PT/OT Accommodations Not in IEP

typeset

Background: the kid failed grasping and came up high failing or low passing for locomotion and object manipulation depending on how you interpret his PT evals from the fall. PT/OT instituted a 10-12 week program to monitor his abilities and work on strengthening. The program was put under additional information in the IEP, not service delivery, despite our repeated written requests to have it moved. It was deemed a courtesy. No goals were written. 

We meet next week to discuss progress. I just got the report for the meeting. He's "gained physical strength in a short period of time," is now age-appropriate in all areas of concern, and they're dropping him from the weekly group sessions after he completes ten (he's done eight). It's unclear whether he's exhibiting all of these skills universally at school without prompting or only in the PT/OT setting. The coordinator has already made and will make the argument that he was not found to have a disability in this area. I think that the state autism advisory covers this as his tone issues directly impact his ability to focus in the classroom. Additionally, one of his daily behavioral expectations is to maintain a "quiet body." Tone affects that. We continue to observe the crossed legs, the lean, the dropping to knees, and the propensity to lie flat on the floor whenever he can versus standing. We continue to have to verbally remind him to press down hard and manually adjust his grasp at home. The private PT I consulted would support him continuing the group. I don't have a report from her but could get one.

Questions: 

Thoughts on using the argument that you don't pull something if it's working? 

More importantly, his classroom teachers have told us they've made accommodations for him during this observation period. These involve seating position at circle, type of chair, and verbal reminders for things like jumping with both feet. I want those added to the IEP. Is that realistic? I expect them to argue they do these things for all students if necessary. We would add to this list reminders to adjust grasp and implement pressure, hand over hand correction of grasp if necessary, that toys and activities be brought to table height, and anything else PT/OT will brainstorm for him.

MaxandRuby

Personally, if you don't like what they are saying push them. Most people probably would not support that but you are the best advocate for your child.  The IEP team consists of multiple people and ALL of you are supposed to agree. If you don't, you don't sign until things get ironed out. 

Keep in mind that I am a pusher of getting goals that are appropriate, I never sign an IEP the day of the meeting, and that I had to request an IEE (for PT) straight out of the gate.  I am sure I am considered "that mom".  We are a military family and since I know this school district is not where DS2 will remain his entire school career I feel I can push more then the others.  If it is true or not, I don't know.  Schools prefer parents who just sit back and accept whatever the school tells them and most parents (from what I'm told) do this.  Schools get nervous when parents start sticking up for their kids. 

I would not use the argument "don't pull something that is not working" because if the child is meeting/exceeding those expectations there is no reason to maintain them.  You have to go about it by showing the educational need to do X, Y, Z.  If you have reports from other therapists and you want them considered, the school has to consider them (note the word is consider not accept them).  Some people will say not to do that but you have to do what you feel is right. You may want to observe the classroom. If they have set up accommodations during the testing would that not alter the test score?  Auntie will probably know the answer to that and have more sound advice then me.

typeset

One of his IEP objectives is age-appropriate sitting. I just looked at the data. His rate during observations declined 11% over this period, even with the unofficial accommodations, to under the stated age-appropriate target. 

Given that there are no PT/OT services or accommodations in the IEP, I'm not sure how hard to push. I at least see traction here for continuing what they're doing whereas my preferred hills are non-starters. 

MaxandRuby

If he is regressing then I would not say that what they are doing is working.  If this is not your hill to die on (and only you can know that) then it is up to you.  Hopefully Auntie or others will chime in.  How much do you agree with what they are coming to the table with?

bumpuser511563

You will have to push as other PP have mentioned.

When DS was 2 1/2 attending the district preschool. I wanted DS to have OT. The teacher said she would keep on eye on it. I let it go. I spoke to the school OT for her to observe DS. The OT did not see anything. So yeah I looked like a crazy mom.

When he was 3, I had to push much harder and I wanted DS to be evaluated by the school district in all areas. There were many behavior issues I wanted ironed out. This took a lot of time to evaluate. I did private OT for the time being to keep DS from getting behind. The school OT saw what I meant and saw the delays through evaluations. PT was a bonus but I am sure the PT saw delays as well.

typeset

-auntie- said:

typeset said:

So this OT/PT involvement was more of a RTI than an IEP item?

Our advocate insisted repeatedly it was a service and should be written as such. Coordinator insisted it was a courtesy and we were lucky to have it at all. Again, "he doesn't have a disability in this area." From the report, they focused on the Peabody items he failed to bring him up to age level. 

Can he move around the classroom efficiently and effectively? Can he access playground equipment? Can he be seated in the proper posture for a reasonable amount of time for seat work? Is his low tone restricted to his trunk? His hands? His entire body? Part of the problem with tone is that 1) so little seat/fine work is expected in preschool, 2) measurable goals are difficult to write since a lot of this has a behavioral overlap and 3) tone kind of is what it is- you can develop strength and impulse control but not "fix" tone.

Weakness is through his shoulders, upper and lower trunk, hips, and lower extremities. He can access the building and playground. The issues are sitting and standing for even expected lengths of time. His seat at circle was moved because of slumping and subsequent inattentiveness (they caught him leaning on a bookshelf at one point). Now he's in the middle on a certain chair. The attention and participation have improved, aided in part by knowing the expectations and his DRO, but it's even harder for him to maintain his posture. He's slumping, backwards, or leaning half the time, hence the decline in sitting data. He's participating with more of a physical toll--on top of the energy it takes to remain engaged while keeping his shit together. The kid is flat on the floor by the afternoon if allowed.  

Maybe a private report would help you advocate, but the bottom line is that sitting up straight and properly is likely the unholy convergence of hypotonia meets inappropriate behavior meets sensory processing. Hypotonia makes sitting upright harder for him than the average bear, but probably not so hard that he can't eventually comply- ... Sensory can also play into this if he isn't fully aware of where his body is in space. ...

Agreed. He has a behaviorist (1:3) in the classroom and is on a DRO. He bumps into doors and walls, but attention gets blamed. 

If he's regressed somewhat on this watch, I'd say their approach isn't effective and something more holistic and individualized should probably be instituted.

In thirty minutes or less. Go! For our part, we've enrolled him in gymnastics and have been doing strengthening activities the private PT gave us as we can get him to comply at home. We've been doing this since the initial evaluation and while they've been working with him at school.

I think it would be fine to include line item accommodations like preferential seating or verbal prompts to his IEP- but realize you aren't there to monitor this and that a good teacher is already doing this. If you insist, it could ruffle feathers- does this matter that much to you? Is it a hill to die on? I mean if they're already doing the prompting and redirecting him and he's still not meeting the expectations of his age group- then including those items in the IEP isn't going to change much. It just has the potential to make it seem as if you don't believe the teachers. 

I believe the teachers. My understanding of the IEP is that it's our protection should my husband's company decide to uproot us across country tomorrow or if he is in a different class in the same program at the beginning of next year. I trust the current teachers to continue to problem solve, but the solutions need to make it into the document so we're covered. 

If we're making physical accommodations, doesn't it stand to reason the underlying need for them should be addressed via a PT service? The report says he can now chuck a tennis ball and walk a line appropriately. Those skills don't negate the musical chairs in the classroom nor the kid unable to stand and focus to play at a table while his peers remain upright. 

Who is taking the lead on the "grasp"? That's usually an OT- it's a fine motor function. The tone stuff is more often a PT, but an OT should be the one addressing the SPD stuff if that's playing into this. A behaviorist might be a good consult as well, since a big part of this is behavior- not that he's necessarily making a bad "choice" but that he's not self regulating with the maturity expected of peers. 

OT worked on the grasp. He started off unable to make legible markings with a pencil and now they're showing us marker lines and saying he's good to go. He balks HARD at craft activities. "Let's do Play Doh" means you, Mom, make something which I, kid, will then play with. We're not clear if it's behavioral, fine motor, sensory, three-year-old boy or (most likely) a combination. Same OT did not pick up any sensory issues worthy of intervention during her initial testing or observation.

As much as possible in this program is dealt with through ABA. Social pragmatics, for instance, is under ABA oversight, which has resulted in our pragmatic goals largely reduced to eye contact. The age-appropriate sitting goal is currently under ABA's purview. We also have quiet body as a behavioral expectation, but it's limited to body tensing and stereotypy. The BCBA, for her part, is a wonderful, responsive woman ... with an enormous caseload. She works with him at least weekly, more frequently if there's a concern, and we meet monthly. 

Thank you, as always, for your thoughtful reply. 

typeset

-auntie- said:

Ugh. You sound so frustrated. Not that anyone would blame you.

How many years to go? Fifteen or so? 

typeset said:

Our advocate insisted repeatedly it was a service and should be written as such. Coordinator insisted it was a courtesy and we were lucky to have it at all. Again, "he doesn't have a disability in this area." From the report, they focused on the Peabody items he failed to bring him up to age level. 

So he failed to be age appropriate in a couple of specifics, without addressing what drives those delays, focused solely on those items and deemed him "responded" and dropped the service?

Yup. He is "fully able to access the curriculum." 

I see why you and your advocate wanted these included in the goals/services area of his IEP, but if you signed off with this listed under "additional information" that's how it is seen.

There's the rub; we never did. We're still batting the IEP back and forth on this and other issues. I think we used something like "we accept this service while rejecting its inclusion under additional information." 

It really chaps my ass that the district is telling your FAPE is a courtesy. I want to dope slap your coordinator.

I'm tempted to ask him to turn backwards in his chair and see how it impacts his ability to coordinate the meeting. 

Weakness is through his shoulders, upper and lower trunk, hips, and lower extremities. He can access the building and playground. The issues are sitting and standing for even expected lengths of time. His seat at circle was moved because of slumping and subsequent inattentiveness (they caught him leaning on a bookshelf at one point). Now he's in the middle on a certain chair. The attention and participation have improved, aided in part by knowing the expectations and his DRO, but it's even harder for him to maintain his posture. He's slumping, backwards, or leaning half the time, hence the decline in sitting data. He's participating with more of a physical toll--on top of the energy it takes to remain engaged while keeping his shit together. The kid is flat on the floor by the afternoon if allowed.  

I don't understand DRO. What's that?

DRO is Differential Reinforcement of Other Behaviors. You reward the kid if an unwanted behavior is not displayed during a set interval. So if he has a loud vocal, he gets an X on his board and no reward at the end of however many minutes. Then they start over. He also loses his big privilege for the day (iPad or whatever). I prefer a token board, but we do one-size-fits-all reinforcement in this program. 

So they moved him to a place where he has to sit up without leaning. For how long? Have they tried any other strategies to keep him engaged and in his seat? A stability ball as a seat? A Sit'n'Fit? A weighted vest or lap pad? How about Therabands on his chair legs? 

That's what we intend to discuss. Once we establish impact to curriculum access. 

He bumps into doors and walls, but attention gets blamed. 

Do you see that at home, too? I wonder if some of this is not knowing where his body is in space- if his proprioception is impacted by sensory issues it could cause him to look clumsy, careless or inattentive. This could imapct his sitting because in addition to fatiguing more quickly than a typical child, he might not be able to sense how sitting properly feels so he can recognize what he needs to do to settle himself into the position expected.

We see it at home. Dev pedi wants his eyes checked. I'm hoping with PT, OT, and ABA in the room today I can throw it to the three of them to spitball something. 

What do you think his social goals should be? 

I would give almost anything for a standardized social pragmatic assessment for this age level to better answer that.  

Are they teaching scripts for asking for things? Taking turns? Demonstrating good "sportsmanship"? Does he have needs around code switching? 

Under social pragmatic goals, we have will respond to peers' emotions, use and respond to gestures, gaze shift to item/refer to face/and comment to peers, and asking why while making eye contact. Conversational concerns were dropped. He can't relate what happened during the day (ToM, I know). We have accommodations about physical proximity reminders, redirecting monologues, holding him to answering questions, a daily picture log to help with recall--

Does he understand "quiet body"? DS used to have trouble with non-literal concepts like "indoor voices" and "quiet body". 

I don't think he has a lick of control over body tensing. I want it charted, though, as a measure of his anxiety levels. Worth exploring this question at clinic. 

typeset

typeset said:

DRO is Differential Reinforcement of Other Behaviors. You reward the kid if an unwanted behavior is not displayed during a set interval. So if he has a loud vocal, he gets an X on his board and no reward at the end of however many minutes. Then they start over. He also loses his big privilege for the day (iPad or whatever). I prefer a token board, but we do one-size-fits-all reinforcement in this program. 

Is the iPad access a school thing or have you decided to carry it over at home? We did our behavior stuff primarily privately, so I never let school behavior- unless it was a morality issue- pollute my home. It's what I mean by the Las Vegas School of Parenting. YMMV, but DS found charts all kinds of anxiety enhancing. IME, they're the go to for the more lazy and least inspiring educators. 

Only at school. We try to avoid electronics as a reward and stick to incidentals to keep it more natural. The kid does much, much better if he's reinforced positively in the moment versus penalized because of the anxiety factor. They do praise and reinforce things as he does well, but one bad interaction can taint similar situations for months. His warm fuzzy speech pathologist told him no one time and he obsessed over it for-ev-er. He's also Jekyll and Hyde as far as school and home. They're charting tantrums, but have never witnessed one. I dealt with two over the weekend. I know it's typical that he can keep it together while he's on their watch and then unleashes once he feels safe. Can make for some very long snow days. 

Surely the school has a Sit'n'Fit they could trial. The feedback from the movement could be all he needs to stay more aware and focused around sitting. 

Meeting went better than expected. They pulled the "courtesy," but agreed to incorporate accommodations like a footrest into the IEP. Integrated preschool model means they can pull the relevant parties in to consult if the teachers flag a problem. The big thing was that the sitting regression corrected over the past month. I got that data as we were convening, which defused my main argument.

What do you think his social goals should be? 

I would give almost anything for a standardized social pragmatic assessment for this age level to better answer that.  

It kind of doesn't exist at this age. The best of the pragmatic scales it normed for age 6. A Vineland will hint at social communication but it's a more comprehensive and blunt instrument. 

I know. I've toyed with becoming a speech pathologist solely for the purpose of creating one. 

Are they teaching scripts for asking for things? Taking turns? Demonstrating good "sportsmanship"? Does he have needs around code switching? 

Under social pragmatic goals, we have will respond to peers' emotions, use and respond to gestures, gaze shift to item/refer to face/and comment to peers, and asking why while making eye contact. Conversational concerns were dropped. He can't relate what happened during the day (ToM, I know). 

JMHO, and I don't know how impaired your DS is around this, but those goals would have been difficult for DS at age 6. Can your son even recognize that peers have emotions that are different than his? Recognize what emotion a peer is signalling? Does he care? Has he mastered the rubric for what his response should be? 

He can peg happy and sad in himself and mad and sad in peers. This took intensive discrete trial work during EI. He started off not even looking up if someone started crying or hurt him or herself. After teaching him to orient to the person in distress, they worked on identifying the emotion. He went through a long phase of "he's crying because he's sad/he's sad because he's crying" and we still hear it. He recognizes the pattern. The next piece is to get him to comfort peers or inform a teacher since the other kids in his class do so. Does he care? Hell no. But he's very good at playing the game. This morning a classmate was having some serious separation anxiety and he marched up to tell her it was going to be okay. Programming win, sensitivity fail. 

He thinks he's thirty and an ABA trainer and not a preschooler. Lopsided skill set is an understatement. He's overly friendly because they took his social interest and programmed on top of it and he's a natural rule follower and enforcer. Very odd little dude. I'll take it, given how shut off he was before we embarked on all this, but he's going to be really, really annoying as he gets older.  

DS was pretty good at reading facial expressions- in fact at 7 he did better than a lot of NT kids. As a baby/toddler he had a bunch of those photo board books with babies laughing, smiling, crying, etc that he loved so in retrospect we put this social skills program in place when he was about 4 months old. But even then, he had difficulty recognizing emotion in others in vivo. And more importantly, even if he could tell a peer was upset, he wasn't able to hazard a guess as to why that might be.

The other wh- questions were hammered in EI. We continue to hit them hard. Still overgeneralizes asking them and dodges "who" when asked about past events. Just trying to get him to ask why about anything right now. We'd only heard it spontaneously three times before they implemented the program: once about why the lawn mower cuts grass and twice about why cars were broken down on the highway. 

We have accommodations about physical proximity reminders, redirecting monologues, holding him to answering questions, a daily picture log to help with recall--

Do you scaffold conversations about school? I always found DS needed time to process his day, and that just before bedtime was the best time to have this conversation. Early on I was scaffolding the crap out of our verbal exchanges. 

We do talk right before he goes to sleep. I remind him that I wasn't there to see what happened as we talk. He loves to go over the visual log to tell the story of his day. He's spontaneously related events twice, both times about aberrant peer behavior. "Who did you play X with?" is a non-starter. I have to ease into it. Now I'm reading up on Vygotsky, thanks. 

What does "tensing" look like? Could it be a tic or a stim? He's a little young for a tic, but motor tics are common on spectrum and best not even mentioned. So you really want to be confident that what he's doing is under his control and not more "involuntary". It can be really hard to tell a tic from a stim and both seem to ramp up with anxiety.

He freezes and shakes/shivers or tenses his mouth like a turtle by jutting out the lower jaw. Neuro pegged it as stim after I asked about seizure. I think he likes the sensation, but he does it when he gets extremely stressed or pressured and when he's bored. Meal times are big for this. 

typeset

Does he not know he's a child? It's said kids with Aspergers are the natural democrats. DS certainly never considered himself a child. He was always drawn to and identified as an adult. Super cute little old soul as a preschooler, a lot less cute as a school aged kid who didn't parse the socially constructed hierarchy the puts adults in charge of children. Took me a long time to figure this out.

Quite possible. He doesn't identify with the group in the classroom. They told him to "go sit with your friends" and he froze. Latches onto and charms, thereby fooling, adults. I'm keeping tabs on it in case we need the engraved invitation accommodation down the line. 

DS's conversational gambit was questions.

What's that? was his opener when he was in the thick of his echolalia, even if he knew what the item was already. We do get who's that with strangers and he loves giving them the third degree. He asked my nurse the other day her name, her middle name, her last name, her kids' names--

Sometimes "who" is harder because he may not "value" peers enough to learn their actual names. In preschool DS initially referred to peers as "that boy who likes cars" and that boy who knows all about dinosaurs". For other kids it could be a function of faceblindness. Has this ever been suggested to you? One quick was to show him a class picture and ask him to tell you about the kiddos. See if he knows their names.

The value thing is interesting. He is faceblind. He was identifying some kids by skin color in EI ("G. is a brown one"), others by clothing ("C. wears flowers"), and mixing up the girls even when staring in their faces. His primary ABA therapist agreed after attending different classroom settings with him. We have an album of all his classmates and an accommodation to help facilitate learning names. I insisted on these despite the district SLP's skepticism.