School Based Interventions

Before exploring the types of school-based services a child with I/DD and co-occurring mental health concerns might be able to access, it is first helpful to understand the way schools operate. In particular, school services are generally available for individuals who are determined “eligible” based on guidelines that are specific to schools. This is qualitatively different from the way services are accessed in a clinical and/or community-based setting.

In the school setting, decisions are based on federal special education law. Each state then interprets this law and sets forth specific guidelines for practice. In North Carolina, the guiding document for practice is Policies Governing Services for Children with Disabilities (Amended March 2018).

For clinicians who practice in clinics, hospitals, or other community-based settings, when the clinician is assessing for and diagnosing a particular condition, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association, 2013) is typically the tool they use to guide their practice. The DSM-5 specifically outlines the criteria for diagnosing several disabilities relevant here, including Intellectual Disability, Global Developmental Delay, and Autism Spectrum Disorder, all of which fall under the umbrella category of "neurodevelopmental disorders."

The clinician who conducts testing in a school setting is usually a school psychologist, who is operating under a license from the NC Department of Public Instruction (NC-DPI). Because eligibility decisions are made by a team and not an individual, and also because eligibility decisions are based on Policies Governing Services for Children with Disabilities and not a DSM-5 diagnosis, school psychologists working within the public schools do not typically provide clinical diagnoses. However, a school psychologist who also holds a license by the State Board of Psychology is capable of providing a diagnosis and may do so if operating outside of the school setting.

Note: The most recent federal laws that inform current practice include the Individuals with Disabilities Education Act of 1997 (IDEA) and The Individuals with Disabilities Education Improvement Act of 2004 (IDEIA). Current special education law is commonly referred to as “IDEA” even though the most recent authorization is technically IDEIA. The US Department of Education Site provides more details about this law. For a brief history of the federal laws, see http://www.wrightslaw.com/law/art/history.spec.ed.law.htm.

The Policies Governing Services for Children with Disabilities (hereafter referred to as the Policies), developed by NC-DPI's Exceptional Children’s Division, defines 13 categories of eligibility. Related to I/DD, these four categories are most relevant:

1. Intellectual Disability (ID) Defined as significantly subaverage general intellectual functioning, existing concurrently with deficits in adaptive behavior and manifested during the developmental period, that adversely affects a child’s educational performance.
   
   To be eligible for services under this category, a child must exhibit delays in both intellectual functioning and adaptive functioning. Delays in intellectual functioning are categorized as Mild (i.e., 2 standard deviations [SD] below mean), moderate (i.e., 3 SD below the mean), or severe (i.e., 4 SD below the mean). Delays in adaptive functioning must be observed to a significant degree in one area (i.e., 2 SD below mean in one area) or to a moderate degree in two areas (1.5 SD below mean in 2 or more areas).
    
2. Autism Spectrum Disorder (ASD) This is a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age three, which adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotypical movements, restricted interests, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. To be eligible for services under this category, a child must demonstrate impairment in at least 3 of these 4 areas:
   • Communication
   • social interaction
   • unusual response to sensory experiences
   • restricted, repetitive, or stereotypic patterns of behavior, interests, and/or activities.
    
3. Developmental Delay (DD) This category applies only to children ages 3 to 7. For delayed/atypical development, a child must exhibit difficulties in at least one of these areas: physical, cognitive, communication, social/emotional, or adaptive functioning. Alternatively, delayed/atypical behavior may be observed, which could include delayed milestones, problems with social interaction, aggression, or social/emotional deficits. More specific information about eligibility requirements for this category can be found in the Policies. Note that children who are initially found eligible for services under this category will need to be re-evaluated by age 8 to determine eligibility in a category appropriate to older children.
    
4. Emotional Disability (ED) A variety of mental health disorders could potentially be captured in this category (e.g., mood disorders such as Major Depressive Disorder or Generalized Anxiety Disorder), but note that the DSM-5 criteria for diagnosis do not necessarily need to be met. Rather, the difficulties must be observed and documented in a somewhat broader way.
   
   There are differences between the disability categories defined for the school setting by the Policies and the disorders outlined in the DSM-5. Essentially, it is important to know that families may hear different terminology, and that there may be slight variations in how clinicians arrive at their decision that a child meets the criteria for a particular label based on the setting in which that clinician is operating.

In addition to the specific eligibility requirements of the I/DD categories, to be eligible for services children must first be determined to have a disability and then that disability must be negatively affecting their educational performance so that they require instruction that is specially designed to meet their needs. This means that it is possible for a child to have a disability yet not be determined eligible for services in the school setting. What must be considered is the impact of the disability on the child's education.

For some students, additional, individualized support that is above and beyond what is typically available in the general education program is needed. In order to obtain these special education services, specific rules and procedures are in place to guide this process.

STEP 1 - Identification of need The child must be identified as possibly in need of special education services. This is often accomplished through a referral from the child’s parent, teacher, or other school professional. Alternatively, the child may be identified through “Child Find,” an IDEA mandate that requires school districts to establish policies and procedures to ensure students with disabilities are identified (and usually involves some type of required screening).

STEP 2 - Evaluation The components of an appropriate evaluation vary based on the area(s) of eligibility that are being considered for a child. A child should be assessed in all areas related to the suspected disability. Thus, an evaluation could consist of screening and/or assessment of health, vision, hearing, social and emotional status, general intelligence, academic performance, communicative status, and motor abilities. The Policies specifically define the areas that must be assessed for each area of eligibility.

STEP 3 - Eligibility determination In order to be determined eligible for services, the student must be determined to meet criteria for one of the disability categories. In addition, that disability must be determined to have an adverse effect on educational performance AND the student must require specially designed instruction.

STEP 4 - Develop Individualized Education Program (IEP) There are additional, important procedures for developing the IEP. First, an IEP meeting must be scheduled and the parents must be invited to this meeting and given an opportunity to participate as a part of this team. In addition, the IEP must include specific components, which are discussed in the section "Special education, related services, and more"

STEP 5 - Implement the IEP Implementation of the IEP includes providing the services as outlined in the IEP to the child, providing a copy of the IEP to the parent, and making sure that other school professionals (e.g., general education teachers, elective teachers, service providers, etc.) are aware of the IEP and their role.

STEP 6 - Ongoing monitoring of the IEP Monitoring includes collecting and evaluating data on the child’s progress on each IEP goal, reviewing the IEP at least yearly, and reevaluating the student’s needs at least every 3 years.

A comprehensive evaluation must be conducted to assess the needs of a child who is being considered for special education eligibility and services. The Policies outline the specific types of information that must be collected for each of the 13 categories of eligibility. Many of the screenings and evaluations are common across multiple categories. For the categories of Intellectual Disability, Autism Spectrum Disorder, and Developmental Delay, the common areas that must be included in the evaluation process include:

• Hearing and vision screening
• Observations across settings to assess academic and functional skills
• Summary of conference(s) with parents/documentation of attempts to conference with parents Social/developmental history
• Educational evaluation Psychological evaluation Adaptive behavior evaluation
   

For Developmental Delay, there are some of the additional required areas of screening and evaluation:

• Motor, health, and speech-language screening
• Psychological evaluation, which must include cognitive and social-emotional measures
   

When making a determination about whether or not a delay is present, "percentage of delay" is used when the assessment procedures yield scores in months, whereas “standard deviation below the mean” is used for standardized tests. For those who are not well-versed in the language used in testing, what is important to understand is that the terminology used to talk about the delays a child exhibits in development may vary based on the type of assessment used. In some cases, the school professional may refer to the percentage of the delay, while in other cases, he or she may talk about how far scores are below the average range.

Intellectual Disability
For this category there are additional required screenings and evaluations of motor, health, and speech- language. Further, if the child does not already have a diagnosis of intellectual disability, two scientific, research-based interventions must be attempted and results documented.

Autism Spectrum Disorder
Additional screenings and evaluations currently required for eligibility in this category include a speech- language evaluation with measures of language semantics and pragmatics and assessments specific to ASD, using an appropriate behavior rating tool or an alternative assessment instrument.

Developmental Delay
Eligibility criteria differ according to the age of the child. Ages 3-5. Delayed/atypical behavior in 1 or more of the following:

• achieving developmental milestones
• attachment and/or interaction, communicating emotional needs, tolerating frustration, controlling behavior, or inhibiting aggression
• fearfulness, withdrawal, or other distress that does not respond to comforting or interventions
• indiscriminate sociability (e.g., excessive familiarity with relative strangers)
• self-injurious or other aggressive behavior.
   

Ages 6-7. Delayed patterns of behavior and adaptive skills in 2 or more of the following:

• ability to interact appropriately with adults/peers
• ability to cope with normal environmental or situational demands aggression, self-injurious behavior
• ability to make educational progress due to social/emotional deficits.
   

Emotional Disability
For this category, one of several possible areas of difficulty related to social-emotional and/or behavioral functioning must be indicated. A variety of mental health disorders could potentially be captured in this category (e.g., mood disorders such as Major Depressive Disorder or Generalized Anxiety Disorder), although it should be noted that the DSM-5 diagnostic criteria do not necessarily need to be met. Rather, the difficulties must be observed and documented in a somewhat broader way.
To be eligible for services in this category, a child must show one of the following (over a long period of time and to a marked degree):

• An inability to make educational progress that cannot be explained by intellectual, sensory, or health factors
• An inability to build or maintain satisfactory interpersonal relationships with peers and teachers
• Inappropriate types of behavior or feelings under normal circumstances
• A general pervasive mood of unhappiness or depression
• A tendency to develop physical symptoms or fears associated with personal or school problems.
   

Once all of the required screenings and evaluations have been conducted, the IEP team (consisting of specific school staff as well as parents) will meet to determine the child’s eligibility for special education services.

If my child has a clinical diagnosis, do I automatically qualify for school-based services?

Answer: Not necessarily. Even with a clinical diagnosis, you will need to go through the eligibility process within the school setting. Remember, in addition to determining if your child meets the criteria for a certain disability category, the important questions you must consider in the school setting are:

• Does my child’s disability have an adverse effect on educational performance?
• Does my child require specially designed instruction as a result?

What if my child has two diagnoses (such as Intellectual Disability and Depression)?

Answer: More than one eligibility category can be selected if the child meets criteria for each area, and each area is thought to be negatively impacting educational performance. One of these areas will need to be selected as the “primary” area of eligibility.

Do all of the required screenings and evaluations have to be conducted by the school?

Answer: Not necessarily. If a family has received an outside evaluation, this information can be shared with the school team and considered in the evaluation process. If the evaluation was fairly recent, the team may elect to use the results of that assessment. The team would then only need to conduct additional screening/assessment in any required areas that were not already addressed in the outside evaluation.

Once a child is determined to be eligible for services, an individualized education program (IEP) can be developed for that child. The IEP generally includes:

• Information about the student’s current skills, or "present level of performance"
• Specific goals and objectives that will be targeted for instruction
• Accommodations and modifications the student requires
• The type of services needed, as well as the duration, frequency, and location of those services

Many resources are available that further outline the development and components of an IEP. One helpful resource for parents of children in North Carolina is the Exceptional Children’s Assistance Center (ECAC). Families may wish to explore their website, which includes information specifically about IEPs.

The IEP developed for a child should be based on that child’s specific needs rather than the eligibility category. There are two types of services that may be appropriate, (1) special education and (2) related services, but first a word about an important concept in how they are provided.

"Least restrictive environment"
There are many ways special education services might be provided to a child. One of the guiding principles of these services is the concept of “least restrictive environment” (LRE). This refers to the process of determining the best placement for a child to receive services by starting with the setting that is the least restrictive (i.e., removes the child for the least amount of time possible from peers) while still enabling the child to learn and make progress on his or her goals.

The setting that is least restrictive for one child may not be the same for another. Some children may be able to learn and make progress in the general education classroom with just consultation or inclusive services from a special educator, while others may require a separate, self-contained setting to learn and make progress on their goals. In addition, what works for a child one year may change over time, and in either direction. When considering students with I/DD and co-occurring mental health concerns, needs related to the intellectual and/or developmental disability or needs related to the mental health concerns may affect the way services are delivered. For example, it might be that a child with mild intellectual disability has been making progress in an inclusive setting, but the exacerbation of mental health symptoms leads that child to require a smaller setting for some time to continue to learn and make progress.

Special education services
Services can be provided in a variety of ways, including (but not limited to) the following:

Who provides instruction?

• Instruction by a general education teacher with consultation from a specialist
• Instruction by both a special education teacher and general education teacher working together
• Direct instruction by a special education teacher.
   

Where is instruction provided?

• In the general education classroom setting
• Partly in a separate setting and partly in the general education setting In a self-contained classroom setting
• In a separate school.
   

Special education services considered for students with I/DD should address both academic and functional skills, and the type of services should be based on the individual student’s needs.

For students with I/DD and co-occurring mental health concerns, special education services might address functional performance. For example:

• Identifying, practicing and using coping skills (e.g., skills to help with anxiety, frustration, etc.)
• Developing social and leisure skills (which can help in a proactive way with issues such as depression, anxiety, or social isolation)
• Self-monitoring of mood and behavior.
   

Speech-language therapy
This can be a direct or related service. Like special education, speech-language services can be provided in a separate setting or in an inclusive setting. The speech-language therapist can also consult with the student’s other teachers. Goals of this service might include improvement in:

• Expressive language (e.g., communicating needs, wants, ideas, and feelings appropriately, expressive vocabulary)
• Receptive language (e.g., understanding what others are saying, following directions, receptive vocabulary)
• Pragmatic language (i.e., using language for social communication, such as using language for different purposes, conversation skills, etc.).
   

Speech-language services can address both academic and functional performance.
For students with I/DD and co-occurring mental health concerns, speech-language therapy services might address functional skills such as:

• Vocabulary related to emotions
• Communicating feelings
• Asking for help/asking for a break.
   

The American Speech-Language-Hearing Association (ASHA) outlines the scope of practice for speech-language pathologists, but note that this information is not specific to the school setting.

Related Services
What are related services? According to the Policies, “related services means transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education.” In other words, these are services that students need to be able to access their special education services. The Policies outline a variety of potential related services. A few of these have been selected and highlighted for discussion here.

Occupational Therapy (OT) - services enable a student to engage in the occupations needed to participate in special education. OT services are commonly understood to address fine motor skills and writing, but they can also address a broader range of occupations, including:

• Student role/interaction skills
• Learning academics and process skills
• Personal care
• Participation in play and recreation activities Integration in community and work settings.

Physical Therapy (PT) - services can also range from direct to consultative services. They focus on students’ physical capabilities and ability to independently and safely access education-related activities. For example, a PT might:

• Observe the student’s educational setting and determine any modifications or special equipment that might be required to support the student’s participation
• Work with the student individually to target specific goals related to strength, coordination, or mobility
• Consult with the teacher and family about practice activities that would further develop certain motor skills

Counseling services - For students with I/DD and co-occurring mental health concerns, counseling services in particular might be considered if the team determines that they are required to help that student access the special education program. For example, a student with I/DD whose anxiety is leading to school refusal may benefit from learning some coping strategies and having additional support in attending school (and thereby accessing any school-based services).

Behavior intervention plan - A behavior intervention plan is another tool for students with I/DD and co-occurring mental health concerns that lead to behaviors that impact the child’s learning.

See the "PBIS World" website for more general information about behavior intervention plans as well as other positive behavior interventions and supports.

Accommodations and Modifications - In addition to services, the IEP also includes accommodations and modifications that may be needed. For students with I/DD and co-occurring mental health needs, this may be another area in which these needs can be addressed. For example, some students may benefit from:

• A calming area to which the child can retreat
• Visual checklists and reminders to use certain coping strategies
• A modified school day.

This discussion of school interventions has focused on children who have long-standing I/DD. However, having experienced traumatic brain injury (TBI) may qualify typically developing children for school- based services, at least temporarily.

Section 504 of the U.S. Rehabilitation Act of 1973 requires that: "No otherwise qualified individual with a disability in the United States . . . shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." According to the U.S. Department of Education, this means that federally funded "school districts are required to provide each student with a disability any special education and/or related aids and services necessary to ensure the student is receiving a free appropriate public education (FAPE). Examples of aids and services a school district may be required to provide include physical therapy or speech language therapy. In addition, a school district may need to modify the regular education program in order to provide FAPE. Examples of such modifications include additional time to take tests or a modification to a policy regarding the permitted number of absences in a school year when a student's absences are due to a disability." (See https://www2.ed.gov/about/offices/list/ocr/docs/504-resource-guide-201612.pdf.) Also included might be plans for gradual return to physical activities (sports, in particular), a shortened school day, no homework, and other changes that facilitates the child's recovery.

Other school-based opportunities
It is important to note that all students in public schools have access to a variety of educational opportunities and supports outside of special education. In addition to the general education instructional program, there may be groups, clubs, interventions, or other special activities taking place within the school setting that could be beneficial.

Multi-tiered System of Support (MTSS)
According to the North Carolina Department of Public Instruction (NC-DPI), MTSS is a “multi-tiered framework, which promotes school improvement through engaging, research-based academics and behavioral practices. NC MTSS employs a systems approach using data-driven problem-solving to maximize growth for all.” One important feature of MTSS is supporting not only academic performance, but also the behavioral and social-emotional functioning of students. The Integrated Academic and Behavior Systems is the division of NC-DPI that supports this work.

One aspect of MTSS is developing a system of interventions for students to address behavioral and social-emotional needs. This means that there may be interventions available within schools, outside of special education, that could be appropriate for some students with I/DD, as well as for students with I/DD and co-occurring mental health concerns.

More information about MTSS can be found at these links:
http://www.ncpublicschools.org/integratedsystems/
https://www.dpi.nc.gov/students-families/parents-corner/multi-tiered-systems-support-mtss-families

School Mental Health Initiative
With regard to mental health concerns specifically, there is currently work being done at the state level to support the mental health of school-age children. It is important to note that the public schools are not mental health service providers. However, state-level partnerships have been developed that include public educators, community-based mental health providers, families, and other stakeholders to determine ways to address the needs of school-age children.
 

Ongoing communication between families and the school team is critical! It is important for them to communicate regularly to ensure that the child’s needs are being addressed appropriately. Students with I/DD often require specialized interventions and supports, and when co-occurring mental health concerns are also present, this further complicates the picture. In addition, these students may have unique needs that fluctuate over time. Thus, regular, ongoing communication between families and professional is critical for supporting the success of these students.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM– 5). https://www.psychiatry.org/psychiatrists/practice/dsm

American Speech-Language Hearing Association. Scope of Practice in Speech-Language Pathology. https://www.asha.org/policy/SP2016-00343/.

Autism Society, NC. https://www.autismsociety-nc.org/.

Division of Integrated Academic and Behavior Systems, NC Department of Public Instruction. NC MTSS Implementation Guide. https://www.dpi.nc.gov/students-families/parents-corner/multi-tiered-systems-support-mtss-families

Exceptional Children’s Assistance Center (ECAC). IEP [Resources for parents.] https://www.ecac-parentcenter.org/.

Individuals with Disabilities Education Act. https://sites.ed.gov/idea/.

Public Schools of North Carolina. Integrated academic and behavior systems. http://www.ncpublicschools.org/integratedsystems/.

North Carolina Department of Public Instruction (NC-DPI).

Parent resources. https://ec.ncpublicschools.gov/parent-resources.

Policies Governing Services for Children with Disabilities (Amended March 2018) https://ec.ncpublicschools.gov/policies/nc-policies-governing-services-for-children-with-disabilities.

PBISWorld. [Information on behavior intervention plans.] http://www.pbisworld.com.

Wright, Pete. (2010). The history of special education law. https://www.wrightslaw.com/law/art/history.spec.ed.law.htm.

U.S. Department of Education. Student Placement in Elementary and Secondary Schools and Section 504 of the Rehabilitation Act and Title II of the Americans with Disabilities Act. https://www2.ed.gov/about/offices/list/ocr/docs/placpub.html.

Dr. Whitney Griffin
We thank Whitney Griffin, PhD, at the Carolina Institute for Developmental Disabilities for the development of this material.