LSHSS

Survey of SLP Caseloads in

Washington State Schools:
Implications and Strategies for Action
Patricia Dowden
Nancy Alarcon
University of Washington, Seattle
Teresa Vollan
Snohomish Health District, Snohomish, WA
Gary D. Cumley
University of Wisconsin-Stevens Point
Carrie M. Kuehn
Dagmar Amtmann
University of Washington, Seattle

T he caseloads of school-based speech-language path-

ologists (SLPs) have risen steadily in recent
years, fueled by a rapid increase in the number of
children receiving special education services (American Speech-
Language-Hearing Association [ASHA], 2002f ). This trend has
reached unmanageable proportions for clinicians in some areas of
the country (ASHA, 2002f ), with important ramifications for
both service delivery and professional practice in our schools.
Without solutions to this problem, the field faces a potential crisis
that will be detrimental to the children served (ASHA, 2002f;
United States Bureau of Labor Statistics [USBLS], 2004).
ASHA attempted to address this rise in caseloads in 1993 by
suggesting a maximum caseload size (ASHA, 1993). It was recom-
mended that a full-time SLP serve no more than 40 individuals under
any circumstances, and fewer students in some specific cases such
as individuals with severe communication impairments. Unfortu-
nately, many school administrators began to use this figure as a
minimum caseload (ASHA, 2002e), resulting in a persistent rise in
caseloads to a national average of 50 for full-time SLPs (ASHA,
2003). Some states show average caseloads as high as 80 students
(ASHA, 2002f ), and some clinicians have reported serving 100
individuals at any given time (Alarcon, 2003; ASHA, 2002f ).

ABSTRACT: Purpose: To document statewide and regional caseloads
and to examine workload management strategies by surveying speech-
language pathologists (SLPs) in Washington State public schools.
Method: All school SLPs who were registered with the Office of the
Superintendent of Public Instruction were mailed a detailed survey in
May, 2001 and a brief follow-up survey 1 year later.
Results: Response rates were 43% (N = 431) and 47% (N = 464),
respectively. Caseload findings showed a statewide mean of 59
students, with regional variation as high as 30%.
Implications: There was no systematic evidence that caseloads were
managed through state, district, or local limits or by distributing clients
on the basis of the severity of impairment or SLP experience or training.
There was significant evidence, however, that clinicians with larger
caseloads were more likely to have assistants and to conduct a higher
proportion of group sessions than were clinicians with smaller
caseloads. The authors discuss the implication of these findings for this
and other states with no caseload limits and a shortage of SLPs. There is
an appeal for more research using newly established measures of
workload as well as a call to action to address the challenges that these
findings represent.
KEY WORDS: schools, caseload, workload, overtime, augmentative

104 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS  Vol. 37  104 – 117  April 2006 A American Speech-Language-Hearing Association
0161-1461/06/3702-0104
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 Students’ speech and language needs have also become more
complex, requiring more intensive and complex intervention and
coordination of services. Recent evidence suggests that students
qualifying for SLP intervention have more severe communication
impairments (Alarcon, 2003; ASHA, 2002f ), come from more lin-
guistically diverse communities (Annett, 2003), and have disabilities
that are both more complex and more medically unstable (ASHA,
2002f ) than ever in the past. For example, between 45% and 63% of
all school SLPs currently serve Bnonspeaking[ individuals, students
who rarely met the candidacy or threshold requirements for services
25 years ago (Beukelman & Mirenda, 1998). The severity of these
impairments necessitates more intense intervention over a longer
time period to demonstrate functional improvement (Blackstone,
1996; Jacoby, Lee, Kummer, Levin, & Creadhead, 2002) and requires
more coordination and cooperation among team members (ASHA,
2002f ).
At the same time, SLP roles and responsibilities have expanded
dramatically with new federal mandates such as the Individuals with
Disabilities Education Act (IDEA, 2004) and the No Child Left
Behind Act (NCLB, 2002). IDEA ensures that children with dis-
abilities receive a free and appropriate public education based on
individual needs by linking services to progress in the general
education curriculum. The NCLB Act is an educational statute that
was designed to improve student achievement through statewide
accountability. In a recent ASHA survey, clinicians in elementary and
secondary schools reported that these laws have greatly increased
prereferral activities and routine paperwork, respectively (ASHA,
2004c). They have also complicated the context of intervention by
requiring students to be served through the general education
curriculum and within the least restrictive environment (ASHA,
2002f ).
In response to these changes in practice, ASHA has begun to
measure more than just the caseload, the number of students with
formal service plans (ASHA, 2002f ). ASHA now examines the
clinician’s entire workload, defined as all activities that are required
and performed by SLPs (ASHA, 2002d, 2002e). In addition to
direct intervention time, workload measures include the less visible
responsibilities that are required to serve students, such as time
spent on documentation, intervention planning, coordination, and
conferencing (ASHA, 2002d). By making these changes, ASHA
has acknowledged the importance of measuring workload activities
to Bensure that students receive the services they need, instead of the
services SLPs have time to offer or services based on administrative
convenience.[ (ASHA, 2002e, p. 89). The distinction between
caseload and workload is important, even as some researchers
and practitioners emphasize one over the other. In this article, we
will use the term caseload to refer to the number of students with
formal plans who are served by clinicians and the term workload
in reference to all activities that an SLP is required to conduct
(ASHA, 2002f ).
It is clear that excessive responsibilities have a detrimental effect
on the practice of speech-language pathology in the schools. First,
according to recent National Outcome Measurement System
(NOMS) studies by ASHA, intervention is less effective when case-
loads are high (2002f). ASHA reported that students on caseloads of
40 clients or fewer made demonstrably more progress than did
students on caseloads of 60 or more. This finding was validated in part
by Karr and Schooling (2001), who measured teachers’ perception
of progress, finding that students whose SLPs had caseloads at or
below 40 were perceived as making more progress than were students
Dowden et al.: SLP Caseloads in Washington State Schools
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whose SLPs had much higher caseloads. Because high caseloads
were also associated with a greater reliance on group treatment
(ASHA, 2002f ), it has been speculated that a high caseload results in
slower progress for individual students because there is less time for
intervention (Annett, 2002; ASHA, 2002f ).
Second, high caseloads have been found to be predictive of low
job satisfaction (Blood, Ridenour, Thomas, Qualls, & Hammer,
2002) and high attrition rates among SLPs (ASHA, 2002f ). A
recent study funded by the U.S. Department of Education (USDOE)
(Carlson, Brauen, Klein, Schroll, & Willig, 2002) found that SLPs
who intended to leave the profession as soon as possible had a
larger average caseload (59.7) than did SLPs who intended to stay
as long as possible until retirement (46.2) (USBLS, 2004). In a
recent study by the Washington Education Association (WEA,
2002), only 36% of respondents, including many SLPs, believed
that they would still be working in the field of special education in 5
years primarily because of uncompensated overtime work (81%)
and high caseloads (65%). This attrition will be exacerbated by the
large numbers of clinicians who are nearing retirement age.
According to a USDOE report released in 2002, the majority of
school-based SLPs are age 45 or older (USDOE, 2001). By the year
2017, 49% of current SLPs will have become eligible for retire-
ment, but there are fewer SLPs to fill the resulting vacancies
(USDOE, 2001). The loss of these clinicians is of particular con-
cern in a field where demand is expected to grow by 39% in the next
6 years (USBLS, 2004).
Washington is one of the states with high caseloads (ASHA,
2002c) and a severe shortage of SLPs (Alarcon, 2005; Bergeson,
Griffin, & Douglas, 2002). The BASHA School Survey[ of 2000
found a mean caseload of 58 students per full-time SLP in
Washington State schools, with a range from 33 to 90 (ASHA,
2002f ). According to this same survey, 12 states reported larger
caseloads: Oregon and Pennsylvania at 59; California and Colorado
at 60; Maryland at 61; Florida at 63; Idaho, Kentucky, Oklahoma,
Texas, and Utah at 64; and Indiana at 77 (ASHA, 2002f ). Three states
had the same caseload as Washington: Nevada, South Carolina, and
Tennessee. These high caseloads are in stark contrast to the 14 states
with mean caseloads below 50 students, including one as low as 38
students per SLP (ASHA, 2002c).
At the same time, there are a large number of unfilled vacancies
for SLPs in Washington State public schools. In biennial surveys, the
Professional Education Standards Board (PESB) of Washington
recorded 171 advertised vacancies for the 1999 –2000 school year,
182 for 2001 –2002 (Bergeson et al., 2002), and 187 for 2003 – 2004,
of which 58% were due to the departure of eligible retirees (Alarcon,
2005).
When caseloads are high, practitioners and managers respond
with a variety of strategies to make clinical practice more manageable
(Spracher, 1999). These strategies may be implemented at the state
or district level, locally by the team or school staff, or simply by the
individual clinician. Some states, such as Virginia, have set max-
imum caseload limits. These serve to cap each clinician’s caseload
and lower the statewide average, even if the limit still exceeds
ASHA recommendations (Speech-Language-Hearing Association of
Virginia [SHAV], 2005). In some districts, there are caseload limits
with relief strategies that are automatically activated when assign-
ments exceed that number; for example, assistance from a pool of
floating SLPs, help from designated program support teachers, and/or
overtime compensation (ASHA, 2002a). Some states, such as
Wisconsin and Michigan, have developed a weighted student formula
105
to assign students to clinicians based on the severity of the
impairments, intensity of need, type and complexity of intervention,
and setting for services (Moore, 2004; Wisconsin Department of
Public Instruction, 2001). A similar formula was developed by
clinicians in Washington through the Washington State Speech
and Hearing Association, although it was not widely implemented
(Togerson, 1997). Other states or districts have encouraged spe-
cialization for efficiency by training clinicians or teams to serve
students with particular clinical needs (ASHA, 2002a) such as
augmentative communication or assistive technology.
Some strategies are implemented at a more local level by the
school staff or the student’s team. Historically, some schools and
managers have allowed time in the work week for newly certified
professionals to develop the clinical skills and materials they need
(ASHA, n. d.). This typically meant assigning smaller caseloads in
general or fewer clients that require intensive intervention. In a newer
development, Cirrin (2004) reported that SLPs on some teams factor
time for all workload activities into each student’s individual edu-
cation plan (IEP) or individual family service plan (IFSP). That report
also documented schools where SLPs with high workloads were
exempt from general school duties, such as monitoring lunch or recess
(Cirrin, 2004). A more controversial solution has been to hire less
qualified SLPs or to assign students to assistants or paraprofessionals
who may or may not have special training (ASHA, 2004a, 2004d;
Banotai, 2005; Carlson et al., 2002). Although assistance is a welcome
relief to clinicians with high caseloads, some authors have warned that
the additional supervisory duties that accompany the use of assistants
may actually increase the clinician’s workload (ASHA, 2004b).
If the state, district, or school team does not implement strategies
for caseload management, the responsibility rests with the individual
clinician. When caseload numbers or workload activities become
unmanageable, some clinicians opt to work late, putting in
uncompensated overtime to accomplish the work that needs to be
done (WEA, 2002). Some SLPs may increase the proportion of group
sessions over individual sessions, serving more students in less time
(ASHA, 2002c, 2002f, 2003). ASHA has reported nationally that
Blarge caseloads have been shown to relate to less individual
treatment I [and] more group treatment[ (ASHA, 2002c, 2002f,
p. 205 ). Research has shown that these may not be effective strategies
in a high caseload environment and may actually worsen the crisis
(ASHA, 2002c, 2002f, 2003). Overtime, for example, has been shown
to increase attrition among clinicians (Jacoby et al., 2002; Karr &
Schooling, 2001). The impact of group sessions over individual
treatment is more controversial. Large, nationwide outcome studies
have suggested that group sessions may limit treatment progress for
the individual, particularly as group size increases (ASHA, 2002c,
2002f, 2003), and particularly with individuals with severe impair-
ments (ASHA, 2002f ). However, there are some smaller studies that
suggest benefits from group treatment for certain speech and language
purposes such as improving generalization (Oliver & Scott, 1981).
Despite the importance of these issues for our profession, there
are no detailed research studies of the caseload or workload status
within any single state. Published studies either focus on select
student populations within a state (Simpson, Beukelman, & Bird,
1998) or report national data state by state, with relatively small
numbers of respondents (ASHA, 2002f ). Some individual states
have developed position papers on the crisis (Karr & Schooling,
2001) and recommendations for solutions (Arkansas DOE, 1993;
Oklahoma State DOE, 1990; Pennsylvania Speech-Language-Hear-
ing Association, 1990).
106 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS  Vol. 37
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Issues related to large caseloads compelled the authors of this
article to conduct a survey of SLPs in Washington State public
schools in 2001/2002. It was thought that a more in-depth look at one
state with a high caseload may be informative to the broader
community of SLPs across the country. Detailed information about
caseload distribution and management may be useful to ASHA and
the state associations as they jointly address the problems of high
caseloads and personnel shortages (ASHA, 2005c). There were two
broad purposes to this study. First, we wanted to document the
characteristics of SLP caseloads in greater depth than the ASHA
survey (ASHA, 2002f ), which was based on only 64 respondents
from Washington State. We wanted to determine not only the
statewide status of caseloads, but also geographic variations in the
individual regional consortia of school districts, known as educa-
tional services districts (ESDs). Second, we were interested in
examining how districts, schools, and clinicians in Washington State
were managing their responsibilities. In particular, we wanted to
determine whether there were any strategies that were common
across the state. To these ends, we posed the following questions:
& What is the SLP caseload in Washington State public schools,
both statewide and in each ESD?
& What factors are used in determining caseload size?
& Do clinicians with less experience carry smaller caseloads?
& Do clinicians who are serving students with severe impairments
have smaller caseloads?
& Do clinicians with larger caseloads have more assistants or
routinely work more overtime than do clinicians with smaller
caseloads?
& Do clinicians with less experience have fewer individuals with
severe impairments on their caseload?
& Do clinicians with more specialized training serve more
individuals with severe impairments?
& Do clinicians with larger caseloads conduct more group therapy
sessions than do clinicians with smaller caseloads?
METHOD
In May, 2001 and again in May, 2002, we mailed surveys to all
SLPs who provided services within the Washington State K– 12
system (See Appendices A and B for relevant sections of these
instruments). The overall purpose of this study was to gather
information about the size of caseloads and the factors that influence
caseload distribution and management. The focus of the first survey,
entitled BSpeech-Language Pathology Caseloads in the Schools,[
was to obtain general information about SLP caseloads and service
delivery in the public schools. This survey was relatively lengthy and
will be described in detail below. A follow-up survey, 1 year later,
was designed to replicate the original caseload findings with
questions that would permit us to adjust for full-time versus part-time
employment status and to obtain some additional information about
time management and the clinician’s geographic location. This was a
single postcard composed of 5 questions on ESD of employment,
caseload, full-time equivalent (FTE) status, administrative and
managerial duties, and overtime. Both surveys were accompanied by
cover letters explaining the purpose of the study and assuring the
anonymity of responses.
 104 – 117  April 2006
Participants
Each survey was mailed to every SLP in Washington State
public schools who was registered with the Washington State
Office of the Superintendent of Public Instruction (WAOSPI) in the
fall of 2000. The response rate for both surveys was satisfactory. In
May of 2001, 984 surveys were mailed, of which 421 were returned
(43%). In April of 2002, 977 surveys were mailed and 464 were
returned (47%). The slightly higher return rate for the second
survey may be attributed to the fact that it was considerably shorter
and required less time to complete than the first one.
Instrument
The 2001 survey was composed of four sections. Section 1
included six questions about caseloads and type of service, four of
which were drawn, with permission, from the BASHA Caseload
Survey[ of 2000 so as to permit direct comparison to that study
(ASHA, 2002c). We requested detailed information about hours of
employment in different settings but neglected to ask directly for the
respondents’ FTE, although many provided that figure. We also asked
how caseload size was determined, providing respondents with a
menu of options. There were two questions concerning the availability
and training of speech-language pathology assistants (SLPAs). Sec-
tion 2 of the survey included questions concerning the respondents’
professional training and years of experience. Because the remaining
sections of the survey were to be filled out only by those clinicians
with a specific type of caseload, most clinicians had completed the
survey at the end of Section 2 and were instructed to mail it in.
Sections 3 and 4 were to be completed only by clinicians who
served Bnonspeaking[ individuals. In order to examine the relation-
ship between caseloads and severity, we used nonspeaking students
as a proxy for individuals with severe communication impairments.
We defined this population as Bindividuals who are unable to use
speech independently as their primary means of communication due
to physical, neuromuscular or cognitive impairments, excluding
those who are nonspeaking due to a hearing impairment.[ This
definition was used in order to be consistent with published research
in Washington State (Matas, Mathy-Laikko, Beukelman, &
Legresley, 1985) and with terminology that is most familiar to the
broadest number of respondents. This approach was broad enough to
include children with a variety of primary speech and language
diagnoses, from cerebral palsy to Down syndrome to autism, whether
they used aided communication methods or not.
Section 3 posed questions about service delivery in general for
nonspeaking students; Section 4 asked respondents to profile each of
these students in detail. These profiles included information about the
age, gender, and diagnosis of the individual as well as details about
the type and length of intervention provided and a summary of
augmentative and alternative communication (AAC) strategies
implemented. With one notable exception, the responses to the
questions in these sections were not used for this article on caseloads
and they are not included in Appendix A. The single exception is that
we counted the number of profiles returned by each respondent, using
that as an indicator of the number of students with severe impairments
on the current caseload.
Data Analyses and Reliability
To minimize the potential for errors such as nonobservation
(nonresponse or noncoverage) and incorrect recording, editing,
Dowden et al.: SLP Caseloads in Washington State Schools
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coding, data entry, or data preparation, the questionnaire and cover
letters were piloted with researchers and clinicians who work on
issues related to caseloads. During the design of the survey and its
pretest, an effort was made to check for consistency of interpretation
of questions and to eliminate ambiguous items. Both surveys were
administered at the same time of year in order to minimize differences
related to the particular time the survey was conducted. For example,
a survey in September would presumably result in a lower caseload
number than a survey in May because some children have not yet
been identified or assigned to a clinician.
Two different research assistants entered the data into a spread-
sheet. The first coder flagged any instances of unclear coding, and the
first author made decisions on how to code the data. The coding sheet
was updated to provide directions on how to code similar items. The
second coder used the updated code sheet and reported no instances of
unclear coding. The two datasets were reconciled to ensure accuracy
using the cf (compare two datasets) command in the STATA software
program (StataCorp LP, 2004). The percentage agreement between
the two coders was 98.07%, suggesting high reliability of the
implementation of the coding scheme.
The data were analyzed using Statistical Package for the Social
Sciences (SPSS; SPSS Inc., 2004) for Windows and STATA
(StataCorp LP, 2004) software. In the 2001 survey, which was longer
and more complex, a few responses appeared outside of values that
are likely or physically feasible. The cutoff point of 3 SD was selected
to define outliers that were not used in analysis, because 99% of the
scores are expected to be located within 3 SD of the mean in an
approximately normal distribution (Stevens, 1996). In the 2002
survey, all responses appeared to be within a reasonable range of
responses and were used in the analyses. All valid information from
incomplete surveys was entered and used in statistical analyses.
Omitted questions were marked as missing data. Pair-wise deletion
was used to handle missing data in the analyses.
Variables of interest were categorized based on published
research and/or variable distribution. Chi-square analysis was used to
investigate associations among the variables. In both surveys, the SLP
caseload was defined as the number of different students who were
personally served (i.e., evaluated, treated, or consulted on) in a typical
month. Caseload size, number of nonspeaking students, and
percentage of group sessions were adjusted by FTE, where available,
before being categorized. No analyses combined data from the two
surveys; that is, only 2001 or only 2002 data were used in each
individual analysis.
RESULTS
Characteristics of the Respondents
The vast majority of respondents to the 2001 survey held master’s
degrees (n = 391, 93%). As Table 1 shows, only 3 respondents
(<1%) held a doctorate and 26 respondents (6%) had completed
only a bachelor’s degree, having been grandfathered in under
new Washington State certification guidelines. Respondents
had been working as SLPs for an average of 15 years (range =
0 –39 years).
To determine the geographic representativeness of our sample, we
compared the proportion of respondents in each ESD to the
proportion of SLPs in that ESD as listed with the WAOSPI for
107
Table 1. Characteristics of respondents (2001) and their caseloads Research Questions
(2001 and 2002).
What is the SLP caseload in Washington State public schools,
both statewide and in each ESD? The mean caseload size for the
Speech-language 2001 survey was 55 (M = 55.0, SD = 14.8, n = 421). Fourteen percent
pathologists of respondents reported caseloads less than or equal to ASHA
Characteristic n % guidelines of 40 clients (Table 1). As noted above, the 2001 survey did
not inquire about the full-time or part-time work status of respondents.
Therefore, we chose to take the most conservative approach in our
Degree analysis, assuming that everyone worked full-time unless the FTE was
Bachelor’s 26 6
Master’s 391 93 providedVa strategy that would deflate the mean caseload figure. In
Doctoral 3 <1 the 2002 survey, we requested new caseload figures as well as the FTE
Years as SLP (M = 15.3 years, SD = 9.3) status for each respondent in order to obtain a more accurate caseload
0–5 94 26 figure. The mean adjusted caseload size from this survey was 59
6 – 15 79 22 (M = 58.7, SD = 13.5, n = 459) students per full-time SLP, showing
16 – 25 117 33 a rise that we had expected once FTEs were taken into account.
>25 65 18
According to the 2002 survey, although not shown in the table,
Caseload 2001 (M = 55.0, SD = 14.8) the mean adjusted caseload in the nine ESDs ranged from 53 to 75
e40 cases 59 14
students. Two ESDs reported a mean of fewer than 60; six ESDs
41 – 60 cases 238 57
>60 cases 124 30 reported caseloads of 60 or more, one as high as 75 students. Viewed
from the clinical perspective, this means that clinicians in one ESD
Adjusted caseload 2002 (M = 58.7, SD = 13.5)
e40 cases 29 6 served 30% more students in a typical month than did clinicians in
41 – 60 cases 262 57 another ESD.
>60 cases 168 36 What factors are used in determining caseload size? When
responding to the question about how caseloads were determined, most
participants marked more than one choice (Table 3), but the infor-
mation about caseload limits was clear. The majority of respondents
2002/2003 (WAOSPI, 2003). As seen in Table 2, nearly all of the
(60%) reported that there were no limits of any kind on caseload
ESDs were adequately represented in our sample, with the proportion
assignments. Only 28 individuals (7%) reported the use of ASHA
of respondents to our survey within 3 percentage points of the
guidelines, either alone or in combination with other methods. Only
proportion of the SLPs in the state. The greatest discrepancy between
116 respondents (28%) reported the use of local contracts or guidelines,
the percentage representation in our sample and the proportion of
alone or in combination. As shown in the table, the overwhelming
SLPs in the state was in the Seattle School District (121) and the
Spokane School District (101), the two largest urban areas in the state.
Seattle’s SLPs were underrepresented among the respondents,
Table 3. A summary of factors used in determining caseload size as
representing 34% in our sample instead of 41%. Spokane’s SLPs reported by SLPs in the 2001 survey.
were overrepresented among respondents, representing 14% in our
sample instead of 10%.
SLPs

Table 2. Geographic representativeness of the survey sample (2002). Caseload size determined byI n %

ASHA guidelinesa 1 0
# SLPs # SLPs % of total State regulationb 4 1
employed % of total responding SLPs responding Contract/local guidelinesc 33 8
ESD in WAa SLPs in WA to surveyb to survey Contract/local guidelines & ASHA guidelines 3 1
SLP/supervisor/teamd 250 60
SLP/supervisor/team & ASHA 8 2
101 110 0.10 65 0.14 SLP/supervisor/team & State regulation 35 8
105 42 0.04 17 0.04 SLP/supervisor/team & State regulation & ASHA 4 1
112 85 0.08 24 0.05 SLP/supervisor/team & Contract/local guidelines 61 15
113 55 0.05 28 0.06 SLP/supervisor/team & Contract/local guidelines & 10 2
114 73 0.07 33 0.07 ASHA guidelines
121 461 0.41 152 0.34 SLP/supervisor/team & Contract/local guidelines & 7 2
123 44 0.04 21 0.05 State regulations
171 37 0.03 21 0.05 SLP/supervisor/team & Contract/local guidelines & 2 0
189 209 0.19 89 0.20 State regs & ASHA
Total 1,116 1 450 1 Total 418 100

a
Note. ESD = educational services district; SLP = speech-language Determined by ASHA guidelines; bMandated by state regulation;
c
pathologist; WA = Washington State. Mandated by contract or local education agency guidelines; dDetermined
a
OSPI for 2002/2003 (WAOSPI, 2003); b2002 survey data; numbers may by the number of individuals with SLP needs, by the IEP team, and/or by
not add up to total due to missing data. the SLP or supervisor.

108 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS  Vol. 37  104 – 117  April 2006

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majority of respondents indicated that caseloads were determined by
the SLP, the supervisor, and/or the IEP team with reference to the
number of individuals with SLP needs and no caseload ceiling.
Do clinicians with less experience carry smaller caseloads? As
shown in Table 4, there was no statistically significant association
between the years of clinical experience (0 – 5, 6 – 15, 16 – 25, >25)
and the size of the caseload (<40, 41 – 60, >60) ( p = 0.361). The
number of years of experience as an SLP was similar across case-
load categories; that is, less experienced SLPs carried caseloads
that were similar in number to those carried by more experienced
SLPs.
Do clinicians who are serving students with severe impairments
have smaller caseloads? We found no statistically significant
association between the number of nonspeaking clients (0, 1, 2, 3 – 5,
>5) and the size of the caseload (<40, 41– 60, >60) ( p = 0.151). As
shown in Table 4, SLPs with higher caseloads were just as likely to
be the primary therapist for nonspeaking students as were those
with smaller caseloads. SLPs serve an average of 2 nonspeaking
individuals on their caseload.
Do clinicians with larger caseloads have more assistants or
routinely work more overtime than do clinicians with smaller
caseloads? Table 4 shows a statistically significant association
( p = 0.020) between the size of the SLP caseload (<40, 41 – 60, >60)
and whether assistants were available or not. Two hundred eighty
(67%) of the respondents did not work with any assistants, 108 (26%)
worked with one assistant, 19 (5%) with two assistants, and 11 (3%)
with more than two assistants at the time of the survey. The 280 SLPs
who did not report working with assistants had an average caseload of
54 clients (SD = 14.5); the 138 SLPs who worked with at least one
assistant reported an average caseload of 58 clients (SD = 14.9).
Also shown in Table 4, a higher caseload was not statistically
significantly associated with routine overtime work ( p = 0.143).
Clinicians with caseloads of fewer than 40 were just as likely to work
overtime as were those with larger caseloads. Although this is not
shown in the table, more than 85% of the respondents reported that
they Broutinely work overtime.[ Of those clinicians, the mean
number of overtime hours reported was 5.9 (SD = 4.63, n = 386). Most
respondents listed planning meetings and paperwork either before or
after regular work hours as the primary activities of overtime work.
Do clinicians with less experience have fewer individuals with
severe impairments on their caseload? Table 5 shows the
relationship between the clinicians’ years of professional practice
and the number of nonspeaking students on their caseload. Ex-
perience as an SLP was significantly associated with the number
of nonspeaking clients on the caseload ( p = 0.061), but the dis-
tribution suggests that those SLPs with less experience were actually

Table 4. Washington State SLP caseload size in relation to years of experience, number
of nonspeaking students, and number of assistants as well as routine overtime.

Caseload ( N = 421)a
e40 41 – 60 >60
Characteristic n % n % n % p*

Years as SLP
0–5 7 14 56 29 31 27
6 – 15 12 24 42 22 25 22
16 – 25 23 45 59 31 35 31
>25 9 18 34 18 22 19 p = 0.361
Nonspeaking (ns) students
0 22 39 104 45 37 32
1 16 28 39 17 20 17
2 7 12 20 9 15 13
3–5 9 16 52 22 32 28
>5 3 5 17 7 12 10 p = 0.151
Assistants
0 45 79 160 67 75 61
1 or more 12 21 78 33 48 39 p = 0.020

Caseload ( N = 464)b
e40 41+
Routinely work overtime? n % n % p*

No 22 76 61 14
Yes 7 24 370 86 p = 0.143

a
2001 survey data; numbers may not add up to total due to missing data; b2002 survey data;
numbers may not add up to total due to missing data.
*Based on chi-square analysis.

Dowden et al.: SLP Caseloads in Washington State Schools 109

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 Table 5. Washington State SLP years of experience in relation to the number of
nonspeaking students on the caseload (2001).

Number of nonspeaking students

0 1 2 3–5 >5
Years as SLP n % n % n % n % n % p*

0–5 37 23 18 24 3 7 24 26 12 39
6 – 15 44 27 19 25 13 32 23 25 7 23
16 – 25 55 34 33 44 20 49 28 30 6 19
>25 26 16 5 7 5 12 17 18 6 19 p = 0.061

*Based on chi-square analysis.

more likely to serve nonspeaking individuals than were SLPs with
more experience.
Do clinicians with more specialized training serve more
individuals with severe impairments? We found no statistically
significant association ( p = 0.397) between the number of academic
courses in AAC that were taken as part of the SLP’s degree program
and whether or not the SLP served nonspeaking individuals (Table 6).
However, there was a statistically significant association ( p = 0.000)
between postgraduate (i.e., in-service or continuing education)
training and whether the SLP served nonspeaking students. Clinicians
serving nonspeaking individuals reported more hours of postgraduate
AAC training in intervention, evaluation, and equipment than did
clinicians who did not serve such clients. In summary, the primary
therapists for nonspeaking students had not, on average, received
more academic coursework in AAC during their degree program, but
they clearly had supplemented their academic training with in-service
lectures, postgraduate coursework, workshops, and demonstrations.
Do clinicians with larger caseloads conduct more group
therapy sessions than do clinicians with smaller caseloads? The
distribution of the proportion of group sessions to total sessions is
shown in Table 7. The size of the caseload was significantly asso-
ciated with the proportion of group sessions ( p = 0.000). SLPs with
higher caseloads tended to have a greater proportion of group
sessions out of their total number of client sessions than did SLPs
with smaller caseloads.
Respondents reported that they conducted an average of 117
sessions per month (SD = 68.2). Out of their total sessions in a typical
month, respondents reported that the proportion of group sessions
was on average 56%. The majority of respondents (54%) reported
that more than 50% of their sessions were group therapy, whereas

Table 6. Washington State SLP training in augmentative and alternative communication

(AAC) in relation to nonspeaking students on the caseload (2001).

Nonspeaking clients?
Yes ( N = 267) No ( N = 150)
n % n % p*

Graduate courses in AAC

0 95 63 51 54
1 42 28 33 35
2+ 14 9 10 11 p = 0.397
Postgraduate training in AAC
0 27 13 42 29
1 – 10 43 20 46 32
11 – 30 61 28 32 22
30 – 60 35 16 7 5
>60 50 23 17 12 p = 0.000
Summary M SD M SD
Degree-related AAC training 40.6 132.5 44.4 236.2
Post-degree AAC traininga 62.7 142.9 45.9 231.6
on intervention/evaluation 19.8 32.3 8.5 12.3
on devices/equipment 12.6 21.1 5.3 8.8

a
Includes intervention/evaluation training, equipment training, and additional academic
coursework completed after they received their graduate degree.
*Based on chi-square analysis.

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Table 7. Washington State SLP caseload size in relation to the clinicians. This pattern of AAC training will undoubtedly change now
proportion of total sessions conducted as group sessions. that ASHA requires coursework in multimodal communication for all
SLPs (ASHA, 2005a). However, it remains to be seen whether such
coursework among the newer clinicians will be taken into account
Caseload ( N = 421)a when students are assigned in the future.
e40 41 – 60 >60 Taken together, our findings suggest that it is typically up to the
individual clinician to manage a large caseload. At the level of
Characteristic n % n % n % p* individual clinician, we examined the use of overtime and group
sessions. Our findings did not suggest that clinicians with larger
e20% 9 16 20 9 4 4 caseloads worked more overtime than did clinicians with smaller
21 – 40% 13 24 39 18 4 4 caseloads; however, 85% of all respondents reported working
41 – 60% 14 25 68 32 23 21 overtime, putting in nearly 6 additional hours a week on paperwork
61 – 80% 9 16 55 26 41 38
and meetings. It may be difficult for clinicians to increase the number
>80% 10 18 32 15 37 34 p = 0.000
of hours worked any further as their caseload rises.
a
One strategy for the individual Washington State clinician was
2001 survey data; numbers may not add up to total due to missing data.
very clear, however. We found that SLPs with larger caseloads
*Based on chi-square analysis.
conducted more group treatment than did SLPs with smaller
caseloads, and this finding was consistent with the results from other
studies (ASHA, 2002c, 2002f ). It may be the case that group
6.4% of the respondents reported that an even higher proportion
treatment is advantageous in some circumstances depending on the
(more than 90%) of their sessions were with groups. A small
specific speech and language goals for each student. However, a
proportion (1.6%) reported no group sessions in a typical month.
statewide association between large caseloads and a high proportion
of group sessions suggests that decisions about group treatment are
being made because of the workload, not the individual needs of the
students. This raises concerns about policies and practices that may
DISCUSSION lead to poorer clinical outcomes than would be true with lower
caseloads.
In this study, we surveyed SLPs in Washington State public
schools in order to (a) replicate and extend the findings for this state
from previous ASHA research and (b) investigate whether there were
any common strategies for managing high caseloads. Such an in-depth LIMITATIONS
examination of caseloads in one state may have implications for
ASHA policies nationwide as the organization works with individual As in any survey, there were limitations that should be addressed
states to manage the caseload crisis (ASHA, 2005c). The results of this in similar studies in the future. First, a question about hours of
study replicated the overall findings for Washington State in the employment in the 2001 survey did not provide accurate information
BASHA School Survey[ of 2000 (ASHA, 2002f ). ASHA reported a about the respondents’ FTE as expected, resulting in inaccurate
mean of 58 students for full-time clinicians, and we found a mean of caseload data for part-time clinicians. This necessitated the 2002
59 in the 2002 survey. This suggests that most clinicians in this state survey, in which straightforward questions about caseload and FTE
served many more clients per month than ASHA recommends. The made it possible to more accurately estimate the size of the caseload.
average caseload varied across ESDs by as much as 30%. Second, although survey respondents appeared to adequately
In examining the strategies for dealing with high caseloads, we represent the population of SLPs working in public schools, it is
looked first for strategies that are beyond the individual SLP, such as possible that clinicians with high caseloads were overrepresented in
caseload limits, the use of assistants, and caseload distribution. Most our sample because of a strong interest in responding or, conversely,
SLPs (60%) reported that there were no established upper limits on underrepresented due to limited time to complete the survey. Third,
their caseloads as they made decisions about serving students. There the number of individuals with severe communication impairments
was clear evidence regarding the use of assistants. Even though there may have been underestimated because it was based on the number of
was no formal training program for SLPAs in this state in 2001/2002, individuals described in the Section 4 profiles. It is possible that some
districts had already begun to hire assistants where caseloads were clinicians serving nonspeakers failed to complete Section 4 because it
high. Further study would be necessary to determine whether SLPs was too time consuming, although they completed and submitted the
are given time in their workload for training and supervision of the other parts of the survey. Last, it is possible that by focusing on
SLPAs. caseload management strategies, we lost sight of some more
Using nonspeakers as a proxy for individuals with severe impair- fundamental challenges in this state. For example, the severe shortage
ments, we found no evidence that students were assigned with regard of SLPs may actually prevent schools from using strategies that
to a weighted student formula based on the severity of the impairment. require the distribution of clients among clinicians. There are many
New and less experienced clinicians reported carrying caseloads schools in Washington State that have only one clinician, making it
similar in size to those of more experienced clinicians. However, less impossible to assign clients through a weighted student formula or on
experienced SLPs reported serving more nonspeaking individuals than the basis of clinician experience or expertise. If we had posed
did their more experienced colleagues. Unfortunately, these clinicians questions about the number of SLPs available, we would have better
had not had any more academic coursework in AAC intervention, understood the nature of the challenge facing such schools and the
although they had had significantly more in-service training than other solutions that might be applicable.

Dowden et al.: SLP Caseloads in Washington State Schools 111

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CLINICAL IMPLICATIONS AND
FUTURE DIRECTIONS
This study in Washington State gives SLPs some insight into
service delivery in a high caseload environment, with implications for
both researchers and clinicians. In 2002, ASHA’s Position Statement
warned that clinicians may be managing their time according to the
number of clients assigned to them rather than the speech and
language needs of the students (ASHA, 2002e), and this appears to be
supported by our findings. Additional research is necessary to
document clinical workloads as well as to examine strategies for high
workload environments. It is likely that these results for Washington
State are not isolated findings; they may be indicative of what
researchers will find in any state or district where there are no
statewide caseload limits and a significant shortage of clinicians. It
would be informative to conduct a similar study in a low caseload
state, comparing the policies and management practices at all levels
that affect service delivery. We might expect clinicians in these states
to manage their caseload in different ways, perhaps resulting in
varying degrees of progress in clients and different job satisfaction
and retention rates among clinicians.
Even before additional studies are conducted, the clinical
implications of our findings are clear: Clinicians who work in a high
caseload environment may be under pressure to make decisions about
service delivery that may not meet the needs of their students. SLPs,
administrators, union representatives, teachers, and families should
take these results as a call to actionVto recognize and to address the
severe challenges facing clinicians in the public schools. In order to
effect change, action must be taken at all levels of the service delivery
system and efforts need to be persistent despite setbacks and obstacles.
Advocacy groups are in a position to take any number of actions.
At the national level, ASHA’s worksheets for workload analysis
(ASHA, 2002b) may be the best way to document the magnitude of
the problem for an individual, district, or state. SLPs in Wisconsin
used this strategy effectively to make changes in their workload
activities (Moore, 2004). At the state level, there have been some
efforts to reduce statewide caseloads. SHAV is currently working
through its Board of Education and state legislature to reduce the
statewide caseload cap from 68 to 60 students (SHAV, 2005).
At the district level or during union negotiations, groups of SLPs
can advocate for caseload or workload limits with formal relief
strategies when the limit is exceeded. If it is not possible to include
formal strategies, SLPs might request that workload language be
included in the agreement or contract, even if the language is non-
binding initially (Cirrin, 2004). Other districts have implemented a
block scheduling model, with weeks of therapy time followed by days
or a week of time for documentation and management duties
(Alarcon, 2003; ASHA, 2002a). Some districts have teams that
specialize in screening, assessment, and evaluation, permitting other
SLPs to focus on intervention itself (Alarcon, 2003; ASHA, 2002a).
More locally, SLPs can formalize mentoring networks so that
clinicians with more experience can assist clinicians who are less
experienced, including 1:1 mentoring and electronic discussion groups
via the Internet. Most significantly, clinicians can advocate for a sys-
tem that weighs the complexity of intervention as students are assigned
to clinicians. As an example, Wisconsin’s formula indexes students by
severity of impairment and complexity of intervention (WIDPI, 2001).
In addition to assisting in these national, state, and regional efforts,
individual SLPs have some strategies that may help them avoid
112 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS
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additional overtime or an inappropriate reliance on assistants as found
in this study. ASHA encourages clinicians to use NOMS data to
justify a smaller caseload by demonstrating the improvements in
performance that have been associated with smaller caseloads
(ASHA, 2002d). ASHA also provides time-saving tips and sample
forms and procedures for SLPs to use to reduce or streamline
paperwork while still meeting federal requirements (ASHA, 2005b).
Even with time-saving strategies, some clinicians recommend
factoring time into each student’s IEP or IFSP for indirect activities
on behalf of each individual (Cirrin, 2004). It is also recommended
that SLPs advocate for relief from non-speech/language duties
(e.g. monitoring lunch) when the caseload exceeds a certain level
(Cirrin, 2004). Most important, however, ASHA recommends that
workload activities now be documented by all clinicians so that the
data can be available when the time is right to advocate for significant
change in workload management (ASHA, 2002b).
Academic and research institutions can also take steps to reduce
the crisis facing SLPs. Research studies can and should be conducted
on the efficacy of common caseload management strategies, in
particular, block scheduling and group versus individual therapy for
specific therapeutic goals. Master’s students must be better prepared
for work in a high caseload environment, with information on how to
analyze their workload activities and advocate for change in their
responsibilities and how to make clinical decisions to manage the
workload without reducing the overall effectiveness of intervention
for individual clients. In addition, university programs and school
administrators should collaborate to increase the number of students
obtaining certification. Scholarship programs, tuition waivers, and
school-to-work stipends can be used to attract more of these students
to public school positions where vacancies are particularly prob-
lematic (ASHA, 2005c).
These strategies may not be applicable to all districts or uniformly
available to all clinicians. Nonetheless, each clinician, administrator,
and educator has an obligation to begin somewhere to make a
change on behalf of students with speech and language needs.
Implementing even modest changes may serve, over time, to decrease
the attrition of experienced clinicians, enhance the attractiveness
of the public school setting to graduate students, and ultimately
improve functional outcomes for the students that SLPs serve. In this
age of evidence-based standards, this will be essential for the future of
service delivery in our field.
ACKNOWLEDGMENT
This research was supported by Grant H224A3006 from the National
Institute on Disability and Rehabilitation Research, U.S. Department of
Education, to the University of Washington Center for Technology and
Disability Studies.
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Received September 17, 2004
Revised March 25, 2005
Accepted September 7, 2005
DOI: 10.1044/0161-1461(2006/013)
Contact author: Patricia Dowden, PhD, CCC-Sp, Assistant Clinical
Professor, Speech & Hearing Sciences, University of Washington, 1417
N.E. 42nd St., Seattle, WA 98105. E-mail: dowden@u.washington.edu

114 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS  Vol. 37  104 – 117  April 2006

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 APPENDIX A. SLP CASELOAD SURVEY OF 2001

Speech-Language Pathology Caseloads in the Schools

Patricia Dowden, Ph.D., CCC-Sp

Clinical Assistant Professor
Department of Speech and Hearing Sciences
University of Washington

Gary D. Cumley, Ph.D., CCC-SLP

Associate Professor
School of Communicative Disorders
University of Wisconsin - Stevens Point

Dagmar Amtmann, Ph.C.

Doctoral Student
Measurement, Statistics, & Research Design
College of Education
University of Washington

SECTION #1: Information About Your Caseload (Questions 1 – 4 appear here courtesy of the American
Speech-Language-Hearing Association from the ASHA Caseload Survey 2000)

1. What is your average monthly caseload? That is, approximately how many different students do you
personally serve (i.e., evaluate, treat, or consult on) in a typical month (i.e., in the middle of the school year)?

Number of different students served Example

by you per month for 71 clients 0 7 1
2. How many individual and group treatment sessions do you average in a typical month? (Exclude group
sessions from the individual sessions count.)
Individual sessions per month Group sessions per month

3. How many individual evaluations do you average in a typical month?

Evaluations per month

4. How is your caseload size determined? (Check ALL that apply.)

Mandated by contract Determined by the individual speech-

Mandated by local education agency guidelines
Mandated by state regulation
Determined by following ASHA guidelines
language pathologist/supervisor
Determined by the IEP team
Determined by the number of individuals
with speech-language pathology needs

5. How many Speech-Language Pathology Assistants (SLPAs) are available to support you in your AAC work?
(Write B0[ if none)

Number of SLPAs available to support you

6. Of these SLPAs, how many received the following types of training? (Please make your best estimate. The total
number of individuals should be the same as in Question 5 above).

Number of SLPAs who received formal training as SLPAs

Number of SLPAs who received on-the-job training as SLPAs

Number of SLPAs who received no training as SLPAs you are aware of.

SECTION #2: Information About Your Training

7. Indicate highest educational degree you earned and year earned:

Year Bachelors Masters Doctoral

continued

Dowden et al.: SLP Caseloads in Washington State Schools 115

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 8. Where did you receive that degree (name US state or other country): ____________________________

9. What formal coursework did you have specifically related to augmentative and alternative communication
(AAC) as part of your degree program? (Check all that apply.)
A single AAC lecture as part of another course

Several lectures on AAC as part of other courses

One course devoted to AAC

Two or more courses devoted to AAC

10. Indicate the number of years you have worked as an SLP: ___________

11. Please list the approximate number of hours per week you typically serve speech-language clients at each of
the following sites:

Birth to 3 Junior High (5/6 through 8)

Preschool/ECSE High School (9 through 12)
Elementary (K through 5/6) Other (Please describe): ________________

12. Have you given presentations, courses, seminars or workshops in AAC in the past five years?

Yes Y List the total number of hours in past 5 years

No

13. For each type of additional AAC training you participated in (i.e., in addition to training provided in your
degree program), please indicate approximately how many hours or academic credits you received in the past
5 years.

In the past 5 years

Type of Training (Post graduate) Total hours Total Academic
Credits

a.) Intervention/Evaluation
One-hour lecture(s) N/A
Half-day workshop(s)
All-day workshop(s)
Participation in evaluation (s) conducted by an AAC N/A
expert in order to train you and/or your team
b.) Training exclusively or primarily on ACC equipment
Demonstration(s) by vendor N/A
One-hour lecture(s) N/A
Half-day workshop(s)
All-day workshop(s)
c.) Post-degree academic courses
Semester-length N/A
Quarter-length N/A
d.) Other (specify):___________________________

14. Do you provide services to nonspeaking individuals (e.g., those individuals who are unable to use speech
independently as their primary means of communication due to physical, neuromuscular, or cognitive
deficits but not due primarily to hearing impairment? (Check ALL that apply.)

Yes, as a primary therapist Y Please complete Section #3 and #4.

Yes, as an AAC consultant Y Please complete Section #3 but not #4.

No, not at all. Y You have completed the survey. Please return the survey in the envelope provided.

Thank you for your participation.

SECTION #3: Information About AAC Service Delivery

SECTION #3 of the survey has been deleted as it does not apply to this article.

116 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS  Vol. 37  104 – 117  April 2006

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 SECTION #4: Characteristics of Nonspeaking Individuals You Serve as a Primary Therapist

Instructions:
This section is to be completed only by clinicians who are primary therapists for one or more nonspeaking
individuals. Please complete one copy of the following table for EACH AND EVERY nonspeaking individual
you serve as a primary therapist.

Definition:
Nonspeaking clients are defined as individuals who are unable to use speech independently as their primary
means of communication due to physical, neuromuscular, or cognitive deficits and not due primarily to hearing
impairment. (Matas, Mathy-Laikko, Beukelman & Legresley, 1985).

SECTION #4 of the survey was used for this article only to obtain the number of nonspeaking individuals for
whom the table was completed by each primary therapist. The specific questions of the table have been deleted as
they do not apply to the article.

APPENDIX B. SLP FOLLOW-UP SURVEY OF 2002

1. What ESD (Educational Service District) do you work in?

ESD 101 Puget Sound ESD 121
ESD 105 ESD 123
ESD 112 Northcentral ESD 171
ESD 113 Northwest ESD 189
Olympic ESD 114

2. What is your average monthly caseload?

That is, approximately how many different students do you personally serve (i.e.,
evaluate, treat, or consult on) in a typical month (i.e., in the middle of the school year)?
Number of different students
served by you per month Example for 71

7 1
3. What is your official appointment in FTE (full-time equivalent)?
FTE: Example for half-time Example for full-time
5 0 1. 0 0

4. Is a certain part of your week set aside for administrative or managerial duties?
Yes No Hours:

If yes, please indicate approximately how many hours you set aside per week and
briefly describe how you use this time:

Duties:_______________________________________________________________
_______________________________________________________________

5. Do you routinely work overtime?

Yes No Hours:

If yes, please indicate approximately how many hours overtime you work per week and
briefly describe how you use this time:

Duties:_______________________________________________________________
_______________________________________________________________

Thank you for your participation.

You have completed the survey. Please return in the envelope provided or to: UWCTDS, UW Mailbox 357920,
Seattle, WA 98195-7920.

Dowden et al.: SLP Caseloads in Washington State Schools 117

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