Chapters Transcript The Pediatrician's Guide to Disabilities, Early Intervention, Education, and the Law Abigail Kissel, MD, discusses the basics of early intervention elligibility. Hi, everyone. Thanks for joining this morning. I apologize in advance. I have a little uri. I hopefully not too groggy. Um I know it's early on a Friday. I appreciate you guys being here today. We're gonna talk about how school and school laws can affect a kid. Um I know that there are so many people out there practicing in the community who already deal with this every day. Um So in some ways, some of this may be some review. Um but I find that each time I give this lecture, whether it's to practicing pediatricians or certainly there's a similar lecture, sort of chalk talk version that I give to all of the pl one residents here at children's and wasu so also good for you guys to know what they're learning um that we fill in some holes that we give some context. So hopefully that's what we'll do today. I'm a very casual presenter. So I have the chat open on one of these screens and hopefully we'll see if you guys write something. You can save your questions to the end, but also feel free to unmute and ask, I'm happy to answer things along the way, if that's more sort of contextual for anybody who's watching. So, I am a DB P as mentioned and have no relevant disclosures, financial or otherwise. And those two things are usually mutually exclusive. Um Today we are gonna talk again about I DEA which is the Individuals With Disabilities Education Act. It's sort of basics will concentrate on part B and part C, part C handling early intervention or what we call first steps here in Missouri and part B handling more special education through a public school district. And then we'll talk a little bit about 504. How the two are different where there's some overlap. I like to always kind of start with. But why am I presenting this? Why is this something that matters? And in this case, I talk a lot about, you know, when residents are with me um practicing on their rotation, we talk a lot about how residency can be really exciting, really fun learning all these very acute things in the hospital. But at the end of the day, most Children aren't in the hospital, right? Most Children spend their time at home and spend their time at school. And this is just a little glimpse at how school is obviously a huge portion of the day. And then as kids advance become preteens and teens, we know that it becomes even more because other activities like sports, chess club, steam debate, band orchestra, whatever are at school. And so we end up having a huge portion of a child's life, at least when they're young being at school. So, as promised, the Individuals with Disabilities Education Act is a federal law. It has four parts. Um, the first one is sort of who we are. The last one is sort of where we'll go and what we'll do as we improve. So we are gonna focus more on the meat, which is part B and part C today. Always joke with the residents that you can remember. These are backwards because Doctor Kissel feels very annoyed that we chose to do part C covering Children, 0 to 3 years old or 0 to 36 months and part B kids that are 31 years old. So we'll start again with that part C 0 to 36 months old. So this as you guys know it in Missouri and I came here about a year and a half from a year and a half ago from Texas. And so some of the small loopholes, small ways that we implement. These federal laws are different state to state. But in Missouri and in general, for most states, you just have to be a resident of Missouri to qualify for being under part C, you have to be in that age range. We talked about have a delay, a physical or mental condition associated with developmental disabilities and a high probability of resulting in a developmental disability in some states, we'll talk about that. You guys know that almost anybody can refer so often kids are referred straight from the NICU if we know that they're gonna have a delay going home. But certainly parents, physicians, teachers, anyone. Um I tell people to think of it a little bit like child abuse. Me worried about a kid, you should refer, you don't have to be confirmed that they have a certain delay or a certain degree of delay. You really just want to make sure that the system is used for what it's made for, which is to catch and find kids who could be running behind and provide them extra help. You know, you can refer online, you can call a hotline. There are many ways to get kids into early intervention first steps, but what are sort of the details of that? So in Missouri, as stated, you have to be a resident, you don't have to prove citizenship. Um This is actually the same in Texas and it, and it's something that's kind of important. We'll talk a little bit more about it when we talk about part B, um you have to have a delay. However, knowing the details of that again, can be important. So in Missouri, our cut off for reaching sort of the amount of delay that you would get first steps, intervention is 50% delay. And that's, you know, one of the most stringent cutoffs in the nation. Um, it's a lot and, and I was a resident, I tell the residents, you know, I used to see families as I'm sure you guys do and I'd refer them for early intervention and they'd come back and say something like, oh, well, they said he didn't qualify and looking at a child in front of me who felt delayed, that was hard to hear. But when you think about a 50% delay, you know, a three year old acting like a 1.5 year old that can be very difficult um to reach that bar sometimes. So it's important for us as, as uh you know, pediatricians to know that um many states can carry an at risk for delay policy. Um Missouri does not. Um So technically, you do not have to be provided services if you are just having a condition that puts you at risk for delay here. Whereas in many states, um they will include this in the kids that they serve right now and then conditions associated with delay or disability. I will not read through all of these for you. And I believe my slides are available at the end or if not, you can email me. I'm happy to make them or a cheat sheet by the way available to you. Um But some of the conditions obviously listed here are things that we know are sort of usually associated with an acute delay at the time again. Some of them may be associated with the delay that happens later. Um And those kids may or may not qualify for services if, when they're evaluated, they aren't really reaching that 50% delay mark. So I often start um the pl one residents who come with me with a small chalk talk on global developmental delay when we start our rotation. In fact, some of the um pediatricians and academics, pediatrics probably could give that chalk talk by memory because they've heard it so many times in clinic. But what I talked to them about are these five areas of development that we're looking? Well, cognitive, speech, language, adaptive, gross and fine motor and social, emotional um and delay in two or more of those is what we call global developmental delay. And I will go on to talk aspects of when we should stop using that term, which by the way is around five. But I point out that these are really, even if we change naming a little bit, what we're looking at when we're looking at early intervention as well because these are the five categories of development that we're always sort of monitoring. So those are the 50% delay categories. We're looking at. Um another important note to know that's specific to Missouri or different in each state is that oftentimes we will correct gestation, the age of a premature, a child born prematurely for up to two years, you should know that technically, first steps only has to correct for one half of that amount of prematurity up to one year. There's a tiny little caveat set in there unless a physician recommends otherwise. So that can be a lot of power to keep certain kids in, you know, an extra year or two of therapy if you're paying attention and saying, hey, well, were red dropped. Oh, because you're only correcting for half up to one year. By the way, it's my recommendation that we continue to correct fully as this child is still behind that power for you. So it's important to know that rule. What does I DEA part C or the law, the federal law that governs early intervention have, it has nine pieces. Um And when they are completed, it makes up a individualized family service plan or ifsp lots of acronyms when it comes to school and school law. So again, I do have a cheat sheet if that's helpful. Um You get assigned a service coordinator to hopefully help you navigate this kind of complicated process. They do a multidisciplinary evaluation of the child. And that's important because if anyone has watched any of my lectures at any other time, you know, I sort of harp on the fact that comorbidities are the norm. It's very rare to have just one area of development down. It's very rare to have one mental behavioral health condition. So certainly you can refer for speech delay but they will take a 360 view of that child. They will also look at the family from a 360. So what, what are the reasons, what else could be affecting that child's care development? They'll set goals based off of what they've looked at, based off of that evaluation. They'll provide services and they have to provide those as you all know, in the most natural environment for kids that's usually in the home or going to the child's daycare to provide those that changes in part B and we'll talk about that a little bit if the child's gonna transition and this really should say to pre kinder at age three. then there has to be an educational transition component to the plan. Again, we'll speak to that and then they add anything else, you know, that could be in the periphery that could be affecting things and there's a payment plan. So oftentimes, I would say the majority of the time, almost every time when I ask residents about early intervention, they tell me it's free. And I tell them to be careful about that. It's technically what we would call sliding scale, meaning you can't be turned away if you qualify and you can't pay, but it's not free. They will try to bill your insurance. And certainly if you are Steve Jobs, you will, you know, to be paying some for that early intervention. So just careful in the phrasing of the payment plan when you talk to families and then how do we pass the baton, you know, from part C, which is this earlier? First steps here in Missouri, 0 to 36 months to part B which is really when the public education system takes over. So 3 to 5, you know, that little early time before kinder before what we call formal schooling often gets called early childhood special education or, or, or ECs E um again, responsibility shifted the public school system. And as I mentioned, if you're coming from first steps into this situation, you're gonna have a transition plan as part of those nine items. And if not, then the process sort of starts at this triage will show with um beginning to get data and evaluate that from there. So this is actually taken off of our Missouri website. So um transition from first steps, begins first service coordinator that they were assigned sort of explaining that first steps is gonna turn out when you turn three and then re reviewing every single available option that will happen at three. And just to be clear, I talked to the residents as as if this is informed consent. So what I wish they could say is, hey, you're in first steps, your child's still requiring a lot of intervention. Therefore, the best step is to go ahead and go to part B at your local school system. Um But it's not phrased that way. It's really given every option, including the option of doing nothing and staying home until you formally have to start school. The age at which you formally have to start school is really different in each state. Um I like to just kind of let the rumor that it's kindergarten ride because I want kids in school for kindergarten. Um, in Missouri, it's actually first grade. Um, some states it's 7th, 8th, some don't actually technically have this law. Um But in general, they give them every available option of what they could do. And the process and this is really similar to the process that we'll talk about in a bit, even if you have an older child who didn't come from first steps is that the, the evaluation is sort of divided into what we call 30 60 30. And that means that they have 30 calendar days from a referral or request, right? For testing to determine if they think there's enough evidence there, right? And to do testing and they provide what's called an no a again, lots of acronyms, they provide a notice of action that says either, hey, yes, we think we should go on and do this testing. There's enough evidence here for that or no, we know we don't feel there's enough evidence for testing here, that kind of thing. And then they have 60 calendar days from that notice of action and the parents consent if they're gonna go on to test to complete an evaluation and determine eligibility for what will become their individualized education plan or IUP, 30 days from that eligibility determination also determined they weren't eligible for a plan, right? And provide an N A of that um to develop that actual iepiep and then meet with the parents about implementing that IEP. But what about summer? Um because public school again obviously isn't in session in summer. And so it's important to know that it's sort of one of those unless the seal is broken things. So technically, schools do not have to do evaluations during breaks. Um And that's unless they do it for one kid. If they do it for any kid in the district, then they have to go on to complete other evaluation strength in that time. So I will put out there that many districts try very hard not to do this. Um And then once eligibility has been determined, even if it is during a break, they still have to kind of try to develop the IEP. So that's sort of a caveat to that rule. Um And then part C going to part B. So again, passing that baton, this is a lot and I don't want you to feel like if through every box may be good to look at later, again, if you have the slides, but it's really what we just talked about, right? So you, the le A determines if there's a reason to suspect a disability, if there's no reason they give them a notice of action. If there is, they go into this 30 60 30. So I just put the table on here because I think it's nice to be able to look through, especially if you're kind of trying to figure out at, at what point in the process a parent may be or a child may be and then what are things to ask? Right. So I always sort of arm the residents with, you know, parent comes in, they're trying to tell you where they are in this process or it's confusing or the kids, you know, two and two and three quarters or something like that, you know, and what can we talk about? What can you, can we ask? So sometimes the question is just, do we have time for first steps prior to school? Right. So that's when you get this like 2.5 year old, right? Sometimes I say, do you have at least three months before they turn three and then you have to factor in that summer break, right? Where we have a summer break? And is it easier to approach the public school directly versus, you know, do you have enough time to go to first considering those um timing things when deciding which route to go? And then sometimes, and I, and I stress that I don't want this to be a burden on pediatricians, but sometimes you can give a little evidence of disability or delay, right? So maybe you charted something um about a percentage delay, but it doesn't have to be that concrete. Maybe you just charted there behind in certain milestones or you did an ages and stages screener that says that perhaps you have some ST or ote valves that were private or that you've got from their first steps time if they were there, that could be helpful. So just, just giving any information you can to help that process along, especially that 1st 30 day process where they're gathering evidence to decide whether or not they want to test, to make a plan. And then sometimes it's just about figuring out sort of where they are in the process. So I'll ask things like, did you sign a waiver to release your information from first steps to the public school system? Oftentimes, even though it's a confusing process, parents will remember signing something. And so they'll kind of say, yeah. And if they didn't, I ask a lot about why, because I have found, um, you know, since being out that depending on who your service coordinator is and how your choices are described to you, it can really influence the decisions made on it. Hey, are we gonna go from first steps to school or? I often get a oh, but they told me he's so young. So it's also ok for him to stay home with grandma until he needs to go to formal school, which is difficult when you have a kid that, you know, could really use that pre academic environment, especially when it's, you know, his or her therapies are done there and involved. Um And then so if they sign the waiver, did they meet with first steps or school yet? You know, there's supposed to be a transition meeting from first steps where they ask all those questions, sign the waiver and then actually a separate meeting which is like an acceptance transmission with the school to talk about, you know, the process that we just went over in these slides if they're starting directly with the school. So they're too old for first steps or it's just too close to that page. Um Then I say, you know, have you received a notice at first? No, a saying that they looked at data and they are, are, are not going to go on to test or have you received a notice that they tested and they're gonna go on to have a plan or not have a plan. So good questions to ask. Ideally, we just transition right from first steps to early special childhood education, we get our IEP we begin needed services and things flow from there. But sometimes like I said, you're not starting, you know, at two years old, you're starting with like a kid in second grade who comes in and parents say, you know, he's really behind, he's really strict juggling in mathematics. And so these same concerns, right are addressed under I DEA part B it's still a child who is 3 to 21 years old. Um Sometimes depending on what the concern is, it may be addressed under a 504 and we'll go over that, but you still go through that formal process, right? It's the same thing except for it starts different instigated, coming from first steps. It's usually instigated by the parent or teacher saying, hey, I think this kid is struggling in behind. So officially part B when we get into it has its own six pieces. And the first is what we call free and appropriate really should say public education or faith. Um And this is important because again, it's for residents in that district. And so I did not say it was for citizens of the United States in that district. So in Texas where I had a lot of immigrant families who maybe were not documented as legal, they would come in and be very fearful of having their kids start school. And I would have a big conversation about how actually they have to start school or they'll be truant and how school is a little bit like me. Um I care most about what's best for their child and I'm not interested in the politics behind it. I also point out to our residents that there are some gus safety nets that can happen at school. Um, certainly you can receive free public transportation to and from, if you need it, you can also maybe have a point of contact with a nurse that may not be available otherwise, and then you can get two square meals a day if that's something that your child needs there. And that can be life changing for certain families so important to know. And then, you know, part two of I DEA part B is identifying and evaluating kids who are struggling and this is otherwise what we'd call child find. So looking out in your district and hopefully they go to your school, but in general, looking into your district and saying, who is struggling, can I evaluate them to see if they need? Part three, which is an individualized education plan which you guys have all heard of an IEP for kids. Now we change from in the most natural environment because when you're in second grade or late 14, no one's gonna go to your home um to do your therapies but to in the least restrictive environment and this is, is back, back, back, further, back, closer to 1975 when things went into place. Um this was a different caveat and really there were kids and a great example as a kid with like a genetic condition. So a kid with Down Syndrome who would come in and they would assume make some assumptions. Oh, you have Down Syndrome, you're probably gonna be in special ed all day. And as we all know, we have certain kids with AAA multitude of different conditions who do not need to be in special ed all day, right? Um They may just struggle in mathematics, they may just struggle in el A. They may, there may be other times they could definitely participate in the general education classroom or even certain times they can participate in gen ed with a push in support or Pera who goes into the classroom with them, even in my Children who really struggle with that, who really kind of have to be in special ed all day, whether it's for um issues of making sure the curriculum is on their level, whether it's behavioral, um we still push for the least restrictive environment in terms of their. So gym, art, music are these times where they could be included in the general um education population. And then five is just, you have to warn the, you have to tell the parent and include them, right? So if a teacher says, I think this kid is struggling when you test him that can't be done without the parents um consent and then there's a due process for grievances. So o oftentimes this is a heightened emotion time for kids, families, even sometimes school administrators. And so there's a process that's followed if people don't agree. So what fits where this is a big part of things I'm asked, um you know what's the difference between an IEP and a 504. So I'll touch on that now and I'm happy to clarify if it's still a little, um, murky for anyone. But, um, an IEP as we've been talking about is through the federal law of I DEA part B 504 is actually a different law. Um, the Rehabilitation Act. Um, I think it's of 1973 section 504. And it's I want want residents and us as pediatricians to start thinking of 504 as accommodations. So I'm actually gonna skip forward because I think I have no, I didn't put it there. Um I somewhere in here and we'll get to it, but I'll say it. Now, the definition of 504 is kind of what I term purposefully vague and what I mean by that is 504. I want you to think of as if the government gives me any sort of funding. If I accept money from the government and clearly public schools do, then I have no right. I cannot discriminate against anyone with a disability and disability is defined vaguely. So any one of you out there who's gotten one of those sheets that says something like my child, the child under my care cannot mentally interact with his environment in the same as someone else, right? And you're like, what is this? This looks so strange and that's just describing a DH D which is probably the most common thing. You guys will see a kid have a 504 for, it's usually under a H I otherwise health impaired and they get a 504 plan. Well, why do they get that? Because a 504 disability is described as a mental or physical inability to interact with the environment around you in the same way as someone else. And because of that, because a DH D inhibits you mentally from interacting with the environment the same way they qualify as having a disability. And therefore school gives them accommodations. Accommodations are a change in the approach to in the approach to in the environment for all of these aspects of your curriculum, so that you can learn the same curriculum alongside your peers. OK? So for a DH D that may mean you get put at the front of the class, so you can pay attention, it may mean that you get pulled to a small group, maybe you get instructions twice for a physical disability, let's say a child is perfectly normal, doing great in school and they break their leg. You may also receive a 504 plan or accommodation and have extra time between classes again, changing your approach to or your environment. So you can learn the same curriculum alongside your peers, right? However, what we're discussing in terms of I DEA part B and an individualized education plan, otherwise known as special ed or Fed is that there's a modification. So the example I give is that if you are having challenges, reading because you have a DH D and you can't seem to stay on task. I may give you a rubric to cover certain parts of the page. I may give you extra time to read a passage if you truly have dyslexia and I teach you your reading curriculum the exact same way and just give you extra time, you are not gonna be successful, right? So an accommodation no longer is gonna help. We have to make a modification to the way where the actual curriculum we're teaching. Um And so that is really kind of the true way. I want you to think of differences between 504 and I DEA part B education IEP. So how do you know which one to request for the family? You know, and the answer is you don't need to know. It's not your job to know which category things will fall into, especially because it's pretty clear here in Saint Louis with special school district, they have kind of a rubric of how it goes. But certainly as you get into more rural school districts and over, over in Illinois things work a little bit differently. Sometimes things I think would be a 504. They classify under an IEP or vice versa. So it's not your job to know which one you just need to know that the kid's struggling. So you can point that out how it should work is that if a kid is struggling, they have tiered instruction. Tier one, if you ever see that terminology is just your average classroom, that's what everyone has. Tier two, there may be some supplemental intervention, right? And that could be a 504 classification, but it could be more informal than that. Tier three is like there's stepped up intervention, it's pretty intense. And if there's a failure to all of that, that is a response to intervention. And RT I, then they should go on to test and do this full evaluation to see if they qualify for an IEP. So technically, it's, we're learning as per normal, something's not working. What can we tweak to see if it'll work? What can we tweak even more intensively? OK. If you failed that RT I now we go on to test and we give a plan through special education if needed. So I put this in here just because it's important to know that the definition of uh learning disorders has changed over time. And so now we really have three major academic domain domains, which is not too different, reading, writing and math, and those can be subdivided but aren't required to be in terms of your I CD nine or 10 code. So, you know, but we have eliminated this IQ achievement discrepancy and we'll talk a little bit about that. I think on the next slide, um we have talked about how we now have, you know, you have to have this caveat of, you have some sort of intervention. So like a failed RT I that I just described and the characteristics we're looking at instead of comparing an IQ achievement gap, we're looking at, you know, your comparison compared to others, your age, right? What's expected for your age? And then as with everything in DS M it has to start in school age years and you have to make sure there's not something else that's causing the problem. Mhm So how can these changes be helpful for kids? This changes from having to have like what we call um you know, test to diagnosed? Right? So if something's wrong, we're gonna test them, we're gonna figure out exactly what it is. We're gonna complete all of this testing and demonstrate there's a discrepancy between what you're performing, what you're doing, your achievement, right? And your IQ. And I tell residents to think of your IQ as your learning potential. So there's still an aspect of the old definition. Hey, my learning potential is up here. My learning achievement, meaning my performance when I'm getting on tests when I'm doing average, you know, math test, et cetera is down here. I must have a learning disorder. There's still some merit in that. But nowadays we also look at, hey, you're performing here and your peers are up here and how does that help? Well, it goes from that, let's test to diagnose you to really, let's try some things. Let's try an RT I and if that helps you great, we'll just keep those accommodations. We don't necessarily have to then go on to test you and go through this very expensive, very long process for every child. What I tell, you know, residents and families when I'm talking with them is that if you have a true, true, you know, learning disorder and reading like dyslexia and we just do these tiny interventions and uh and um and you do and you truly have dyslexia, it's not gonna fix the problem and we'll go on to test and find that out and, and do a true formal IEP but if you're just struggling and reading in these tiny interventions, things like small group or repeat instruction do bring your grade up to be the same as your peers. And it's very unlikely you actually we have and we haven't sort of wasted your kids' time, wasted the system time with testing going on for that. It also used to be that we would have kids with these borderline IQs, so not intellectual disability, which would be two standard deviations or kind of like below 70 in terms of their cognitive testing, but 7375 and then there would be this old notion like, well, the there, you know, there's no gap for them because their IQ is so low, they're just achieving low. That's it. And they would go on to get no plan because they, it was understood that or thought to be understood that. That was why they were performing poorly. But you'd look at their grades and they'd have like, you know, mostly bees and then an F and math. And you think, well, there's some discrepancy there or you look at the fact that still in the new definition, they are not performing like their peers. And, and we do know partly why that is, but it doesn't mean there can't be some gain and we've seen this through multiple studies by giving them a really supportive academic plan. And so that is part of the reason for some of those definition changes. So back to this kind of second grader, we're trying to get evaluated important questions because moms, as you guys know, or dads, anyone kind of bring kids in and they'll say something like the school won't test them. I'm sure a lot of people out there can identify with that statement. And so I always first ask, does the school know he's struggling? I know that seems like an odd question to ask, but there are times they don't and we'll talk about that. Um But if they do, what are they currently doing about it? Because I would say 98% of the time when a kid is struggling. And a parent says to me, you know, they won't test him that, that kid is in the middle of an RT. I, so when I say, are they doing anything differently? And they say, uh you know, no, I mean, I guess he goes to the resource room twice a week for 40 minutes or something that keys me in. Ok. That kid's not in a totally normal gen ed setting all day, you know, every day. So clearly there's something different. He's probably in the middle of an RT I and we talk about that. Um And if they say no, absolutely everything the same as everyone else, then I say, you know, have you gotten a notification of action after you sort of asked, you know, did you ask about this, ask about testing? Um And that will be helpful because if they say, yeah, they said they looked at all that data and said he didn't qualify for testing. That's a whole separate triage. We're gonna go down then if they say no, this never happened. Um And if it didn't happen, I will ask a lot about how they notified the school he was struggling or asked for testing. As you guys know that 30 60 30 is pretty formal. But it, you know, if the parents like, oh, I sidelined it sort of sideline curb side, um ask the sped teacher about it and there's no request in writing and it's not dated, then it doesn't necessarily trigger that clock. So I'm careful to talk with them about that and I actually have a form template that can help a parent fill out. Hey, my child's name is blank. You know, I'm concerned that he may have a disability or delay given his performance at school. I'm requesting testing that kind of thing. Um That can be very helpful. Again, I cannot as a pediatrician go into that school environment and ask for that for that kit, but I can help the family advocate for it. Um If um the parent says they are doing something different, it's often like I explained an RT I and so I'll arm them with questions, like ask about how long the RT I is supposed to go for and what success or failure looks like. And so sometimes they'll come back and say, OK, I did ask, they said they're doing this current thing until the and then if he's still behind, they're gonna test him. And then it's sort of the question is answered. Everyone can calm down, we're following the normal process. Um And then I also tell them it's not about getting a label of a learning disorder, right? It's about doing well. There's nothing wrong with staying in an, you know, an RT I tier two or three. If that's what's working for the kid. I think that's really important to emphasize, not every child has to be tested, to go on to get a diagnosis and some IUP, it could just be doing great and I have many kids in my practice who are hanging in there doing wonderfully in tier two or three instruction. Um And then again, that's always that or, or 504, if it's serving the child's needs, which is something you discuss. And then, so this is the page of if the school doesn't know that they're struggling. Um There's a couple of situations in which I think that can happen, I'll pick up my pace here a little bit. So we have time for questions, but a kid can be too high or too low, meaning they're very bright and they're actually doing well. So they, the school says, how can you think they have a problem? They're doing well. And then the parent reveals to me that the parents spending, you know, 89 hours with them every night with this child who's like killing themselves to do as well as it looks like they're doing during the day. And so some of that can be relevant, right? Um And then we talked about kids who are sort of lower on that borderline. And so sometimes I put things in a note to the parents that they're welcome to share with the school that says something about definition changes. And we know that there are very many and who are able to achieve decent grades with great effort and this kind of thing and that, and that has been helpful that's on the left and bold. And then there's these kids that um are only harming themselves. So kids with like inattentive, especially girls inattentive presentation of a DH D or anxiety or selective mutism whom the school may say they're never a problem. What are you talking about? Right. But they're, they're internally, you know, with those internal symptoms, struggling quite a bit and maybe you need to provide that diagnosis of A DH D IP for them to share with the school or anxiety. And then there's the kids that's har that are quote, harming everyone, right? Those really Externalizing symptom kids who are really acting out. And these other things like combined presentation A DH D or um emotional disturbance category are sort of overshadowing the fact that the kids acting out because they don't understand something or they have a learning issue and that kind of thing. And we maybe need to say, hey, that's a common presentation of a learning disorder because the contents going over their head or are not sitting right? And then child find provision and we have to go out into our district, find people who are struggling and give them a plan pro you know, provides for kids who are private or religious school or who are homeschooled. They are still able to be tested right in a district receive a plan. Now, the person that plans going back to which may be mom if she's homeschooling or this private school or this religious school may not have to be implemented to achieve the way that it would in a public school. But just know that they do have the right to be tested in the district. Um Just so you guys have seen this, I know you've heard about meetings, admission review dismissal. These are the formal meetings in which you meet to talk about an initial, the very first time or an annual or a revision um or discontinuation of an IEP plan, they're usually done yearly. Um But technically is within a parent's right to call on at any time. So if there's a big change and they say, hey, we need to meet again because this isn't meeting, you know, so and so's needs. Um And then you definitely want, right? Because Children change and grow and develop so much and that's why we love treating them and working with them um every three years. But if the school doesn't automatically do that and most do, but if they don't, um then the family may need to request it. So what else can we do to help? We look for barriers to learning and treat the part that you can to, to sort of eliminate that as an aspect at school. Um And then we partner with them. So I think there can be a very us versus them mentality that happens with school. You know, when a parent says they won't test him, they won't give him what he needs this kind of thing. It can be sort of inflaming and I often work really hard to say we're all gonna partner, right. There's no, I don't want to get into a big an antagonistic fight with the school system because as noted the child spends tons of time at school. Right. So we go back to those. Does the school know he's struggling? Where are we in the process? What are the barriers and criteria for moving forward in a collaborative way? Um We talked about 504 here. Was that right? So if you take money from the government, you cannot be excluded from participation and denied benefits of or subject to discrimination um for any disability. And again, disability defined very um vaguely there. And so this is the slide we already went over of a 504 versus an IEP I really wanna mention quickly though that medical versus educational component, this is can be very confusing for families. And I think even for some people out practicing um oftentimes we feel hey, and a great example that I'll just use because it comes up all the time is autism. If I go through all the rigor all the needed testing readers, et cetera to diagnose a child with autism, school can turn around and say that's wonderful, but they're not getting an IEP for autism. This is very as you can imagine confusing to a family. And so what I always say is be careful to explain the difference between a medical diagnosis and an educational designation, right? So they may not be able to diagnose autism at school. There are special, special school district that will do an ADOS and can, but they will only give an educational designation of autism if they feel that autism is truly impacting daily in a way that they could plan for and give support for at school. So a great example of the first kid I ever saw was she was a 16 year old who's self referred because he felt he had autism and he did, he had what level one autism, what we formerly called Asperger's. But in no way, did it really affect him at school? He's top of his class. He had a small friend group he liked. Um and we talked about some social strategies to do elsewhere, but there was no way that school is gonna do say let's go through this whole testing thing to give you an IEP for autism because it wasn't impactful to him daily educationally. So I'm always careful to say I can diagnose medically that that won't carry over to school unless they want it to. There are some, you know, um more gray areas of this A DH D is one, oftentimes an A DH D medical diagnosis will carry over to school if that evidence is provided the to school, same thing with anxiety, but just helpful to know that they will have to see something on their data and to show that yes, they're seeing some of those things there as well if they want to give that educational um, designation. And then oftentimes we go back to this conversation of it's less about the label, right? What exact designation they gave? And it's more about are we getting the support that, that child needs? And then I'll just put in here that there is a section 303 4, um which is related services and this sort of is all the ancillary auxiliary things that go with a kid with a plan. So it could be transportation could be um speech language, path and audiology. And just quick side note at those meetings, the parent does have a right to request other service providers be there if they're relevant. So if your kid is struggling in, it could just be the normal ST who's there. But you could ask for an S LP to be present at that meeting, a speech language pathologist, um rehabilitation counseling, there's a whole whole of things that go under this special considerations category. Don't forget it. This for me usually comes more in with my complex kids. So I used to work a bunch with kids with spina bifida and it really would come in with, right? Because it was sort of like sometimes we needed to send someone or have someone come and learn from training on how that child may need a certain um you know, table or something to be able to lie down to self cath things like this. And so you never want to forget those things that maybe seem so rote to us in medicine but can su super impact a preteen or teenager's daily moments at school in a huge, huge way. If all else fails, there are gonna be times you ask these questions, you ask for paperwork, you're looking at it and still something's not making sense. Um And so oftentimes in that case, then I would really say armed with all of this information I just gave you guys, it doesn't happen very much to me. Don't forget if the parent thinks they're doing nothing. They're usually in an RT I, um, but sometimes I'll have them sign a waiver so I can just reach out to the school and ask and still when that happens, they usually RT I um, but certainly helping that way, it really gets to that point can be impor important. And then very rarely that I will advise a family to go on to having a school advocate who maybe can attend the meetings with them. I wish I had time to do it. Um, but I don't, and so each state, especially through LD Navigator has a network of people who can be really helpful with that or parent center hub. And I explained that there is a due process. It's not as if they can walk into school and say I'm gonna sue you, right? Because you didn't do what I want, but that um advocate can really help them. I see a question in the chat. I think we're super close to the end. So I'm gonna keep going and then I'll circle back and read it. Um Part B sub part B again. So confusing. So many parts, but go back and look at the slides um if, if you have time. So each place local education agency has to locate, identify and evaluate kids. This is really that child finding provision just so you know, this weird caveat if you're a kid in private school instead of the district in which you reside, it's actually a district in which you're private. So like if you live in Illinois, but you go to a private school in Missouri, it would actually be your private Missouri district that tests you. That is a weird loophole. Um But everything else just know that there is a way for a kid living in any district to get tested. And then this is just some links. Um Again, when you look back to look at some of those rules and regulations that can be helpful. Um We don't actually have to look at IEP si more put this in here for the residents, but so that you guys know there's some great skeletons of these if you're ever trying to teach like out in um anatomy and of an IEP that kind of walks through the different parts that can be in an IEP always talking about present level of performance annual goals, progress reporting, which services they're getting, which supplements, like we said, there's so many under that supplementation part, um participations kind of where and when and how much percentage is in each classroom and then consent. Um And I think that I ended there. Created by Presenters Abigail Kissel, MD Developmental and Behavioral Pediatrics View full profile
