The roulette wheel of qualifying for preschool special education services.

I received a referral today for Trevon, who I initially evaluated eight months ago. His mother was concerned about his development and asked the school system for help when he turned three years old. The initial OT evaluation indicated that he had significant fine motor delays and a speech evaluation indicated that he had significant speech and language delays. The school approved speech therapy and a special education teacher but declined the occupational therapy.

Eight months later, I received an authorization to provide services because the motor concerns were impacting his participation in preschool. In the interim months when there was no OT intervention a second OT evaluation was completed which had essentially identical findings to the first evaluation. Apparently, the lobbying efforts of the preschool teacher and speech language pathologist helped convince the district that the OT services were required.

There are many studies that have been completed that discuss the value of prevention and early intervention services for children - I linked a couple good RAND summaries below for primer reading. I wish that we had more sensible policy about child identification - specifically entrance and exit criteria for pediatric services. So much is left to the decision making of committees, and so often the reasoning behind what is or is not approved is impossible to decipher.

In preschool services, a school district has approximately 24 months (between the ages of three and five) to identify children and provide an intervention program. In Trevon's case, this particular district's whimsical decision making threw 8 of those 24 months away. Based on typical patterns within this school district, it is likely that he will be declassified at the end of his preschool career and an additional 1-2 years will pass before he is reconsidered for CSE participation. How much more opportunity will be lost?

There is no doubt that failure to identify needs and failure to provide services saves money in the short term, but in the above referenced studies it is reported that the returns to society for each dollar invested in early intervention services extend from $1.80 to $17.07. The large variability is due to the nature of individuals. For some, early intervention prevents the need for special education services in later grades. For others there are longer term benefits to society like crime prevention and decreased reliance on social safety nets. Short term savings are notoriously shortsighted.

None of this even touches on the subject of the cost to Trevon. In class he is frustrated and now he tantrums when someone places crayons or scissors in front of him. He has the functional skills of an eighteen month old - and now the world is demanding things of him that he can not do. He could have had support, and his family could have received training and education on how to help him, but we have tossed 30% of his available preschool years away.

If there was reasoning behind the school's decision it is not apparent. He didn't qualify before but now he does. We will improve our system tremendously by employing common sense guidelines for related service entry and exit. There will always be room for individual decision making on borderline cases - but real criteria would allow us to appropriately target children who have needs and who would benefit from timely help.

It shouldn't feel so much like a roulette wheel with the likelihood of a child getting the help they need being governed by chance or house rules.

References:

Karoly, L.A..; Greenwood,P.W., et.al. (1998) Investing in our children: What we know and don't know about the costs and benefits of early childhood interventions. Santa Monica: RAND Corporation.

Karoly, L.A., Kilburn, M.R., and Cannon, J.S. (2005). Early childhood interventions: Proven results, future promise. Santa Monica: RAND Corporation.

Comments

TherExtras said…
The roulette wheel analogy is more accurate than I like to admit. At the same time, I've never been a proponent of strict 'criteria' for 'eligibility' of OT services. I am a proponent of 'professional decision'. In the case of Trevon, what school-OT would not have recommended for related services of OT in preschool? Did the school have a criteria for, say, a 24 month delay in order to qualify for OT in preschool?

I will ask for a little more clarification, Chris....You seem to be making a case that Trevon without OT in preschool is getting nothing/nada/no services. But in fact he is getting preschool with a special ed teacher and speech services. The IEP team may have determined that the curriculum and ST support would be sufficient for him initially in a half-day program. Could it be that the OT is in the classroom often enough to influence accommodations for all the students by means of her relationship with the teacher?

The next clarification is the role of Tevron's parents. If they did not or could not advocate for OT services - that seems to me to be natural consequences. Parents have both the right and the responsibility to participate in the special education process. School districts assume the responsibility for service decision as variously as the people who sit in the meetings. A throw of the die on the wheel.

And why shouldn't services be so variously provided given the various circumstances of each child? The I in IDEA and IEP is for individual. Mountains of regulation has not made all education equal nor can more regulation. Our American culture formed IDEA with the mind of rights and personal decision-making. I think we would have it no other way. Barbara
Chris said…
Great comments - thank you. In theory I like the idea of natural consequences because actually I am a big proponent of people taking care of things themselves. The problem that I run into with this is that the playing field itself may not be well suited for people who are dis-empowered (for whatever reason) or who do not have the resources (and I use the term in the broadest sense) to advocate effectively. It is a conundrum. It also would be a secondary lifework to explore in its full depth!

I think that what I was bothered about in this situation is that there was no apparent reason for the decision that the child didn't qualify.

I understand that entrance and exit criteria are potentially dangerous if they are wielded without consideration of individual factors - but on some days it would be nice to at least have some sense of a standard or a guidepost. Service eligibility, in my experience, is a whimsical decision and varies dramatically between districts. Most therapists that I talk to have a difficult time understanding this because they approach the concept of eligibility within the context of a single district where they work. I look at this from a broad perspective across dozens of districts - and I know that is an uncommon promontory to stand upon and make comments from.

I want it to be more predictable - at least I would have something concrete to expect on a day to day basis!
TherExtras said…
This is an excellent post for discussion, Chris. Agreeing with you on the conundrum of a(n un)level playing field and the expanse of a lifework to level it. But perhaps more than a 'lifework' this conundrum is at more of a 'socialwork'-level. Just think of the natural consequences for a child like Trevon a generation ago. I hope you will agree there has been progress since we began our careers. (Ooops. You appear a tad younger than me.) I believe services and special education (since its inception) have changed the life-trajectory of more people will ever be documented via some published study.

Your desire for more predictability might be an expression of your age, too. Perhaps I became jaded too early in my career, and then began to believe in the rightness of the "individual" and therefore unpredictable decisions made in each IEP meeting. (I did a post related to this - expanding on the many and different agendas brought to the table at each meeting.)

I believe my perspective to be broad also, having provided related services in 4 different states, in districts both inner-city-urban, rural and upper-scale-suburban, between 1979 and 2005.

Trying to squeeze predictability and sameness-of-mind across our country - I'm just not up for trying to make that happen or for living with the constant disappointment from not having it. Within myself I have made/will make consistent and, I believe, good decisions for recommending services for each child given me. Experience and learning morphs my decision-making over time but gradually and not varying much from the question of: can services make a difference for this child under the constraints of his life? I had to learn to walk away from many circumstances where I knew OT could not make a difference, sad, but resigned. Only recently have I had the opportunity to explore my thinking via blogging. You have had that advantage earlier in your life than me - appreciate that, Chris.

Blogging has made a terrific difference in my professional life and I am grateful we can connect here. Barbara
Chris said…
This conversation leads me right back to Mary Reilly's Slagle lecture - where she intimates that good occupational therapy is indeed social work (or perhaps more accurately economic work).

I am not sure if my ideas lead to a broader opportunity for being able to deliver a service. You are correct - trying to balance (perceived) inequities is an interminably disappointing endeavor. That is precisely why I quote Cervantes on the front page of the blog though.

I don't feel like I know how NOT to try though. It's genetically programmed behavior, perhaps - because certainly it is not reinforced by external contexts!

Thanks for your thoughts - I truly appreciate the dialogue. I am humbled and realize that I have no answers. Sometimes I may sound like I do - but more often I am just venting ideas.
TherExtras said…
Well, said, Chris. Vent away! This is your space to do it. Seems to me you are capable of staying in a healthy place despite the realization of inequities in service provision. Genetically programmed behavior - heh, I can relate.
Barbara
Another thought provoking post (and of course love the comments between you and Barbara, sad to see that she is no longer blogging).

Anyhow, I do think that there should be a broad range of entrance and exit criteria especially exit criteria. At times, individual 1:1 therapy services can go on and on at the expense of the child's education. I am all for consultation services for long term involvement of an OT or PT.

Another option to consider instead of entrance and exit criteria is shorter term services. How about 8 week sessions and reevaluate progress towards goals? Are we helping or hindering the overall education? So many OT and PT services are still pull out sessions that take away time from learning in the classroom. An ideal situation would be pre and post academic testing along with pre and post functional testing so that all parties involved are well informed to make decisions regarding services. Obviously that would most likely be impossible because too much paperwork and time but the data collection would help to provide a clearer picture of pros and cons to continuing services.

Have to make this comment about the "individual" in IEP. I think we can still set criteria and still be individual. To compare in regular education, perhaps a certain math instruction is chosen for across a grade level. All teachers use the same curriculum (not individualized) but in each room the teacher has to differentiate based on the skill level of the student.

Interesting topic much better suited to discuss over coffee!

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