analysis summary

COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)

Special Needs: Scholastic Disability Accommodations from K-12 and Transitions to Higher Education

Vivien Chan1,2

Published online: 25 January 2016 # Springer Science+Business Media New York 2016

Abstract The number of students entering post-secondary education with already diagnosed disabilities is on the rise and mirrors the percentage of children in primary and second- ary public schools with registered disabilities. Requirements governed by civil rights laws fundamentally change when comparing the support schools have to provide to students during primary and secondary school with disability access in postsecondary higher education. Psychiatrists may be asked to assist with scholastic disability at any stage of education and need to know about available supports and the parameters of disability in schools. Specifically, special attention should to be made in preparation for transition to postsecondary ed- ucation when prior accommodations exist.

Keywords College . Disability . IEP . Accommodation .

Psychiatry

Introduction

According to the National Center for Education Statistics, American school-age youth spend an average of 6.64 h in the classroom in 180 days out of the year [1], which is roughly

40 % of their waking lives for about 50 % of a calendar year. How our nation’s children and adolescents achieve in school can foreshadow some measurable predictors, such as future education, job opportunity, and occupation. In-school behav- ior may also predict many indirect and possibly more impor- tant life skills, like interpersonal competence. The cognitive flexibility and higher executive skills fostered in early educa- tion can later impact resilience and functioning [2].

Because diagnoses of psychiatric conditions, by their def- inition, require “clinically significant distress or impairment in social, occupation or other important areas of functioning” [3], many patients struggle in school and in the workplace. Pa- tients have rights and protections afforded to them based pri- marily in three federal civil rights laws: (1) Individuals with Disabilities Education Act (IDEA) of 2004 [4], (2) Americans with Disabilities Act (ADA) of 1990, sometimes called Title II and Title III, which was amended significantly in 2008 as ADAA [5], and (3) Section 504 of the Rehabilitation Act of 1973, often called “Section 504” [6]. The first law, IDEA, offers early family intervention for infants and toddlers with disabilities as well as significant support in public education for children with educationally impacting disabilities age 3 to 21 years during school attendance through high school. It also gives federal funding support to states for special education services. Legislating a “free, appropriate public education,” commonly abbreviated as “FAPE” [4], this tenet is the foun- dation of a complex system of rules, regulations, and formal processes that can, despite its nomenclature, be expensive and time-consuming to navigate. As challenging as IDEA can be, it is structured to potentially offer a high degree of support to children and adolescents. It requires a unique educational pro- gram that is customized to each specific child who needs spe- cial education services to receive them in the least restrictive environment, and it offers due process when a family has disagreement with the school district.

This article is part of the Topical Collection on Complex Medical- Psychiatric Issues

* Vivien Chan [email protected]

1 Psychiatry Service, Student Health Center, 501 Student Health, Irvine, CA 92697-5200, USA

2 Department of Psychiatry & Human Behavior, UCI Health, University of California, Irvine, USA

Curr Psychiatry Rep (2016) 18: 21 DOI 10.1007/s11920-015-0645-2

When students with disabilities, whether through early in- terventions or natural development, advance to higher educa- tion, the rules for educationally based support change dramat- ically. In higher education, the latter two laws, ADA and Section 504 apply, and their focus is on equality of access and nondiscrimination. Public and private institutions which receive federal funds must make certain accommodations for students with disabilities so as not to be discriminatory. For example, prior to 2011, some colleges and universities interpreted students who made suicide or self-harm attempts as “direct threats” defined in ADA and would impose sanc- tions on these students, including dismissal. However, recent Title II clarifications made by the Office of Civil Rights (OCR) in March 2011 stopped including “threat to self” in its direct threat language, thereby sending a message that sanc- tions for suicidal or self-harm behaviors would be considered discriminatory. Described in a helpful paper from the National Association of College and University Attorneys published in 2014 [7], guidance on how campuses can assist students with suicidal and self-harm behaviors while remaining in compli- ance is inferred from the federal government’s various rulings. The knowledgeable psychiatrist can be ideally suited to help guide patients and families with special needs.

IDEA from Birth Through Grade 12

Pathway to Referral

Babies and toddlers (up to age 3 years) who have develop- mental delay or disability can be eligible for early intervention under Part C of IDEA [4]. Developmental areas supported include cognitive, physical communication, social or emo- tional, and adaptive (i.e., self-care). Most of the time, primary referral sources, such as medical providers (pediatricians), public health, and social service agencies initiate the process. Each state has a designated lead agency to manage these ser- vices. The Early Childhood Technical Assistance Center has organized a list of these centers by state at http://ectacenter. org/contact/ptccoord.asp. Families themselves who are concerned can also make self-referrals. Part C early intervention services end at the transition to preschool. At that time, Part B of IDEA supports FAPE for children with disabilities age 3 through 5 years under preschool program criteria, primarily working with Head Start [4].

Vignette: A psychiatrist is working with a mother who, during delivery of her now 8 month old baby, had sig- nificant perinatal medical complications. The mother describes that her child is not yet sitting up. The psychi- atrist encourages her to see the pediatrician or a developmental-behavioral pediatrician so that a referral

to early intervention services can bemade on the infant’s behalf.

The process in kindergarten through grade 12 is parallel but more restrictive. Parents themselves or schools can refer chil- dren and adolescents with suspected disability for evaluation. The difference in K-12 grades is that there are no other qual- ifying primary referral sources other than schools and parents. Those with qualifying disabilities include “mental retardation, a hearing impairment (including deafness), a speech or lan- guage impairment, a visual impairment (including blindness), a serious emotional disturbance (referred to in this part as “emotional disturbance”), an orthopedic impairment, autism, traumatic brain injury, another health impairment, a specific learning disability, deaf-blindness, or multiple disabilities, and who, by reason thereof, needs special education and related services” [4]. Schools can initiate assessments, and parents can request assessment. In order for an assessment to be con- ducted, parental consent is required. Modifications to the law in 2008, however, hold schools accountable to continue their obligation for assessment and services even if parents do not consent by creating consent-override procedures [4]. To nav- igate the individual educational plan (IEP) process, parents may need to consult with formal educational advocates and attorneys. About 11.6 % of students in public schools [8] and about 7.1 % of private school students [9] have an IEP.

Vignette: The same psychiatrist continues to work with the same mother across the span of years. The mother’s child is now 7 years old. The child graduated from mo- tor skills services as an infant, but now the mother de- scribes that the child seems to be reading slowly. Even though some cognitive language delays were detected earlier, these have been attributed to bilingual language status in the home by the school. The child has been placed in English-second language services. The psy- chiatrist, with permission, consults with the child’s new pediatrician who writes a note on a prescription pad to the school for the child to get an assessment for more reading services. Nothing happens.

Eligibility, Letter Writing, and Plan Types

Note that the start to special education services is a written request for an assessment at public expense. The qualifying initial assessment is one conducted by the public school dis- trict. At birth to 3 years, once a baby or toddler qualifies, an individual family service plan (IFSP) is written, which articu- lates the current level of functioning; major expected results; specific intervention services to be received; and their fre- quency, location, and duration. A service coordinator is

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assigned, and steps to transition out of early intervention to preschool are also written [4].

Once a child completes an IFSP, a child may have to be re- assessed to qualify for special education services after age 3 years, written as an IEP. Initiating an IEP assessment, again, starts with a written request from the parent. Having an IFSP does not naturally guarantee progression to an IEP. Just be- cause a disability or a qualifying condition has been identified at any point between 3 and 21 years, it does not automatically trigger special education services. The qualifying initial IEP assessment is required to show that disability is directly ad- versely impacting educational progress [4].

Vignette: The same psychiatrist and same mother are more informed about the process on how to obtain ser- vices. This time, the mother generates a letter and de- livers it to the school principal requesting an assessment about her child’s language skill development. She re- ceives a response letter that an assessment will be started within 30 days’ time, and it also notices her about her rights and consent to the process.

The qualifying initial assessment is required to contain a “variety of assessment tools and strategies” and collateral in- put, including parental. One of the main areas of controversy between parents, clinicians, and schools can be the qualifying data and the interpretation of data used in the assessment. The school system is responsible for an “evaluation that is suffi- ciently comprehensive to identify all of the children’s special education and related service needs, whether or not commonly linked to the disability category in which the child has been classified” [4]. Some states require diagnoses by medical pro- fessionals, but many other states do not. Parents and children, as well as educators, are then in a strange limbo where the schools do not officially render diagnoses but are required to perform assessments. Assessments may pick up discrepancies in learning, such as slower visual or auditory skills that are commonly described as processing disorders or deficits, but these terms have no formal corollary in the medical field. Also, some assessment reports are written to emphasize the positive so well and describe deficits so minimally, parents may not understand the implications of significant deficits found by assessment.

Vignette: Parents of an adolescent consult with a psy- chiatrist because their teenager is exhibiting neurovegetative symptoms and acting out behaviors. When giving the developmental history, they report that the adolescent received speech and language services in elementary and middle school. The parents do not iden- tify any specific learning disorders by name. Now in high school, those services have not been continued. The psychiatrist obtains consent and receives copies of

several years’ worth of IEPs. In them, it is clearly and repeatedly stated that the then-child had significant lan- guage disorder and was qualified for services under both expressive and receptive language deficits. When the parents and psychiatrist meet again, the parents mention a vague recollection about “language” and ask to be educated on the diagnoses. With the psychiatrist’s guid- ance, the parents request another IEP review in writing, and curricular modifications are made. The adolescent continues to receive psychiatric services, and the new educational changes are significant.

When parents disagree with assessment evaluation results, they may request an independent educational evaluation (IEE), which is an evaluation conducted by a qualified exam- iner who is not employed by the public agency responsible for the child’s education [4]. This request also sets a chain of events regarding due process, recognition of private evalua- tion data by the school district, and payment for the IEE. Once a student qualifies for special education, the rules require re- evaluation every 3 years, colloquially known as the triennial IEP. Schools are also required to accommodate parents who need their own special assistance or language interpreter ser- vices for due process throughout.

To describe special education services, an IEP is written which must meet certain federal regulatory (and relevant state) requirements. Special education does not always mean attend- ing a special classroom. The IEP is put together by the IEP team whose members are also described by regulation (e.g., parent, regular education teacher, special education teacher). The specific IEP needs to include descriptions of the “present level of academic achievement and functional performance, a statement of measurable annual goals for progress, description of supplementary aids, any individual accommodations to state and district assessments and how periodic progress will be measured” [4]. Many schools work diligently with their faculty, students, and parents collaboratively for great out- comes. But, it is also important to note that IEPs are required to offer appropriate services to meet the needs of an individ- ual student, but rulings have found that schools are not held to the standard of providing the best possible services.

Vignette: Parents of a struggling adolescent have been working with their local school on the IEP to provide educational supports, including those for emotional de- velopment. The parents become increasingly frustrated at the pace of accommodations and decide to remove their adolescent from public school to enroll in private school. Meanwhile, the parents engage in litigation against the school for what the parents believe to be IDEA noncompliance. The parents are seeking private school tuition be covered at public expense. This pro- cess takes several years to resolve, and the

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administrative law judge finds that the school is not responsible for the private tuition because the public school offered reasonable accommodations.

Parents and psychiatrists need to know that all communi- cations with schools and school districts regarding special education assessments and ongoing services should be con- ducted in writing. Written requests are the only types of re- quests that are formally supported by the law, and written requests start the procedural clock on due process timelines. One very helpful resource is the third edition of “Communi- cating with Your Child’s School Through Letter Writing,” (January 2011), accessed at http://www.parentcenterhub.org/ repository/letterwriting/. This guide, available in both English and Spanish, helpfully templates many possible letters a parent may need to communicate with their local school or school district (starting the process, following up, requesting evaluation, requesting placement change, invoking safeguards to resolve disputes).

The IEP is the most formal type of plan subject to due process about special education services between the school district and an individual student. Not all students with diag- noses or learning disorders may require comprehensive spe- cial education services. This is where Section 504 of the Re- habilitation Act may apply. Section 504 of the Rehabilitation Act is a civil rights law which predates IDEA and ADA that prohibits discrimination in federally funded programs based exclusively in disability. Unlike the 13 qualifying conditions cited in IDEA, Section 504 more broadly defines individuals with disabilities. Both the ADA and Section 504 define dis- abilities as having impairments in general major life activities or in major bodily functions, including the operation of an individual organ within a body system. Major life activities are described as “including but not limited to caring for one’s self, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, commu- nicating and working.” Disability impairments are supposed to be weighed “without regard to the ameliorative effects of mitigating measures such as medical technology and supplies, use of assistive technology, reasonable accommodations or auxiliary aids or services, or learned behavioral or adaptive neurological modifications.” Determination of disability also “usually will not require scientific, medical, or statistical anal- ysis” [5, 6]. As a result, schools are required to provide adap- tations so that students have equal access to their learning needs. Under a 504 plan, a team also must be convened to offer services and possibly, accommodations. However, a 504 plan does not have to be written, and it has much less regula- tory burden to the school. Section 504 plans tend to be regu- lated at the individual state level. Section 504 does not distrib- ute any state or federal funds to schools to be in compliance. There are many free resources available which contrast the

differences between IEPs and Section 504 plans, including online.

Vignette: A father writes a letter to the middle school asking for assistance with his pre-adolescent child’s chronic motor and vocal tics. At first, the school con- venes an informal team under a 504 Plan to have some in-class education about tics. Motor and vocal tics con- tinue to be exhibited in school, and these are interfering with learning. Later, the father writes a specific letter requesting a formal assessment for an IEP, and after qualifying for special services, accommodations are made for the student to be given extra time on classwork and to take tests in isolation.

Accommodations for students in an educational system can vary significantly. The educational system defines evidence- based practices differently than medical systems. In the edu- cational system, reaching improved outcomes and attaining previously stated goals are considered effective. Even though various strategies are often applied, there, to date, have been no equivalent “double blind, placebo controlled, randomized” trials examining the components of modifications like allowing extra time on work, or testing in a quiet envi- ronment. Many schools and educators are sufficiently occupied with delivering educational content to engage in the rigorous research that may elucidate best practices in accommodations.

Transition Services

IEP regulations require that, just like IFSPs, transition out of special education into the “post-education” world need to be addressed, and the regulations require it be discussed at least by age 16 years [4]. They also require that the adolescent take part in their transition services and that an adolescent be fully informed about the process at least 1 year before exiting spe- cial education when appropriate. Transition services range from vocational and employment training, independent living and adult services, and postsecondary education. Hopefully, options about graduation and diploma versus certificate com- pletion options will have long been discussed. Even though IDEA requires that public schools include students in a tran- sition of services starting at age 16 years, many families are unprepared for the student to be “in charge.” Here, the knowl- edgeable psychiatrist may be ideally suited to guide patients and to explicitly discuss taking on more self management skills. Parents may fear seeking special education services out of a misbelief that their child will be permanently labeled in some way. The federal government is very clear through the Department of Education that special education classes are not permitted to be particularly identified on high school tran- scripts [10]. Careful reading of certain class titles, e.g., “basic

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math,” “resource social studies,” may reveal the special edu- cation class, but other specific disclosures would violate dis- ability laws.

Vignette: A parent and 19 year old student with a diag- nosis of autism have been working cooperatively with their school district on the transitional IEP. This plan allows the student to practice independence by taking classes at the local community college. The student wants to eventually apply to law school, but due to the student’s intellectual abilities, the student will not actu- ally graduate with a traditional high school diploma. It is instead anticipated that the student will receive, by age 21 years, a certificate of IEP completion. Any transcripts released to postsecondary institution applications, how- ever, will not carry specific IEP notifications except for some descriptions of class names which could be revealing.

Written IEPs are often lengthy, and when a child has had services from an early age, parents may have mul- tiple three-ring binders’ worth of documentation. Once students exit grade 12 equivalents, they have formally exited public school as well as the rights afforded to them within IDEA. Adolescents and young adults who move directly into the workforce will then enter rules and regulations under the ADA or Section 504 in the workplace. Similarly, those entering higher education who require services will do so under the ADA or Section 504. There, the educational content or curricu- lum is treated more like “work.” It is a significant change where the educational program can no longer be altered, modified, or changed in any fundamental way as it could within special education. The material or environment must be made accessible, but the con- tent must be the same for all students. Many students and families, having been specially nurtured during kin- dergarten through 12th grade, are in for a change in higher education. Around 11 % of enrolled postsecond- ary students register with pre-existing disabilities, mirroring the rates in primary and secondary schools [11]. Some colleges, workplaces, and vocational pro- grams may continue with written individual plans, but they will no longer formally be IEPs. The staffing ratios for support in higher education compared with K-12 grades are also significantly different. Based on national survey data, current public school staffing ratios are 1 full-time equivalent (FTE) counselor to 370 students, 1 FTE psychologist to 820 students, and 1 FTE social worker to 660 students [12]. In higher education, an often-quoted target ratio for counseling services, which is usually applied to psychological services, is 1 coun- selor to 1000–1500 students [13].

Challenges and Controversies in Higher Education

Change in Accommodations

When transitional age youth and emerging adults require accommodations beyond grade 12, they move into a world where accommodations no longer have any at- tached federal funding. Unlike the IEP process where large teams convene for each individual student, many institutions of higher education have an office or center to assist them and their students in being compliant with ADA and ADAA. While professors and parents may be consulted, they are no longer central to educa- tional accommodations. A common role of professors is to provide an alternate examination that may be admin- istered in a separate location at a different time. It is the role of the disability office, and not the role of students, parents, professors, or medical professionals to deter- mine what accommodations are given. On many cam- puses, students are discouraged from making individual arrangements with professors about their academic needs. Medical practitioners also may need to be clear that disability services in higher education may or may not be linked to state Department of Rehabilitation or federal Social Security Administration disability benefit services. In the majority of times in postsecondary edu- cation, they are completely separate.

Vignette: A student with multiple recognized disabilities entering his first year of college does not want any ac- commodations for the first year, instead wanting an ex- perience “like everybody else’s.” After he obtains a fail- ing grade in the first term, his mother calls the health office and the disability office to make arrangements. She is told that the student must make his own appoint- ments. He does not present to the psychiatrist until he is in subjective crisis, having received a letter of dismissal after the third term, for failing grades. He eventually decides to enroll in a different, community college, and this time, he makes a plan to go to the disability office at the start.

Higher education students must initiate their services. Unlike Section 504, where schools are required to an- nually identify children with disabilities and to provide services, in postsecondary education, students (and not their parents) must self-identify. Young adults are also now the ones responsible for any self-advocacy if they believe that their accommodations are insufficient. There are many preparatory resources also freely available about the transition, including this guideline by the US Department of Education http://www2.ed.gov/about/ offices/list/ocr/transitionguide.html.

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