting to receive special services” (McCarthy, 1994, p. 1).

Despite the current emphasis on inclusion, the term has not been consistently defined and programs that incorporate the inclusion philosophy are highly variable. For example, some authors advocate a fully inclusive model for all students regardless of severity of disability (Fuchs & Fuchs, 1994; Stainback, Stainback, East, & Sapon-Shevin, 1994). Others support full inclusion models specifically for the mild to moderate population (cf. Fuchs & Fuchs, 1994). Furthermore, the term “inclusion” is not defined in the Individuals with Disabilities Education Act of 1990. Instead, IDEA states that children must be provided a free, appropriate public education (FAPE) in the least restrictive environment (LRE). LRE stipulates that “to the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with nondisabled children” (34 CFR 300.550). This implies the need for an array of environments and services that meet the evolving learning requirements of children with disabilities. The philosophy of inclusive practices meets this need.

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Models of Inclusive Practices

Models of intervention for students with communication disorders have developed and changed over time. Traditionally, service delivery was based on a medical model in which the clinical process was often separated into diagnostic and treatment functions that encouraged isolated, individualized assessment and treatment (Marvin, 1987). Frequently, when clinical speech-language pathology services were rendered, there was insufficient communication between the speech-language pathologist and other instructional staff (Holzhauser-Peters & Husemann, 1988). This came to be known as “pull-out” intervention.

The Regular Education Initiative in special education questioned pull-out programs as the only option for children with learning problems (Will, 1986). The move for change in special education led to parallel change in the manner in which speech, language, and hearing services were conceptualized and provided. This encouraged speech-language pathologists to explore new options for service delivery to children with communication disorders (Dublinske, 1989; Montgomery, 1992; Nelson, 1993; Roller, Rodriguez, Warner, & Lindahl, 1992).

Recent literature presents an array of service delivery models for communication disorders—direct service delivery, classroom-based, community-based, and consultative—that can be used independently or in combination to meet a student's individual needs (cf. Cirrin & Penner, 1995; Holzhauser-Peters & Husemann, 1988; Nelson, 1993; Silliman & Wilkinson, 1991). All models, in keeping with inclusive practice, include collaboration with teachers, support staff, parents, and others as needed. And when appropriate, the natural environment is used as an intervention context, and services integrate classroom content and curriculum/activities with IEP goals (Nelson, 1989; Westby, Watson, & Murphy, 1994).

Examples of the array of service delivery models include:

1. A direct service delivery model (pull-out) involves working with an individual or small groups of students with the goal of establishing particular communication skills. (See example in Westby & Roman, 1995.) Pull-out services may be provided to students individually and in small groups in the treatment room; in some cases services may be provided within the physical space of the classroom. Direct service delivery may be warranted at particular stages in intervention programming and/or for children with specific communication needs. Suggested candidates are those students with articulation, voice or fluency disorders; those with severe speech-language impairment; and those first learning an augmentative communication system who may initially need direct training (Holzhauser-Peters & Husemann, 1988).

2. In classroom-based service delivery, development of communication skills occurs within the classroom context. Teachers and speech-language pathologists may assume a variety of collaborative roles in classroom-based approaches (for examples see Elksnin & Capilouto, 1994; Norris, 1989; Prelock, 1993; Rice & Wilcox, 1995; Secord, 1990; Watson, Layton, Pierce, & Abraham, 1994). Preschool and kindergarten students whose goals involve interaction with peers are some of the students who may benefit. Identified students as well as their “at risk” classmates also may be candidates for this model when speech-language pathologists address language goals that are applicable to entire classrooms.

3. Community-based models address communication goals and objectives in home and community settings (cf. Sailor, Anderson, Halvorsen, Doering, Filler, & Goetz, 1989; Snell & Janney, 1993). Students who may benefit from this model are those with pragmatic problems, those who need to generalize communication skills to new environments, and special education students whose curriculum is community-based (Holzhauser-Peters & Husemann, 1988). Such models are particularly appropriate for addressing functional communication goals in vocational and work study settings.

4. Consultation models are implemented by the speech-language pathologist and parent, teacher, and/or other professionals. In a consultation approach, the speech-language pathologist does not provide direct assistance or instruction to the learner, but consults with others to promote the achievement of the learner's communication goals (cf. ASHA, 1991; Coufal, 1993; Nelson, 1993; Schetz, 1990). This model is suggested when students need to continue the carryover process of new communication skills. Additionally, consultation only with a student's teacher may be appropriate when student goals are so specific that they do not apply to other students in a classroom (Holzhauser-Peters & Husemann, 1988).

These models should be seen as flexible options that may change depending on student needs. The children and youths who are candidates for these models will vary, and the above examples are intended only as suggestions. The speech-language pathologist—in collaboration with parents, the student, teachers, support personnel, and others—will be in the best position to determine the model or combination of models that best meets a student's needs in early intervention through secondary school programs.

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The Individuals with Disabilities Education Act and Inclusive Practices

The Individuals with Disabilities Education Act of 1990 stipulates that children with disabilities must be provided a free, appropriate public education in the least restrictive environment. The IDEA regulations specify that children can receive special education services within an array of alternative placements that include general education classes, special classes, special schools, home instruction, and instruction in hospitals and institutions. The regulations state that general class placement must be the first consideration when determining appropriate placement and that the array of options must make the provision for supplementary services to be provided in conjunction with general class placement (Bateman, 1995; 34 CFR Part 300.551). This array of options includes alternative environments in which speech, language, and hearing services can appropriately be provided, and includes the variety of service delivery models cited previously.

Identification of appropriate intervention goals guides the members of the education team in designing systems of support for individual students. This requires an individualized inquiry into the unique education needs of each child in determining the possible range of aids and supports needed to facilitate the student's placement in the general education environment before a more restrictive option is considered (OSEP Questions and Answers on the Least Restrictive Environment Requirements of the IDEA, November 23, 1994).

The concept of an array of services remains consistent with inclusive practices because it offers a variety of options in which to determine the appropriate services on an individual student basis. The responsibility for developing education plans must be shared by general and special educators, speech-language pathologists, support personnel, parents, and student consumers of the services. Once developed, that plan must be supported at all levels of the education system (National Joint Committee on Learning Disabilities, 1990).

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Issues in Inclusive Practices

Program efficacy. Substantial research literature on inclusion efficacy is available in the area of special education (cf. Lamorey & Bricker, 1993). Review of available studies suggests the following key findings:

• Children benefit from services provided in inclusive settings, showing gains in specific competencies as well as in broad social and interactive skills (Guralnick & Groom, 1988; Jenkins, Odom, & Speltz, 1989; Lamorey & Bricker, 1993; Notari & Cole, 1993; Wolery & Wilburs, 1994).

• Early integration efforts demonstrate that simply integrating children does not ensure positive outcomes. Instead, benefits depend on planned efforts to facilitate them (Lamorey & Bricker, 1993; Notari & Cole, 1993; Wolery & Wilbers, 1994). Existing research suggests that carefully constructed intervention plans and strategies are required to achieve desired outcomes in inclusive programming.

A number of descriptions of inclusive service delivery models are available in the specific area of speech and language intervention (Borsch & Oaks, 1992; Butler & Coufal, 1993; Calculator & Jorgenson, l993; Campbell, Stremel-Campbell, & Rogers-Warren, 1985; Christensen & Luckett, 1990; Montgomery, 1993; Norris, 1989; Roller, Rodriguez, Warner, & Lindahl, 1991). However, few empirical investigations have documented the effectiveness of various types of inclusionary programs for children and youths with communication disabilities (Cirrin & Penner, 1995; Cole, Mills, Dale, & Jenkins, 1991; Ellis, Schlandecker, & Regimbal, 1995; Farber, Denenberg, Klyman, & Lachman, 1992; Wilcox, Kouri, & Caswell, 1991). In addition, available studies differ in the types of inclusive services they evaluate, the populations served, and the communication skills targeted. For example, in the area of direct services provided in a classroom setting, Wilcox et al. (1991) contrasted individual intervention with classroom-based services in facilitating lexical acquisition in preschoolers. Although both intervention settings led to gains in word learning, it was found that generalized use of new forms was greater for the children who received intervention in the classroom context. In a study of intervention used for children with autism, Dyer, Williams, and Luce (1991) used a consultative program in which a speech-language pathologist trained special educators in the use of naturalistic intervention strategies. Findings revealed gains in the communication skills of the children and, to some degree, increases in the teachers' use of naturalistic intervention strategies. Coufal (1990) used collaborative consultation with a general education team as an intervention approach for three kindergarten children with specific language impairment. She determined that such individual education services were effective in changing teachers' instructional discourse, as well as the expressive language performance of the target students.

The available research provides tentative support for inclusionary efforts; however, many critical questions are not yet resolved. Directions for future research are elaborated later in this report. One conclusion that can be made about the effectiveness of inclusive speech, language, and hearing services is the need for additional study.

Cost effectiveness and administrative issues. Administrative support for or resistance to inclusive models may rest with funding concerns and perceptions of inclusion efficacy (Salisbury & Chambers, 1994). In general, relatively little is known about the costs of inclusion, particularly in comparison to direct intervention or self-contained programs. Available research has addressed the costs associated with overall special education programming. For example, Salisbury and Chambers (1994) documented the expenditures of one school district during the shift from segregated to inclusive programming for children with special needs. Cost comparisons revealed that serving children in integrated settings was less expensive for the district than contracting for special services through a cooperative agency, even though integrated programming required hiring new personnel and providing staff collaboration opportunities. Other recent investigations report that costs per pupil were similar in inclusive programming and traditional special education service delivery (McLaughlin & Warren, 1994; Roahrig, 1995). With inclusive programming, costs in certain areas were reduced (e.g., transportation); however, additional funds were required for staff development and support personnel (Roahrig, 1995).

Additional study is needed in this area of cost effectiveness. Of particular interest are investigations that specifically address the cost of providing speech, language, and hearing services in integrated settings. The task of collecting such data will be complex given that speech, language, and hearing services are likely to be provided through a continuum of options, rather than in inclusive versus segregated contexts. Evaluations of cost effectiveness might usefully begin by contrasting the most divergent treatment approaches (i.e., traditional pull-out treatment with integrative options, such as classroom-based or consultative approaches).

Educational preparation needs. Alternative service delivery models have been adopted in advance of parallel changes in the preservice training of speech-language pathologists. Many speech-language pathologists have received inadequate preparation for the new responsibilities, tasks, and strategies that are inherent in inclusive programming (Coufal, 1992; Coufal & Butler, 1991; Elksnin & Capilouto, 1994). Thus, particular focus on inclusion is needed at preservice and in-service levels to address both qualitative and quantitative needs in the field (Goldberg, 1993).

At the preservice level, two aspects of preparation are relevant. First, students must obtain supervised experiences in general education settings. Traditional university-based clinics continue to be primary preparation sites, yet they may not provide adequate experience with current service delivery models. Of particular importance are opportunities that facilitate collaborative skills in developing and implementing assessment and intervention plans. Second, strategies and techniques for working in inclusive environments should be infused into appropriate academic coursework. In addition, development of new academic courses that specifically address issues related to inclusion might be considered (e.g., working on collaborative teams). In summary, the desegregation of many current preservice preparation programs is warranted. One avenue to be considered is integration with general education preparation programs.

At the in-service level, attending workshops and conferences on inclusive programming is many clinicians' preferred learning activity (Elksnin & Capilouto, 1994). However, current literature (Kontos & File, 1993; Montgomery, 1992; Russell & Kaderavek, 1993) suggests that mentoring, consultation, peer coaching, and co-teaching provide more effective staff development than workshops alone. When promoting adequate in-service preparation, support for obtaining these alternative models is both challenging and important to practicing clinicians.

Personnel qualifications. Inclusive practices necessitate alternative roles, responsibilities, and qualifications for personnel. While serving children and youths with communication disorders in inclusive programs, speech-language pathologists, general and special educators, various related service personnel, and family members will inevitably engage in collaborative role sharing. In this model, concerns may arise regarding personnel qualifications and preparation. The goal of best practice is the delivery of inclusive services in a manner that is consistent with ASHA's Code of Ethics as well as the personnel standards provided in IDEA. It is generally recommended that speech-language pathologists in inclusive models continue to serve a primary role in developing, monitoring, and implementing programming for children with speech, language, or hearing impairments as the primary problem. Within this broad guideline exists a wide range of options for consultation and implementation of intervention programs (e.g., teachers assuming more of a primary role for language instruction; Campbell, Stremel-Campbell, & Rogers-Warren, 1985).

Effects on all learners. One concern in the implementation of inclusive practices is the influence of children with disabilities on the instructional environment of the classroom. There is the belief that the presence of a learner with special needs may compromise the ability of nondisabled peers to benefit from instruction (Sharpe, York, & Knight, 1994). Case law has identified several factors to be considered in the determination of least restrictive environment, including: (a) efforts to accommodate the needs of the child with disabilities in general education; (b) consideration of educational benefit in general education; and (c) the influence of the child with disabilities on the education of other students (Cernosia, 1994).

Some studies have directly investigated the academic influences of including children with disabilities in general education. For example, Sharpe, York, and Knight (1994) contrasted the academic achievement of nondisabled children who were educated with and without children with disabilities. No significant differences were identified in the academic outcomes of the two groups. Giangreco, Dennis, Cloninger, Edelman, and Schattman (1993) reported that many teachers' attitudes and experiences regarding inclusion improved significantly after including students with disabilities in their classrooms. Again, successful experiences for all learners must be carefully and intentionally planned. Prizant (1995) suggested that modifications to the environment, activities, and child interactions should all be considered when planning for a variety of inclusive experiences. Additional research is needed to evaluate the influence of inclusive practices on all learners.

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Evaluating Program Efficacy: Recommendations for Research

As mentioned previously, additional research is needed to evaluate the efficacy of inclusive practices for children and youths with speech, language, and hearing disabilities. Efficacy is a broad term that includes the effectiveness of particular intervention strategies, the efficiency of such strategies in promoting change, and the general effects or outcomes of treatment (Gutkin, 1993; Olswang, 1990). All facets of efficacy are pertinent for future research on inclusive practices. Although designing and implementing such research is both complex and exacting, efficacy data are essential to achieve optimal service delivery for children and youths with communication disorders. Building on the findings of previous research, a number of recommendations for future study of the efficacy of inclusion can be offered.

1. Implement multiple research methodologies. To date, much of the research on inclusion has used traditional group designs. This research has provided a valuable foundation; however, given the heterogeneity of subject populations and the nature of the questions posed, greater reliance on diverse methods is warranted. Single-subject designs and qualitative methodologies may be particularly well suited to examinations of the efficacy of inclusive practices for children and youths with speech, language, and hearing disorders (cf. Reid, Robinson, & Bunsen, 1995). Methodologically defensible work will most frequently result from designs that incorporate multiple research approaches.

2. Expand range of investigation. Future investigations of inclusion efficacy should expand the range of study in three primary ways.

   First, a broader vision of desired outcomes is needed. Although research focusing on variables such as standardized test scores has been informative, the most significant outcomes of inclusive practices may occur in more general social and cognitive areas (e.g., the use of language for social interaction, peer relationships, and/or academic problem-solving; academic achievement; changes in self-esteem and/or the frequency of negative or challenging behaviors).

   Thus, it is appropriate for investigations to adopt a more general view of the ways in which the effectiveness of inclusive practices should be evaluated.

   Second, increased effort should be directed toward assessing the influences of inclusive practices on families, speech-language pathologists, teachers, administrators, and peers. Useful information will be gained from socially valid measures, such as family and teacher perceptions and attitudes about inclusion efficacy. In addition, consideration of the ways in which inclusive interventions affect children without communication disorders will also be beneficial (i.e., in classroom-based approaches, what influence does speech and language intervention have on all learners?).

   Finally, the ultimate measure of the efficacy of inclusive practices is long-term enhancement of speech, language, and hearing skills within the important communication contexts of a child's life. Longitudinal tracking of children in academic and social settings will be necessary to fully address the influence of inclusive versus segregated interventions.

3. Include a diverse population of children and youths. A significant number of children and youths with communication disorders also come from diverse linguistic and cultural backgrounds. Delivery of inclusive services to this population warrants specific research attention. For example, recent work suggests that children from diverse cultural backgrounds may approach learning differently, employing varied cognitive styles and strategies (cf. Battle, 1993; Ewing & Yong, 1992; Shade, 1989). Further, considerable research has documented discourse-style differences in diverse populations (Campbell, 1994; Cheng, 1994; Westby & Roman, 1995). Discourse and learning-style differences may influence the efficacy of certain inclusive practices. In general, children and youths who exhibit speech and language disorders in the presence of communication differences present multifaceted needs and concerns; research specifically evaluating inclusive practices with diverse populations is needed.

4. Consider the contribution of individual abilities. Given a commitment to providing service in the manner that best fits individual strengths and needs, information about optimizing the match between student abilities and service contexts must be obtained. At present, a limited empirical base is available to guide clinicians and other team members in making service-delivery decisions. Available data suggest that particular child attributes, such as cognitive level, may influence the relative benefits obtained from integrated versus segregated programming (cf. Cole et al., 1991). However, such differences may be relatively minimal, relationships between skill areas may change across time, and the value of benefits in related areas (e.g., social competence gains) must also be considered. Overall, more study is essential in this area before child profiles can be matched with confidence to optimal service settings.

5. Redefine research settings and address clinician concerns. A considerable portion of the extant research on inclusion has been conducted in relatively uncommon classroom settings (e.g., model demonstration programs, university-based preschools, and university lab schools). Findings from these studies may have limited application to the realities of integrating children with communication disorders in community settings. A desirable next step in inclusion research is to shift study into community classrooms involving a wide range of children and youths with communication disorders, speech-language pathologists, teachers, administrators, and family members. Such a shift will require that researchers recognize and acknowledge the concerns of personnel involved in the day-to-day implementation and maintenance of inclusive practices. For example, many questions related to planning, delivering, and monitoring inclusive services are particularly pressing from the perspective of practicing speech-language pathologists (e.g., appropriate entrance and exit criteria for inclusive programming, the influence of the amount of intervention time on outcomes).

6. Evaluate strategies for inclusive practice. To date, limited research has examined the effectiveness of specific intervention strategies to be used with children and youths with communication disorders in inclusive settings. In addition, research is needed to address how critical developmental achievements, such as literacy acquisition, are influenced by inclusive practices. Some specific strategies, as well as general areas of study (cf. ASHA, 1991), that could be evaluated include:

   • Peer-tutoring;

   • Collaborative learning groups;

   • Various models of teaming and collaboration;

   • Naturalistic and conversation-based approaches;

   • Influences of inclusive practices on literacy.

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Summary

An array of inclusive service delivery models is recommended for the implementation of services to children and youths with communication disorders. Inclusive practices are intervention services that are based on the unique and specific needs of the individual, and provided in a context that is least restrictive. There are a variety of models through which inclusive practices can be provided, including a direct (pull-out) program, in classroom-based service delivery, community-based models, and consultative interventions. These models should be seen as flexible options that may change depending on student needs. The speech-language pathologist, in collaboration with parents, the student, teachers, support personnel, and administrators, is in the ideal position to decide the model or combination of models that best serves each individual student's communication needs.

Implementation of inclusive practices requires consideration of multiple issues, including general education reform, cost effectiveness, and program efficacy. In addition, administrative and school system support, personnel qualifications, staff development, flexible scheduling, and the effects of inclusive practices on all learners need to be considered. At present, available research suggests guarded optimism for the effectiveness of inclusive practices. However, many critical questions have not yet been addressed and additional research is needed to assess the full impact of inclusive practices for students with communication disorders.