Education Advocacy for Physicians: Ensuring patient access to appropriate educational programming and services

Training Objectives Understand basic educational rights Learn to screen patients for educational issues Learn advocacy strategies to help families navigate the educational system and enforce their rights

Links Between Education and Child Health: When children have access to a quality education . . . Improved social and emotional competence Decreased disciplinary problems Increased graduation rates Increased occupational success following school School success and graduation rates tied to lifelong economic success Links to improved health throughout life

Children have a right . . . To enroll in school To be timely evaluated for special education services and to receive appropriate services in a timely manner To reasonable accommodations for medical and disabling conditions To safety To fair discipline

Key Terms SPECIAL EDUCATION Specifically designed instruction intended to meet the unique needs of a child with a disability. Required by federal and state laws and is provided at no cost to the parent. Children are eligible for special education services from age 0 through 21.

Key Terms 504 PLAN Required when a child with a mental or physical condition that substantially limits at least one major life activity (i.e. caring for oneself, walking, seeing, hearing, breathing, or learning) to allow full participation in school.

Key Terms EARLY INTERVENTION Provides evaluation and services to developmentally delayed children between the ages of zero – 3.

How to identify a child in need of educational services or accommodations GABS (Grades, Attendance, Behavior, Services) Is the child receiving poor grades? Did the child repeat any grades or was the child assigned to the next grade level? Is the child repeatedly sent from the classroom, suspended, disciplined on a regular basis? Does the child miss a lot of school because of a medical or mental health condition? Does the child have a mental or physical condition which seems to be inhibiting her ability to learn and progress in school?

Patient coming in because school says needs “medicine” Case Scenario #1 Patient coming in because school says needs “medicine” Behavior issues at school but not at home What can you do?

Case scenario #1 Differential? Remember Schools can’t mandate medication for kids

Case Scenario #1 Next Steps ADHD evaluation completed Vanderbilt Teacher scale: identify performance and hyperactive/inattentive symptoms Vanderbilt Parent scale: no performance or behavior issues identified What is your next step? Discussion

Response to Intervention (RTI) Response to intervention (RTI) strategies are tools that enable educators to target instructional interventions to children’s areas of specific need as soon as those needs become apparent. Response to intervention integrates assessment and intervention within a multi-level prevention system to maximize student achievement and to reduce behavioral problems.

RTI cont. With RTI, schools use data to identify students at risk for poor learning outcomes, monitor student progress, provide evidence-based interventions and adjust the intensity and nature of those interventions depending on a student’s responsiveness, and identify students with learning disabilities or other disabilities. RTI is not special education. Developed to provide typical students with needed academic supports to reduce the over identification of students of color as students with disabilities.

RTI in Practice Many local districts have developed Intervention Response Teams to provide RTI to students. Only required as a tool in determining suspected eligibility for special education for students with a suspected specific learning disability. May be appropriate for students with behavioral concerns who are not suspected as eligible for special education.

Case scenario #1: Patient returns follow-up Per parent: “Nothing really has happened yet” School Performance: behavior issues reported (multiple letters from teacher) Two suspensions Mom told child will likely fail Mom says requested “help” at last parent-teacher conference What to do?

Special Education: Individuals with Disabilities Education Improvement Act (IDEIA) Federal law that mandates the provision of special education services. Guarantees that a child who is disabled and in need of special education services receive a Free and Appropriate Public Education (FAPE). Requires that children be served in the Least Restrictive Environment (LRE).

What does IDEIA (IDEA) get you? Services that may be provided to a child receiving special education services can include: Tutoring Behavior Intervention services Counseling and Psychiatry services One-on-one aide Small class setting Alternate testing OP/PT services Special equipment for school use Transition services for children age 15 and up Educational services until the child’s 22nd birthday

Disabling Conditions under IDEIA Cognitive Disability Hearing impairments, deafness Speech or language impairments Visual impairments, blindness Orthopedic impairments Autism Traumatic brain injury Deaf-blindness Learning Disabilities Emotional Disturbance Other Health Impairment – includes chronic or acute health problems like a heart condition, sickle cell anemia, hemophilia, epilepsy, asthma, ADD, ADHD, etc. Mental retardation (a cognitive disability) or mental health impairment Hearing impairments (includes deafness) Speech or language impairments Visual impairments (includes blindness) Orthopedic impairments Autism Traumatic brain injury Deaf-blindness (the combination causes such severe communication and other developmental and educational needs that cannot be accommodated in special education programs for children solely with deafness or blindness) Learning Disabilities – disorders in one or more of the basic psychological processes involved in understanding or using the spoken or written language Emotional Disturbance – often chronic and intense including diagnosis such as depression, anxiety, personality disorder, aggression, and schizophrenia Other Health Impairment – includes chronic or acute health problems like a heart condition, sickle cell anemia, hemophilia, epilepsy, asthma, ADD, ADHD, etc.

Special Education Eligibility Child must have a disabling condition and the condition must substantially impact the child’s ability to learn in order to be eligible for special education services.

Special Education Eligibility cont. Children age 0 to 3 may be entitled to Early Intervention services or an Individualized Family Service Plan (IFSP) if experiencing developmental delays in: Cognitive development Physical development Communication development Social development Adaptive development Diagnosed physical or mental condition that has a high probability of resulting in developmental delay Children age 0 to 3 may be entitled to Early Intervention services or an Individualized Family Service Plan (IFSP) if experiencing developmental delays, as measured by appropriate diagnostic instruments and procedures in one or more of the following areas: Cognitive development Physical development Communication development Social development Adaptive development Diagnosed physical or mental condition that has a high probability of resulting in developmental delay.

Who can identify a child with a suspected disability under IDEIA? School staff (teacher, principal, nurse, school social worker, guidance counselor) – Required to identify under “Child Find” Parent Pediatrician, child psychologist, social worker, counselor (medical staff)

The Special Education Evaluation or MFE (Multi-Factored Evaluation) Before a child can receive special education services, the child must be evaluated. Generally, a special education evaluation is called a Multi-Factored Evaluation or MFE. A parent or legal guardian can request an evaluation to determine whether their child is in need of special education. The request should be in writing and should contain: statement of request for a “special education evaluation” of MFE, statement of consent for the child to participate in the evaluation, and statement regarding why the parent believes the child needs an evaluation.

Sample Parent Evaluation Request Letter Date Dear Special Education Coordinator/Principal/Counselor, I am writing to request that my child, child name, child date of birth, be evaluated for eligibility for special education services. I am the parent/legal guardian of child name. My child attends name of school. I suspect that my child has a disability and may be in need of special education services because state the reasons for believing that your child may have a disability and need special education services. (If there are any supporting outside diagnostic assessments or medical records, reference here and attach to this letter.) I understand that you have thirty days to respond to this request by either 1). meeting with me to obtain my informed consent for the multi-factored evaluation and to complete an Evaluation Team Report planning form, or 2) by providing me with a prior written notice indicating the district’s refusal to initiate the evaluation, the reasons for the refusal, and informing me of my right to challenge the refusal to evaluate. If you have any questions or would like to discuss this matter further, please contact me at phone number. The best time to reach me is state a time that you are usually available by phone. Sincerely, Parent/Guardian Name

Deadlines for the school School must respond to a parental request for an evaluation within 30 days by either obtaining informed parental consent for the evaluation or providing “prior written notice” explaining why the school is refusing to initiate an evaluation and providing the parent with information regarding how they can challenge the school’s position. The school must respond to a parental request for an evaluation within 30 days by either obtaining informed parental consent for the evaluation or providing “prior written notice” explaining why the school is refusing to initiate an evaluation and providing the parent with information regarding how they can challenge the school’s position. Once parental consent is obtained, the school must complete the evaluation within 60 days. The school should then invite the parent to attend an Evaluation Team Report meeting to discuss the outcome of the evaluation and to make a determination about eligibility for special education services. The school must provide the parent with a copy of the evaluation within 30 days of its completion and before an Individualized Education Program meeting (IEP). If the child is determined disabled, an IEP must be held within 30 days of the completion of the evaluation and within 90 days of the date of parental consent.

Deadlines for the school Once parental consent is obtained, school must complete evaluation within 60 days. School should then invite the parent to attend an Evaluation Team Report meeting to discuss the outcome of the evaluation and to make a determination about eligibility for special education services. The school must respond to a parental request for an evaluation within 30 days by either obtaining informed parental consent for the evaluation or providing “prior written notice” explaining why the school is refusing to initiate an evaluation and providing the parent with information regarding how they can challenge the school’s position. Once parental consent is obtained, the school must complete the evaluation within 60 days. The school should then invite the parent to attend an Evaluation Team Report meeting to discuss the outcome of the evaluation and to make a determination about eligibility for special education services. The school must provide the parent with a copy of the evaluation within 30 days of its completion and before an Individualized Education Program meeting (IEP). If the child is determined disabled, an IEP must be held within 30 days of the completion of the evaluation and within 90 days of the date of parental consent.

Deadlines for the school cont. The school must provide the parent with a copy of the evaluation within 30 days of its completion and before an Individualized Education Program meeting (IEP). If the child is determined disabled, an IEP must be held within 30 days of the completion of the evaluation and within 90 days of the date of parental consent. The school must respond to a parental request for an evaluation within 30 days by either obtaining informed parental consent for the evaluation or providing “prior written notice” explaining why the school is refusing to initiate an evaluation and providing the parent with information regarding how they can challenge the school’s position. Once parental consent is obtained, the school must complete the evaluation within 60 days. The school should then invite the parent to attend an Evaluation Team Report meeting to discuss the outcome of the evaluation and to make a determination about eligibility for special education services. The school must provide the parent with a copy of the evaluation within 30 days of its completion and before an Individualized Education Program meeting (IEP). If the child is determined disabled, an IEP must be held within 30 days of the completion of the evaluation and within 90 days of the date of parental consent.

Case Scenario #1 Parent comes back for follow up appt Reports IEP in place Physician: “How did the IEP meeting go?” Parent response: “Huh? They just had me sign the IEP!”

Individualized Education Program (IEP) The IEP should be developed by a team including: The child’s parent or legal guardian; A special education teacher; A regular education teacher; A representative of the local education agency; An individual who can interpret the results of the MFE; Other individuals who have knowledge or special expertise (can include counselors and pediatricians); and The child when appropriate (older children should be involved particularly when transitional services are being designed). REMEMBER: Once a child has been identified as a child eligible for special education services, an IEP must be developed within 30 days.

Individualized Education Program (IEP) The IEP should contain: A statement of the child’s present level of performance (PLOPS); A statement of measurable annual functional and academic goals; A description of how the child’s progress towards the goals will be measured; A statement of the special education and related services to be provided to the child;

Important things to remember An IEP should be specifically tailored to meet a child’s unique and individualized needs. A standard IEP for children with a specific kind of disability is not appropriate. The IEP should place the child in the least restrictive setting possible to promote the child’s ability to interact with other students who do not have disabilities. A parent can request an IEP meeting at any time. Money is not an excuse! Public schools cannot limit services according to what resources are available.

Section 504 of the Rehabilitation Act: Section 504 is a federal civil rights law protecting the right of individuals with disabilities to equal treatment and equal access to opportunities. Under Section 504, a student with a disability may be entitled to accommodations, modifications, and additional services at school.

Section 504 Eligibility: Section 504 protects individuals with a mental or physical impairment that substantially limits one or more major life activity. Major life activities include: Learning Walking Seeing Hearing Speaking Breathing Reading Writing Performing math calculations Working Caring for oneself Performing manual tasks

Section 504 Eligibility A school must evaluate a student to determine whether he is covered by Section 504. The evaluation can simply involve a process of information gathering from different sources including reviewing tests and evaluations completed by various professionals.

504 Plan If a child is determined to be eligible under Section 504, a 504 plan should be developed to provide for the necessary accommodations and modifications for the child. Modifications and accommodations under Section 504 can include: Preferential seating Extra time to complete assignments Alternate formats for work Shortened assignments Schedule modifications Assistance with health needs Modifications to the school building, etc.

Case Scenario #2 Allison, a 9-year-old patient with diabetes, comes to your office. She was found ineligible under IDEIA. Allison’s mother is worried that Allison’s school is not letting her drink juice when she feels she needs it and is limiting her opportunity to check her blood sugar. What should you do?

Case Scenario #2 discussion Child needs accommodations at school What would you suggest? School needs a Care plan? What would you tell the family to do if it were at home?

The differences between Section 504 and IDEA Section 504 protects student access to education. This is different from a student’s right to benefit from their education as required for special education students. Providing access means providing students with disabilities the same opportunities as students who do not have disabilities. For example, a child who needs a wheelchair may need ramps built in the school to allow access to classrooms. A child with an impairment that affects her ability to read may need additional time on tests. Section 504 protects student access to education. This is different from a student’s right to benefit from their education as required for special education students. Providing access means providing students with disabilities the same opportunities as students who do not have disabilities. For example, a child who needs a wheelchair may need ramps built in the school to allow access to classrooms. A child with an impairment that affects her ability to read may need additional time on tests. All students who receive special education services are protected by Section 504. However students protected under Section 504 are not necessarily entitled to special education services. Students entitled to special education services generally have more severe impairments which affect educational performance and therefore need special education and related services.

The differences between Section 504 and IDEA All students who receive special education services are protected by Section 504. However students protected under Section 504 are not necessarily entitled to special education services. Students entitled to special education services generally have more severe impairments which affect educational performance and therefore need special education and related services. Section 504 protects student access to education. This is different from a student’s right to benefit from their education as required for special education students. Providing access means providing students with disabilities the same opportunities as students who do not have disabilities. For example, a child who needs a wheelchair may need ramps built in the school to allow access to classrooms. A child with an impairment that affects her ability to read may need additional time on tests. All students who receive special education services are protected by Section 504. However students protected under Section 504 are not necessarily entitled to special education services. Students entitled to special education services generally have more severe impairments which affect educational performance and therefore need special education and related services.

Case Scenario: Child comes for follow up visit Parent reports school performance issues Keeps getting in trouble for not paying attention Teacher won’t allow the child to use the bathroom Blood sugars been running “high” How do you counsel the family?

School Discipline and Students with Disabilities Children with disabilities have protections in school disciplinary procedures Children whose behaviors are manifestations of their disabilities cannot be continuously disciplined and removed from school because of their disability under the IDEIA or 504

Suspension vs. Expulsion A form of discipline which prohibits a student from attending classes for up to 10 consecutive days. Can be in school or out of school. EXPULSION May be used to remove a student for more than 10 days when serious violations of the disciplinary code occur. A student may be expelled for up to 1 year if the student brings a firearm or knife to the school. Under rare circumstances, a student can be permanently excluded from Ohio public schools (i.e. for murder or a deadly weapon on school property).

Student’s Rights when facing Suspension or Expulsion Right to Notice of reason for suspension or expulsion and of right to appeal (does not apply to in-school suspensions). Right to Appeal Right to Hearing challenging the suspension. For suspensions hearing is informal. For expulsions, formal hearing before the superintendent or his representative. Right to an attorney or other representative.

Special Education students and Discipline There are strong links between learning disabilities and anti-social/criminal behavior. Punishment and isolation from the school system worsens the problem. Children with learning disabilities need to be engaged through special education programs. “Abandoned in the Back Row, New Lessons in Education and Delinquency Prevention” Coalition for Juvenile Justice (2001)

Special Education Students have additional protections in disciplinary proceedings Special education students must receive education services after removal for 10 school days. For any removal over 10 days, the IEP team must meet and determine: If the student’s conduct was caused by her disability; or Whether the conduct resulted from the school’s failure to implement the child’s IEP. If the answer to either is Yes The child cannot be removed for the behavior unless involved serious bodily injury or bringing drugs or weapons to school, and A Functional Behavioral Assessment (FBA) and Behavior Intervention Plan (BIP) must be done by the IEP team.

Behavioral Intervention Plans (BIPs) Whenever a student’s behavior interferes with learning, the IEP team must consider appropriate strategies, including positive behavioral interventions and supports, to address the behavior. The BIP should be developed by a team that knows the student well and should be based on a “functional behavior assessment.” The BIP should be included in the child’s IEP! First question to ask is: Where is the student’s BIP? If there is no BIP and there is a history of past behavioral difficulties, then it will be harder for the school to remove the student.

The Pediatrician’s Role Help identify when a child may be eligible for special education or school accommodations. With some basic legal knowledge, help parents advocate for their children.

The Pediatrician’s Role Help parents collect necessary medical information. Write a letter to the school identifying any diagnosis that the child has which is impacting his ability to access or benefit from his education. Refer the parent to the MLPC.

Resources www.EdResourcesOhio.org Ohio Department of Education, www.ode.state.oh.us Ohio Legal Rights Services, www.olrs.ohio.gov The Ability Center of Greater Toledo, www.abilitycenter.org Lucas County Board of Developmental Disabilities, www.lucasdd.org

Speaker Contacts Cathi Badik, Pediatric Program Director, Assistant Professor Pediatrics, University of Toledo College of Medicine Email: Cathi.badik@utoledo.edu Phone: (419) 383-4403