The Special Education system in New York City is an ever-evolving work in progress, and any shortcomings of the current system might be excused by the difficulty of the task at hand and/or the relatively short time-frame the system has had to evolve. Other challenges include changes in the prevalence and nature of developmental disorders, as well as changes in the preferred methods and approaches used for treatment. Thomas Insel, the Director of the National Institute of Mental Health recently wrote, “Part of the polarization and confusion around autism is that it now applies to a 5-year-old who has no language, a 20-year-old computer science student at MIT who is socially awkward, and a 40-year-old parent who has no interest in social interaction” (http://www.nimh.nih.gov/about/director/2013/the-four-kingdoms-of-autism.shtml). Dr. Insel goes on to say that “Autisms” is a better term to describe the broad spectrum of traits that comprise autism. This sentiment was echoed by Dr. Eric London in his article An Interdisciplinary Treatment Program in the School: A New Model, which appeared in the Winter 2013 Issue of Autism Spectrum News. In his article, Dr. London outlines the core components of the “Medical Home” model, an interdisciplinary approach that says the “complete treatment” of individuals with autism spectrum disorders and other brain-based developmental disorders is difficult for any one provider since most disorders comprise a host of medical, neurological, psychiatric, and behavioral problems, all of which combine to impact learning and development in different ways across individuals. Dr. London and other proponents of the medical home model also recognize that children spend most of their time at school and in order to have the most accurate picture of their functioning at any one time-point, input from professionals who work with the child on a consistent basis is valuable information that they do not typically receive in the present system. Accordingly, the medical home model dictates that “best practices” for the educational and clinical treatment of this population involves teachers and school personnel working closely with physicians and other members of each child’s clinical team.
The Medical Home Model and the Inclusion Model: Shared Philosophies
I was pleased to read Dr. London’s article because it is a sign that medical doctors are beginning to advocate for more involvement in the school system. In today’s day and age, psychiatrists and other medical doctors often prescribe medication to regulate behavior and functioning at school. Unfortunately, the information that most doctors receive about the learning and behavior of their patients is usually limited to what they hear from parents and the patients themselves. Contact with teachers and related service providers continues to be the exception and not the rule, although when there is contact with a medical doctor or specialist, school officials and IEP team members are usually open to collaboration. This makes sense because the inclusion model of special education that guides IEP development calls for a team approach involving specialists from different disciplines collaborating to optimize the learning and development of a specific student. The medical home model also calls for a team approach. In fact, the only difference between both approaches seems to be that the medical home model includes a physician as part of the interdisciplinary treatment team, whereas the inclusion model is limited to providers who are mandated by student IEPs to deliver services.
Some of the more common IEP-mandated services include speech therapy, occupational therapy, physical therapy and counseling, although the number and type of services that each student receives varies depending on the needs of the student, the age of the student, and the type of school the student attends. Interestingly, the number and type of services any given student receives is also influenced by geographical location, since some states are known to rely more heavily on related service providers than others. An analysis of publicly available IDEA data reveals that New York State employs more related service staff-members per student than any other state in the country (http://www.cbcny.org/cbc-blogs/blogs/needed-mandate-relief-way). Unfortunately, more providers does not automatically translate to better outcomes for our students.
Years of experience with special education in New York City as a classroom teacher, school counselor, classroom consultant and neuropsychologist have taught me that the most effective treatment teams communicate on a regular basis and value the contributions of other team members. The truth is, all of the related service disciplines overlap in many ways and are capable of having different views about the etiology and treatment of developmental and learning disorders. In the same article quoted above, NIMH director Thomas Insel states, “People with autism are likely to be viewed differently by pediatricians, child neurologists, child psychiatrists, developmental psychologists, behavior therapists, special education experts, occupational therapists, speech and language therapists, and any of the other range of providers” (http://www.nimh.nih.gov/about/director/2013/the-four-kingdoms-of-autism.shtml). This is where the team concept becomes key. The only way to possibly combine such a diverse group of practitioners is to unify them on a common task. The IEP unifies team members with the common goal of optimizing the learning and development of a particular student. According to the IEP process, as students meet their goals, services are modified to meet their changing needs. Moreover, if a goal is not being met after repeated trials, the goal is modified, or a different solution is attempted. Focusing on solutions is an effective way to neutralize any differences in opinion that treating clinicians may have regarding the best way to target a specific goal. Utilizing a solution-focused approach transforms the task of optimizing learning and development from an abstract concept into an objective measure.
Unfortunately, the IEP is a relatively static document in that it is updated annually; a rather unhelpful time-scale when the task at hand involves customizing the educational and related service program for a growing and developing child or adolescent. Individual providers can and do modify goals throughout the year, however they have no way of communicating these updates with the rest of the treatment team. They submit their written reports for yearly annual review meetings, however they are not required to attend these meetings, where important decisions are made about the student. These and other factors combine to thwart interdisciplinary communication and undermine the team concept. In many cases, different providers end up targeting the same goals using different approaches. What’s worse, they are unable to see what other providers are working on and/or what has been successful for a particular student. In addition, providers frequently change during the school year and may be located outside of the school building. If a related service provider is new or located outside of the school building, or if their schedule is so busy that they see kids back to back (as is often the case), and the IEP describes the child’s behavior from the previous school year, how are they supposed to get an accurate picture of the child’s current classroom needs, both academic and social? After all, didn’t children begin receiving mandated related services because of their difficulty meeting academic and/or social demands in the classroom, as measured by functional behavioral assessments, performance on academic testing and their ability to follow social norms and conventions?
Bottom-Up Solution: Program Reviews, An Affordable Way for Parents to Intervene
Parents of students who find themselves in one of these terribly frustrating situations, when they know their child needs help but are forced to drop mandated-related services, should know about Program Reviews, an affordable way to effect change in their child’s educational plan.
A Program Review is a formal name for an expert consultation on special education matters. During a Program Review, a neuropsychologist and/or educational expert reviews a child’s records including past assessments and report cards, visits their school and interviews different related service providers. After considering the treatment plan and related service goals, a summary report is produced that gives specific recommendations for each related service discipline. In addition, part of the program review includes follow up with providers to help explain the findings. Program reviews are privately funded and are not typically covered by insurance, however they are an affordable way to get an expert opinion that would normally cost $4,000 to $5,000 (the average cost of a private neuropsychological assessment). The price of a Program Review ranges between $500 and $2,000 depending on the amount of time and work required. Prior to the beginning of the review, parents are informed how much work the review will likely require and both parties agree on the cost.
Top-Down Solution: Increasing the Time-Scale of the IEP as a Way of Improving the Efficiency of Our Related Service Departments
In addition, one simple solution with great potential for improving the current system would be to improve the time scale of the IEP by creating an online system for reporting results and communicating with other members of the team. As mentioned above, by the time school starts in September, even the most recent IEPs are nearly 6 months old. In addition, related service providers often provide their services in isolation, or without proper contact with the rest of the team. Why not increase the temporal resolution of the current data stream (i.e. the IEP) by collecting information about student performance from the complete team more frequently throughout the year. One way to do this is to create a dynamic, web-based document that is accessible by the students’ family and by all members of the educational and clinical team. All members of the clinical treatment team would benefit from input regarding the cognitive, academic and social progress of the student obtained from other team members. In addition, if there is a successful strategy that would benefit from coordination among team members, such is the case with executive functioning, social skills and the remediation of many academic skills, then common language, strategies and information could be shared. The benefits would be far-reaching. Aside from allowing us to better meet the educational and developmental needs of our children, increasing the efficiency of special education teams would provide needed relief to the strained NYS system.
The Special Education system of NYC has grown and developed a great deal in recent years, and our students now receive more IEP-mandated related services than any other state in the country. Unfortunately, increasing the amount of related services does not equate to a higher quality of education for many students, especially when provider roles are poorly defined and when providers are unable to communicate or see what fellow team members are working on. The IEP is based on an evidence-based, interdisciplinary approach that focuses on solutions as a way of optimizing the educational program for each child. Using a solution-focused approach is an effective way of neutralizing any differences in opinion or style that exist among members of the treatment team. Unfortunately, several obstacles exist in the current system, namely overlapping responsibilities and the infrequent time-scale of the IEP, that stifle teamwork and communication amongst members of the treatment team. As a result, it is very difficult for all team members to stay informed about how students are performing in the classroom and with other providers. Moreover, medical doctors who prescribe medications are often out of the loop regarding everyday school occurrences. These issues are exacerbated when students go to outside locations for related services, when providers are switched during an academic year, and as students get older and begin to have additional teachers for certain subjects.
Parents should know that they are now powerless to effect change, and also that they do not have to come up with $5,000 for a private neuropsychological evaluation in order to advocate for their kids. Instead, they can ask the same neuropsychologist for a program review. If the neuropsychologist never heard of a program review, refer them to this article. Last, many or all of these problems would be fixed by improving the frequency and quality of information that is shared by team members. This could be accomplished by adopting a web-based system whereby team members could log on to see up-to-date posts about student progress and other important information, such as medications, effective learning and behavioral strategies. Adopting such a system would greatly improve our ability to educate our children while improving the efficiency of our clinical treatment teams. In doing so, we would also reduce the overall number of mandates and related service providers on each student’s clinical treatment team while also doing a better job of meeting the needs of each student.
John Ferrera, PhD, is Director of John Ferrera PhD and Associates. John conducts program reviews, psychotherapy, homework therapy, academic remediation and neuropsychological/psychoeducational testing. For more information, please email firstname.lastname@example.org or visit www.johnfphd.com.