Coordinating your child’s goals across therapists so that they have individual goals that support success.

    There are several ways children get referred for special services. Some children’s needs are identified in the school first, which prompts an evaluation and establishes services that are school specific. When this happens and parents seek supports in the private sector, they are met with and entirely different process, which basically requires them to start over. Some children are identified by a doctor and formally diagnosed before school begins. When this happens and parents inform the school of their child’s special education requirements, they are met with another hurdle because the school’s system has their own process for evaluation/determination of need. The only thing a medical diagnosis guarantees in a school system is that the child is provided a 504, which does not offer the level of support provided by an IEP. Even when you bring a formal diagnosis to the school, they must perform their own evaluation to identify the child’s needs in order to develop an IEP. Conversely, if you bring an IEP to the pediatrician (all IEPs have a diagnosis which they call ‘primary eligibility’), they cannot use this to provide a referral for services covered by insurance. This disconnect happens due to the criteria each institution (education and health care) is bound by. Each school system is federally mandated by legislation (section 504 of the rehabilitation act or IDEA) to provide a free appropriate public education (FAPE) to students with disabilities. They are also bound by NCLB which is designed to establish a criterion for educating all students. These federal mandates are interpreted differently by each school district and therefor create a variety of criteria that establishes services in schools (which any parent who has moved to another county with an IEP has probably experienced firsthand). While medical necessity is determined by insurance provider or varies under different plans and has a whole other set a criterion, they use to determine the services provided. This complicated process typically results in a set of therapists work with a child at school and a whole other set of therapists (of the same specialty) working with the child privately outside school.

             In addition to the different criteria used to determine need, these systems also have very different targeted goals. School systems are aiming to meet mandates by NCLB and FAPE, which are focused entirely on academic growth. While health care is focused on quality of life and the services determined by medical necessity. There is nothing wrong with these systems individually, schools should focus on educating children and health care should focus on quality of life. The conflict lies in the fact that typically, those services needed to participate in education are the same services needed to function in everyday living. The result is a complicated mess of uncoordinated therapies and therapists. At school a child maybe receiving services from an SLP, OT, PT, BCBA, Social Worker, psychologist, or counselor. Each of these are bound by the focus of getting the child to participate in the lessons delivered by the teacher. This means that if they cannot justify educational relevance, then they cannot provide those services. This is very apparent in older children who have more severe disabilities. So, a 15-year-old who cannot feed himself or hold a pencil, would not get the same OT services that a kindergarten student would receive. Why? Simple, there is more benefit and prognosis for the 5 year, by 15 there are a limited number of skills that the OT could work on related to school. School therapists are working on things like, being able to produce a sound needed for reading skills or developing the muscle coordination to navigate walking with a backpack, using a pencil for writing, and other academic related items. A school-based therapist would not be concerned with shoe tying or using a fork (they may incorporate it sometimes, but the goal they are working on is academic). In home-based therapy the therapists are working on things the child may need to participate in daily life such as getting dressed, brushing teeth, behavior outbursts, ect. Another factor is that each therapist has a unique way of approaching interventions. One behavior analyst would not necessarily approach intervention the way another behavior analyst would, even if they had none of the barriers mentioned. So, the result? A child who has a team of therapists at school and a whole different team at home, all working on different things.

             So where is the detriment in having two specialized teams focusing on different aspects of a child’s life? On the surface it seems like the child is getting services and supports wherever they need it. It is in the details that everything gets muddled, which can significantly impact a child’s progress. The same fine motor skills are needed for writing and brushing your own teeth. So, a child who is receiving OT to help with writing at school is developing the same fine motor skills that a child getting OT at home to support toothbrushing is. If a child is working on the same skills in different context, it isn’t necessarily a determent on its own, it is the approach being used to develop those skills that can impact them. If the school OT is using method A and the home OT is using method B then, regardless of each method having its own merit, the child is being taught two ways of doing the exact same thing. Think of learning the alphabet, some teachers take a phonetic approach and teach /a/ instead of ‘A’ because that is what we need to read. Other teachers (more commonly) start with naming the letters before introducing their sounds. Both have pros and cons, one isn’t better than the other, but if a child is taught the phonetics in the morning and the names in the afternoon it is going to take them MUCH longer to learn the alphabet. Young learners especially get frustrated when tasks take a long time to learn and often loose interest. By focusing on one instructional method, the child will have a focused learning that fosters faster acquisition and more participation or buy-in.

Parents are in the unique situation of being able to look at the whole picture. The school-based team is rarely going to illicit collaboration from the private based team especially because of HIPPA rules which prohibit it. Parents are not restricted by HIPPA, so they are the quickest and easiest method of collaboration. The first thing a parent can do is get a list or progress report from each therapist that works with the child. This should be relatively easy, as in both schools and in medicine, records are kept up to date. Once a list of goals is gathered, schedule a meeting with each therapist to review those goals. Most parents aren’t aware of the nuances involved with specific interventions from each provider, but each provider should be familiar with the interventions another provider of the same services is using.  Look for goals that seem the same or similar. It is rare for a child, who is receiving services from two specialists in the same area, to have goals that work on completely unrelated things. The developmental delays they are working on do not change with the environment, just the way those delays impact each environment. Find the fundamental similarities in the areas they are addressing and try to understand the interventions being used. Putting this work into understanding a child’s program will highlight those areas that overlap. Like it was stated earlier, maybe the goal is writing and brushing teeth, but the skill is fine motor development. Work with each therapist to align those interventions so that the child has consistency between home and school interventions.

Will everything go perfectly? No. The same legislation that rules the school supports also give parent a lot of say in the services their child is receiving. Each school district has procedural safeguards that are provided to parents at every IEP meeting. These will educate parents in what their rights are and what they can demand. The schools really only have the power when the parents are asking for services determined irrelevant to educational gains. The saying “you get more flies with honey than you do vinegar” absolutely applies as well. Letting the therapists know the goal of aligning interventions will go a long way. Think of a child’s whole program like a roof. Each therapist is a truss supporting their part of the roof. If one truss has a weakness, there isn’t an obvious problem, but if all the trusses are out of alignment, then the roof caves in. Go in with an open mind and a child-centered focus. The only result will be a better program for the child.

 By Sheila Panno, M.Ed, BCBA, LBA

Works Cited:

No Child Left Behind (NCLB) Act of 2001, Pub. L. No. 107-110, § 101, Stat. 1425 (2002).

Individuals With Disabilities Education Act, 20 U.S.C. § 1400 (2004).

U.S. Department of Education, Office for Civil Rights, Free Appropriate Public Education for Students With Disabilities: Requirements Under Section 504 of the Rehabilitation Act of 1973, Washington, D.C., 2010.