About IDEA

Prior to 1975 the School-to-Work Act, Perkins 504, and the ADA had unclear guidelines as to how to provide services to those with disability. Of the nearly 4 million children identified with disabilities at this time, more than half were denied access to public schools, and the remainder were segregated in inadequate classrooms or placed in regular classrooms without sufficient support(14). In 1975 congress enacted the Education for All Handicapped Children Act to clarify the delivery of the services to children with disabilities between the ages of 3-21 years of age (13). The law was originally enacted in order to ensure that children with disabilities would have access to free public education, similar to other children. The purpose was to provide more clear cut guidelines for providing such services in educational settings and help provide funds to states to assist in covering the costs of these services. In 1986 services were extended to toddlers and infants and this portion is now know as IDEA part C. The law was reauthorization in 1991 and at this time the name was changed to what we now know as IDEA, Individuals with Disabilities Education Act. The most recent reaffirmation of the law occurred in 2004. (14)

Site which summarizes differences between Part B and Part C of IDEA:
http://earlychildhoodcop.blogspot.com/2008/02/differences-between-part-c-and-part-b.html


IDEA and Physical Therapy

‍‍‍Physical therapy services are included under parts B and C of IDEA.‍‍‍ To meet the requirements of IDEA, physical therapists are encouraged to collaborate with parents, teachers, psychologists and school administrators in the writing of educationally relevant and measurable goals and objectives(1). If this collaboration fails to occur, fragmented service delivery guided by discipline specific goals and objectives may occur. These goals and objectives may not relate well to the overall educational plan for the child. These physical therapy interventions may include teaching and training of family and education personnel as well as measurement and documentation of progress in order to assist students in attaining their goals.

Effgen et al (2007) identified the following core competencies for physical therapists in the early intervention environment:
  • The context of therapy in early intervention settings
  • Wellness and prevention in early intervention settings
  • Coordinated care in early intervention settings
  • Evaluation and assessment in the early intervention setting
  • Planning
  • Intervention
  • Documentation issues in early-intervention settings
  • Administration issues in early intervention settings
  • Research in early intervention settings



"Families Perspective of Desired Competencies of Early Intervention Therapists" Box 29-3, p 948 Cambell
  • Above provides a great outline of what families think makes a good PT for their children

Dole et al.(2003) attempted to obtain a consensus among pediatric physical and occupational therapists regarding the elements of effective individualized education programs.

In order to comply with IDEA, IEP goals and objectives must:
  • Be focused on the child’s educational experience,
  • Be written in measurable terms,
  • Require specific content as stated in the law.

Common problems with IEP’s
  • Goals and objectives were poorly written
  • Lacked functional relevance and lacked the required elements in order to comply with IDEA
  • Poorly written IEP goals describe something which was done to the child, rather than what the child will do or learn to do
  • Contained few criteria for measurement.
  • IEP goals were also frequently found to be discipline specific rather than collaborative.
  • Goals were often generalized, with objectives written for the service provider, not the child.

The purpose of this study was to develop a consensus on the essential characteristics of IEP goals and objectives. Then determine which characteristics were most important for an IEP objective to be measurable, educationally relevant and contain the necessary content to comply with IDEA.

First round of surveys revealed that
  • Goals were consistently described as being for a longer time period, more general, related to the academic environment and involved overall improvement in function or behavior.
  • Goals were believed to not being required to be measurable. This is in contrast to the language of IDEA.
  • IEP objectives were found to be described as components of the goal, the measurable steps toward a goal, occurring over a shorter time period and used for objective and measurable behaviors.

The second round surveys revealed that
  • IEP’s should relate or describe a functional skill or behavior.
  • IEP objectives should use a valid and acceptable measurement tool in order to measure achievement and specify the level of assistance or cuing required to complete an activity.
  • IDEA compliance required that IEP goals and objectives be educationally relevant.
  • Objectives should enhance school function, relate directly to classroom curriculum or requirements, be associated with a general school activity and assist in gaining benefit from educational placement

The final round of surveys developed the consensus that:
  • Objectives should relate to a functional skill, they should be child focused and include an action verb
  • Objectives should focus on an activity of behavior that the child is to achieve and outline the environment in which it is to occur as well as any assistance from the therapist or equipment utilized
  • Objectives should be connected to the achievement of long term goals

These findings should assist in the facilitation of a child’s achievement and should incorporate input from the child’s family, teachers, psychologist and school administrators‍

IDEA Part B


‍‍‍Providing school-based services under IDEA Part B‍‍‍
The educational setting is unique in emphasizing individualized outcomes for student participation as well as opportunities and challenges for pediatric therapists. In the early 20th century, any children with physical disabilities were relegated to hospitals and special schools. Section 504 of the Rehabilitation Act of 1973 was created to ensure that any recipients receiving federal funding must provide equal opportunity to people with disabilities. Section 504 regulation requires a school district to provide a “free appropriate public education” (FAPE) to each qualified person with a disability who is in the school district’s jurisdiction, regardless of the nature or severity of the person’s disability (22). In 1975, the U.S. Congress passed the Education for All Handicapped Children Act that included the concepts of zero reject, education in the least restrictive environment, right to due process, nondiscriminatory evaluation, individualized education program, parent participation and the right to related services (4). Other important provisions include transition services, assistive technology and response to intervention.

IDEA defines the term "child with a disability" which includes 14 specific disability terms which are also defined by IDEA. These terms and definitions guide how states are able to define disability and determine who is eligible for free intervention services. IDEA applies only to students with one of the below disabilities and need special education as a result. The 14 disability terms include:


Zero Reject:
All children regardless of the degree of disability are to receive an education. Initially, these children were to receive priority for service due to the fact that they were probably not receiving appropriate service at the time (4).

Least Restrictive Environment:
The Least Restrictive Environment (LRE) requirements of the Individuals with Disabilities Act, 2004 (IDEA) state that, “ to the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities are educated with children who are non-disabled and special classes, separate schooling or other removal of children with disabilities from the regular educational environment occurs only if the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.” A child’s level of classroom participation will depend on what is appropriate for their needs and age (4).
http://www.parentednet.org/publicationPDF/LRE.pdf

Right to Due Process
The right to due process outlines the parent’s numerous rights including the right to an impartial hearing, the right to be represented by counsel, and the right to verbatim transcript of a hearing and written findings. It also states that a parent should be able to get reimbursed for legal fees if they prevailed in a court case (4).

Nondiscriminatory evaluation
According to onlineacademics.org, in order for a child to be eligible for special education services, the child needs to be evaluated through appropriate assessment. Nondiscriminatory tests should be administered, with no one test being the sole criterion on which a child’s placement be based. For example, a student with mental retardation needs IQ and adaptive skills qualification (6).


‍‍‍Individualized Educational Program‍‍‍

School-aged children, ‍‍‍3 to 21‍‍‍ years of age receiving special education must have an individualized educational program (IEP) (4). This program outlines the specific special education, related services, and supports the child will need throughout their education. The IEP is developed annually.

According to nichcy.org an IEP must contain the following:
  • A statement about the child’s present levels of academic achievement and functional performance
  • Measurable annual goals
  • A description of the child’s progress
  • A statement of the special education and related services and supplementary aids and services provided
  • A statement of program modifications or supports for school personnel
  • An explanation of the extent, if any, to which the child will not participate with nondisabled children
  • A statement of any individual accommodations
  • The projected date for the beginning of the services and modifications, and the anticipated frequency, location, and duration of those services and modifications

An IEP meeting consists of:
  • The child’s parents
  • At least one regular educator
  • At least one special education teacher
  • A representative of the local educational agency who is qualified to provide or supervise specially designed instruction and is knowledgeable about the general education curriculum and resources
  • An individual who can interpret the instructional implication of the evaluation
  • Other individuals who have knowledge or special expertise regarding the child
  • The physical therapist has a professional obligation to participate when decisions regarding PT are being made.
external image iepteam.gif
http://www2.ed.gov/parents/needs/speced/iepguide/index.html

http://www.sagepub.com/gargiulo3estudy/pdf/Gargiulo_IEP.pdf shows a sample IEP.


Parent Participation
Parents are encouraged to be active participants under the Education of All Handicapped Children Act. It is the parent’s responsibility to ensure continuity of services for their child. The parent’s role is important to the IEP because they can provide information on their child’s strengths and weaknesses as well as any family factors that may affect the child’s learning (4).


Related Services
Any developmental, corrective or other services which help the child meet educational goals such as but not limited to: counseling, PT/OT/ST, audiology, mobility, and health services.(5)

Transitions Services
Coordinated set of activities that promote movement from school to post-school activities, such as (among other things) employment, post-secondary education, or vocational training (5).

Assistive Technology
An assistive technology device can refer to any equipment that helps assist a child with disabilities. Assistive technology services include the evaluation, selection, purchasing, and coordination with education and rehabilitation plans and programs (4). As physical therapist we can play a part by adapting a child’s seat, providing walkers or wheelchairs so they can better participate in school.

Response to Intervention
Response to intervention uses evaluation and intervention processes to determine if the child needs a change in instructional modification and increasingly intensified services for students having problems in school. Physical therapists can add input by not only providing adaptive equipment but also by suggesting learning strategies (4).

Extended School Year
Some parents were beginning to realize that their children with special needs were regressing during summer break and they needed several months to regain those skills when they returned to school in the fall. Eligibility for extended school year (ESY) services is based on several criteria. These include “individual need, nature and severity of the disability, educational benefit, regression and recoupment, self-sufficiency and independence, and failing to meet short-term goals and objectives.” (4) As physical therapists it is important to do an examination and evaluation before and after school breaks. By documenting a child’s regression after a break it will better enable a child to receive physical therapy over the summer (4).

‍‍‍Models of Service Delivery‍‍‍

Service delivery models are the frameworks that describe the format in which intervention is provided. Research shows that therapists often use a combination of these models (4).

Direct Model (4)
  • Therapists is the primary service provider
  • Most common model
  • Best for acquisition of motor skills and when therapy cannot be delegated
  • Natural environment or an isolated “pull-out” setting

Integrated Model (4)
  1. Therapist interacts with both child and teacher/aide/family
  2. Services provided in learning environment
  3. Several people involved in implementing therapy program
  • Frequently includes direct and consultative services
  • Everyone serving the child should be instructed on how to incorporate therapy

Consultative Model (4)
  • Therapist interacts with educational team, including the parents, who will implement recommended activities
  • PT provides instruction and demonstration, but no direct intervention
  • Responsibility lies with the individuals receiving the consultation
  • Programmatic consultation is the major activity of the PT at the beginning of the year and is often be more important than child-specific goals
    • Safety, transportation, architectural barriers, equipment, documentation, continuing education, and improvement of program quality
    • Goals can't be made until the environment is safe, child is positioned correctly, and a safe means of mobility has been established

Monitor Model (4)
  • PT shares information/provides instruction to team, maintains regular contact with child to check status, and is responsibility for outcomes
  • No direct intervention
  • Important for follow-up of children who have impairments/activity limitations/participation restrictions that might progress
  • Therapist can check adaptive equipment/assistive devices
  • Monitoring is important to determine whether the child is progressing to next level of education or transitioning from direct to no services

Collaborative Model (4)
  • An interactive team approach focusing on enhancing the academic achievement and functional performance of all students
  • It focuses on team management and how to interact to select appropriate services
  • Should play a part in each model
  • Role release and crossing of disciplinary boundaries is greater than integrated model
  • Team consensus must be found for goals/objectives/activities

Relational Goal-Oriented Model (4)
  • Focuses on the “how” of service delivery and incorporates relationship-based practice with goal orientation
  • Six elements: 1) Overarching goals 2) Desired outcomes 3) Fundamental needs 4) Relational processes 5) Approaches, world-views, and priorities 6) Strategies
  • Elements are applied to client-practitioner and practitioner-organization relationships

Table 30-1: Physical Therapy Services-Delivery Models in Education Settings (pg. 978)
Table 30-3.png

Eligibility for Physical Therapy (4)

  • A motor delay or disability doesn’t qualify a student for special education and related services; the child must have an educational need for special education in one of the categories previously listed
  • “Required to assist a child with a disability to benefit from special education”

Evaluation (4)
  • Used to determine school-based PT needs, IEP goals, frequency and duration selection, and ESY services
  • Federal education law differs from Guide to PT Practice in reference to evaluation, main objective is to “assist in determining whether the child is a child with a disability” and to determine educational needs.
  • Comprehensive evaluation completed no more than once a year and at least every 3 years
  • Evaluation follows ICF model and is reported from the perspective of access, participation, and progress
  • IDEA 2004 mandates that goals/interventions be based on academic demands and functional performance
  • Assessments should focus on identifying level of assistance needed and the modification of the environment needed to fully participate
  • School Function Assessment
    • Judgement-based, criterion-referenced measure that is discriminative and evaluative
    • Assesses activity, required support, and performance in daily school routines
    • ~30 min and multidisciplinary team to complete
    • Overview of the School Function Assessment (17)
  • School Outcome Measures

‍‍‍Developing Goals and Objectives‍‍‍ (4)
  • PT assists in developing appropriate, measurable, annual goals that are academic and functional.
  • Outcome statements don’t have to be measurable, but must be functional and should define the goals required to meet them
  • Short-term objectives break goals down into manageable parts, tracked through progress reports. These allow additional services to be added that may not have originally been included
  • Goals must be measurable, meet IDEA 2004 requirements, be discipline-free, and be written to be achieved within the year
  • Outcomes should:
    1. Relate to functional skills and activities
    2. Enhance the child’s performance in school
    3. Be easily understood
    4. Be free of professional jargon
    5. Be realistic and achievable within the IEP timeframe
  • Annual goals should state the behavior and explain the conditions and the criteria used to determine if they are accomplished

Frequency and Intensity of Intervention (4)
  • Frequency and intensity are determined in the IEP meeting, determining a balance of education, therapy, and leisure
  • Table 30-3 shows the Iowa guidelines, a matrix of factors to consider when deciding the extent of PT
  • The Considerations for Educationally Relevant Therapy for OT and PT (CERT), is a clinical reasoning tool that used to assist in determining school-based therapy services
  • Determination of Relevant Therapy Tool (DERT) is a clinical reasoning tool used to validate decisions related to models and delivery of services, beyond the use of clinical judgement alone

Intervention (4)
The Guide to PT Practice describes 3 components of intervention: coordination/communication/documentation, patient/client-related instruction, and procedural interventions
  • Coordination, Communication, and Documentation (4)
    • Communication must be maintained with all personnel
    • Documentation in pediatrics must be family-centered and should emphasize function abilities
    • Documentation must follow state and national requirements for education and PT
    • PT must document
      • All strategies, interventions, staff/student training/education, and communication with the parents or community based services; including writing a discharge summary
  • Child-and Family-Related Instruction (4)
    • Practice is essential for acquisition, fluency, and generalization of skills
    • Instructing parents/staff members should be a major component of all plans
    • Integrated & collaborative models both require that teachers/staff/parents assist in delivering intervention
    • The PT should directly intervene at the acquisition stage of learning, allowing team to take over at fluency & generalization stages
  • Procedural Interventions (4)
    • Direct intervention
    • Natural environment is recommended but may not be realistic or appropriate with older students
    • Use furniture and tools in the natural environment instead of bringing in tools, to allow children to practice when therapy is not in session
    • Therapy is discontinued after a period of service with no measurable progress

IDEA Part C


Providing early intervention services

‍‍‍Under Part C of the IDEA, early intervention services designed to meet the developmental needs of the infant/toddler (birth-3 years) with a developmental delay and their families (4). Services providers collaborate with parents and caregivers to provide services in natural environments to develop and encourage participation in daily activities and routines‍‍‍ (4)‍‍‍. Early intervention services is family-centered care, it respects the rights and roles of family members while providing child interventions to support the child's development and function to meet family needs (4).

Site which is summarial of Part C and a nice source for parents, teachers, and professionals:
http://www.wrightslaw.com/info/ei.index.htm

Eligibility

Children qualifying for IDEA Part C must have a diagnosed condition associated with developmental delays or developmental delay in any of the following areas: physical, cognitive, social/emotional, communication, and adaptive development (4). ‍‍‍The percentage of developmental delay required to qualify for IDEA part C varies from state to state.
  • Missouri requires a diagnosed condition or 50% developmental delay in one of the above areas (12). MO Requirements
  • Kansas requires 25% (1.5 SD) developmental delay in one area or 20% (1 SD) in two or more areas (11). KS requirements

Below is the site which links to Part C eligibility requirements state by state:
http://www.nectac.org/~pdfs/topics/earlyid/partc_elig_table.pdf

Early intervention services included in the IDEA (4)

  • family training, counseling, home visits
  • special instruction
  • speech-language services, and sign language/cued language services
  • occupational therapy
  • physical therapy
  • psychological services
  • service coordination
  • medical services for diagnostic/evaluation
  • identification, screening, and assessment services
  • social work services
  • vision services
  • assistive devices
  • transportation

Components of Part C (4)

  • ‍‍‍Early intervention services for all infants and toddlers with disabilities (from birth to age 3) and their families
  • Child Find
    • Screenings provided free of charge as a requirement of the state to identify and evaluate children who may need early intervention services (3)
    • external image hide_and_seek.jpg
  • Comprehensive, multidisciplinary evaluation (MDE)
    • Evaluations funded by the state to determine the nature of the child's strengths, delays or difficulties and to determine whether or not the child is eligible for early intervention services (3)
    • If eligible then the child will be assessed to determine the appropriate services necessary to meet the needs of the child and family (3)
  • Individualized family service plan (IFSP)
    • A written document that outlines the early intervention services that the child and family will receive (3)
    • Guiding principle of the IFSP is that the family is the child's greatest resource and the best way to help the child is to support and build upon the strengths of the family (3)
    • Reviewed every 6 months and updated atleast once a year
  • Procedural safeguards
    • Helps to explain the rights and safeguards in a way the family can understand to make sure that the family is fully informed (20)
  • Public awareness program
    • Part of the comprehensive child find system; keeping the general public, families and primary referral sources in the know (20)
  • Central directory
    • Database containing information on community services, counseling, evaluation, early intervention services, education, screening, support groups and therapies for children
    • National toll-free line 1-800-654-4440 can be used as the electronic link for callers to be connected to their State and Local Departments of Health (21)
  • Comprehensive system of personnel development
    • Recruitment and retention of early service providers; training personnel to coordinate transition services for infants and toddlers (20)
  • Administration by a lead agency- designated by the governor
    • Kansas: Health and Environment
    • Missouri: Education
  • State interagency coordinating council‍‍‍- appointed by the governor to assist the lead agency in program implementation
    • At least 20% of the members must be parents of children with disabilities (20)

Providing early intervention services (4)

The role of the physical therapist: The acquisition of motor skills. Interventions promote children's activity and participation through motor learning, environmental adaptations, assistive technology, family support, and education.

Team collaboration

  • Form partnerships among family, transdisciplinary service providers "coaches", and the community through home visits, co-visits by team members, regular communication with the service coordinator, use of individual and group interventions, parental service options, and flexibility in schedule/staffing.

Evaluation & assessment

  • Gather information through family interview, observation in child's natural environment, test and measures to evaluate motor development, function, and body structures/function.

Individualized Family Service Plan

  • Includes a statement of the child's present level of development; family resources, priorities, and concerns; expected measurable outcomes; specific early intervention services needed: frequency, intensity, methods; natural environments where services will be provided; other services to enhance child development; projected initiation and duration of services; identify the service coordinator; and transition plan.
  • Description of IFSP

Providing services in natural environments

  • Natural environments are settings that are normal for non-disabled peers, any place where children participate in activities and routines that provide learning, development, function, and behavioral support. Therapists also can adapt the environment to better support the child's access and participation.
  • external image 017.jpgexternal image swings.JPG

Transition

  • Steps to be taken to assure smooth transition into the educational system or into the community. Increased coordination between IDEA part C and IDEA part B Preschool services. With family permission, share information with the preschool so they can meet the child's needs. Provide the family with resources, information and support services as they prepare for preschool transition.
  • external image Toucan-Story-Time.jpg

Effectiveness of Early Intervention

    • A collaborative team model developed by Palisano, Chiarello, and O'Neil (10)
      • Provides framework for implementing the components of early intervention strategies.
      • Components of Intervention on the left; Child and family outcomes on the right

screen-capture.png
Figure 1. taken from Palisano et al.

Questions to Discuss with Families when Establishing Activities in Natural Environment (4)
  1. What activities make up your weekdays and weekends?
  2. What activities are going well/ not well?
  3. What activities would you like support for?
  4. What activities does the child prefer to participate in?
  5. What activities provide natural learning opportunities?
  6. What activities provide opportunities for child initiation?
  7. What activities provide opportunities for peer interaction?
  8. Are there new activities that you would like to try?

Strategies for PT Interventions (4)
  • Communication and Coordination of Services
    • Early intervention team meetings every 3 months
    • Co-visits of early intervention team providers every 3 months
    • Identification and access of community resources
    • visit or phone conference with other health care professionals
  • Information Sharing with the Family
    • Provide information on family-identified needs
    • Embed interventions into child's and family's daily life
    • Conduct visits when family members can participate
    • Conduct visits at a community location when family indicates need
    • Provide intervention in different rooms in the home to support a variety of daily activities/routines
    • Implement adaptations, functional training and restorative/preventive techniques
      • to support self-regulation, parent-child interaction, play, self-care, and mobility


Local Services

Kansas:
  • ‍‍‍The Kansas Infant-Toddler Services website provides information for both families and professionals, as well as forms, publications, a list of meetings and events, programs, and a list of state contacts. The also has a link to a brochure list of Local Networks that the Kansas Department of Health and Environment provides grants to maintain early disciplinary services to infants and toddlers with disabilities. (11)
Missouri:
  • First Steps is the Missouri Department of Elementary and Secondary Education's early intervention program. This site includes news updates regarding services and developments, information for parents and providers, contact information, eligibility, referral, and a parent newsletter.
  • First Steps System Point of Entry for regions of Missouri
  • Key Features of Part B and Part C in Missouri‍‍‍ (12)

Case summary


References

  1. Dole, R. Arvidson, K. Byrne, E. Robbins, J. (2003) Consensus Among Experts in Pediatric Occupational and Physical Therapy on Elements of Individualized Education Programs. Pediatric Physical Therapy. 15:159-166.
  2. http://idea.ed.gov/
  3. http://nichcy.org
  4. Campbell, S., Orlin, M., & Palisano, R. (2012). Physical Therapy for Children (4th Ed.). P 944-993. St. Louis: Saunders Elsevier.
  5. http://ada.ky.gov/education_act.htm
  6. "Nondiscriminatory Evaluation in Special Education (Sawyer & Aitken)." Nondiscriminatory Evaluation in Special Education (Sawyer & Aitken). N.p., n.d. Web. 23 Sept. 2012. <http://onlineacademics.org/Nondiscriminatory.html>.
  7. "Sample Individualized Education Program." N.p., n.d. Web. 23 Sept. 2012. <http://www.sagepub.com/gargiulo3estudy/pdf/Gargiulo_IEP.pdf>.
  8. "The Least Restrictive Environment." Parent Education Network. N.p., n.d. Web. 23 Sept. 2012. http://www.parentednet.org/publicationPDF/LRE.pdf
  9. Effgen SK, Chiarello L, Milbourne SA. Updated competencies for physical therapists working in schools. Pediatric Physical Therapy 2007. Winter; 19(4): 266-274. PMID 18004193.
  10. Palisano R. A collaborative model for service delivery for children with movement disorders: a framework for evidence-based decision making. Physical Therapy [serial online]. September 2006;86(9):1295-1305. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 24, 2012.
  11. http://www.ksits.org
  12. http://dese.mo.gov/se/fs/
  13. http://www2.ed.gov/policy/speced/leg/idea/history.html
  14. http://febp.newamerica.net/background-analysis/individuals-disabilities-education-act-overview
  15. "Contents of the IEP." — National Dissemination Center for Children with Disabilities. N.p., n.d. Web. 25 Sept. 2012. <http://nichcy.org/schoolage/iep/iepcontents>.
  16. http://www.ksde.org/LinkClick.aspx?fileticket=ywa9UK3yBnA%3D&tabid=3757&mid=8919
  17. http://www.pearsonassessments.com/NR/rdonlyres/488D674B-461A-44CD-B1DD-232E77AD0924/0/SFAOverview.pdf
  18. http://www.ah.ouhsc.edu/somresearch/adminGuide.pdf
  19. http://www.fldoe.org/ese/pdf/therapy.pdf
  20. http://www.nectac.org/topics/procsafe/procsafe.asp
  21. http://www.centraldirectory.org/about.cfm
  22. http://www2.ed.gov/about/offices/list/ocr/docs/edlite-FAPE504.html