ADHD

Case 1: Ben – History of Present Concern

School has been calling mother daily about Ben’s disruptive behavior. He is bossy. He can’t wait his turn. He blurts out answers in the classroom and has a hard time staying in his chair. He makes friends but can’t keep them. 

At home, he rushes through his homework and makes careless mistakes. He can’t stay seated at the dinner table. Mother needs to repeat instructions multiple times. He is active and impulsive. He has difficulty quieting for sleep, but once asleep, no frequent waking.

Ben was always a very active toddler, “getting into things” and “always moving”.

Case 1: Ben – History Continued

Birth History/Past Medical History

Full term. No complications.

ED visits: laceration requiring stitches and an arm fracture after a fall.

No medications or allergies.

Review of Systems:

Negative. Sleeps well. He eats a normal varied diet.

Family History

Younger brother, Sam (3 years old), is “very busy.”

Father had a hard time in school, he was the “class clown,” and had trouble focusing.

The rest of the family history was negative.

Social History 

Ben lives with his mother, father, and 3 year old brother.

His mother has a Masters degree and his father has an MBA. 

His mother is the primary caregiver and does not work outside the home.

Extended family support exists in the area.

Case 3: Jill – History of Present Concern

History of Present Concern:

Jill is currently in the middle of her third-grade year. No history of grade retention or special education services.

Her mother describes her as always “flighty”—frequently daydreaming. 

Last year, her second-grade teacher said she was a “good kid, but often did not pay attention during class activities.” Her reading skills were somewhat lower than other children second graders. Because she was making progress and was not showing disruptive behavior, Jill’s teacher and parents decided to observe her over the next year.

Now, in the third grade, Jill has not been able to keep up with the class in reading.  She reads slowly and often has difficulty when asked questions about a story. Her math skills are above average and her spelling is at age level.

Jill’s parents describe her as a shy girl; she has a few friends. Jill seems to worry a lot. She is especially fearful of shots at the doctor’s office. She enjoys ballet class, but worries about her performance before recitals.

Case 3: Jill – Treatment

One month later:

Jill returns to the office with her mother. 

After her initial ADHD, inattentive type diagnosis, Jill was started on a long-acting stimulant.  Follow-up parent/teacher rating scales show significant decrease in inattentive symptoms. 

However, Jill continues to have difficulty with reading, especially comprehension. What do you do next and how do you counsel the family about next steps?

School District Services – IEP

The Individualized Education Plan (IEP)

The Individuals with Disabilities Education Act (IDEA) is a federal law, first established in 1975, but amended several times since, with the main goal of protecting the rights of children with disabilities by providing them access to a free and appropriate public education, provided in the least restrictive environment. The IDEA is the legislation that dictates the special education, i.e Individualized Education Plan (IEP), for children in public school.

Eligibility for an IEP

To be eligible for special education services, the student must undergo an evaluation performed by the school district to determine whether they meet eligibility criteria under one (or more) of the defined eligibility categories. There are 13 categories for eligibility:

  • Autism (120,095)
  • Deaf-blindness (114)
  • Deafness (3,223)
  • Emotional disturbance (25,233)
  • Hard of hearing (10,657)
  • Intellectual disabilities (43,770)
  • Multiple disabilities (7,308)
  • Orthopedic impairment (9,916)
  • Other health impairment (104,792)
  • Specific learning disability (300,295)
  • Speech or language impairment (164,698)
  • Traumatic brain injury (1,541)
  • Visual impairment (3,405)

** The numbers in parentheses reflect enrollment breakdown per eligibility category in California for individuals (newborn through twenty-two years of age) who received special education services in 2018–19. The pie chart below shows the proportion of the different eligibility categories. cde.ca.gov

The IEP Assessment Timeline

The assessment request must be a note in writing to the school district. It can be made by a parent, teacher, or other service provider.

Once the school district receives the request for assessment, the school must give the parent/guardian a proposed assessment plan within 15 days. The plan must specify the types of assessments to be conducted.

Once the parent/guardian receives the school’s proposed assessment plan, the parent/guardian should review the plan to decide whether to consent to the plan. If the parent/guardian agrees to the plan, it must be signed and returned to the school district within 15 days.

Once the school receives the signed assessment plan, it has 60 calendar days to conduct the assessment and hold a meeting to discuss the results of the testing.

This timeline is dictated by law: courts.ca.gov

Sample Letters

Below are sample letters a family may use to request an evaluation from the school district. The second letter is a more abbreviated version.

More sample letters can be found at:

If the child is not eligible for an IEP:

If the school district believes the child is not eligible for special education services based on its assessment:

  • The parent/guardian can agree with the school district and no special education services will be offered to the child

 Or

  • The parent/guardian can disagree.
    • If the parent/guardian disagrees with the school district’s assessment, they have the right to request an independent assessment from a qualified specialists, at public expense
    • The school has to pay for this independent evaluation if the parent can show that the district’s assessment did not correctly identify the child’s disability and/or the child was placed in the wrong category, or if the IEP is not good for the child because it was based on a bad assessment
    • Any request should be made in writing and directed to the school district
    • The district can then either pay for the independent assessment or go to a hearing to prove their evaluation was correct
    • If the district wins the hearing, the parent can still get an independent evaluation, but the school will not pay for it

The IEP Timeline once IEP is established:

After an IEP has been signed and finalized, it is supposed to go into effect as soon as possible. The IEP can be thought of as a written contract – the school is expected to provide the special education and related services that were identified in the IEP.

After the IEP starts, it must be reviewed at least yearly to determine if the child is actually achieving his/her annual goals and to develop the next year’s IEP. In addition, the IEP team must revise the IEP to address:

  • Any lack of child progress
  • Results of any re-evaluation or re-tests
  • New information provided by the parents
  • Change in anticipated child needs

The revised IEP may include new goals and the child may be identified as needing additional or reduced special education and related services.

Since 2004, one can amend or modify an IEP without a formal IEP meeting if the parent and the school agree on the change, otherwise, a meeting must convene.

Revisions and/or modifications do not always require additional or updated evaluations of the child, however, in California, students undergo a more comprehensive re-evaluation every 3 years to determine whether or not they continue to meet criteria for special education services

The IEP team may meet periodically throughout the course of the school year as circumstances warrant. Parents/guardians also can request an IEP meeting at any time.

School District Services – 504 Plan

504 Plan

The 504 plan gets its name from Section 504 of the Rehabilitation Act of 1973. This is a federal civil rights law. It is designed to protect the rights of individuals with disabilities in programs and activities that receive federal financial assistance like public schools, institutes of higher learning, and other state and local education agencies.

A 504 plans are formal plans that the school develops to give a child with disabilities the support that is needed. This plan is used for any condition that limits daily activities in a major way.

Schools typically create written 504 plans, but having the plan in writing is not required. There are no set rules for what a 504 plan should look like, or what it should include. The only thing that schools have to put in writing is their policies on 504 plans.

504 Plan versus IEP

It’s easy to mix up 504 plans with the IEP – they’re not the same:

  • The IEP provides specialized instruction for children who need more than standard teaching. For a child to receive special education through an IEP, the child’s disability (or eligibility criterion) needs to adversely affect the child’s educational performance and the child’s needs cannot be solely met within the general classroom setting.
  • A 504 plan describes changes at school to support a child’s learning. These changes are typically called accommodations. Often, a family makes a request for a 504 plan at the same time as an IEP evaluation.

Case 3: Jill – Treatment Continued

Four months later:

Jill returns to the office with her mother.  Jill’s mother submitted the letter to the school, as you had encouraged, and Jill was found eligible for special education services. Her mother attended the IEP meeting last week, but was a little overwhelmed by all of the information.

Jill’s mother brought the IEP with her to the appointment today and asks you for your thoughts.

Case 3: Jill – Treatment Continued (Duplicate)

Four months later:

Jill returns to the office with her mother.  Jill’s mother submitted the letter to the school, as you had encouraged, and Jill was found eligible for special education services. Her mother attended the IEP meeting last week, but was a little overwhelmed by all of the information.

Jill’s mother brought the IEP with her to the appointment today and asks you for your thoughts.

Case 2: Oliver – History of Present Concern

History of Present Concern:

Oliver had been attending his preschool program for the last 4 months.

His teachers have made many complaints about his activity level and impulsivity around other children in the classroom. He won’t sit still, he has difficulty sharing, he pushes others, and he interrupts nap time.

The preschool teachers described to Oliver’s parents that he was just too much for the school to handle.

His mother states that she can relate, as there are similar difficulties with Oliver at home.