DBP Community Systems-Based Cases - Case 2: Mark

Background: Mark is a 7.5-year-old boy in second grade at a local public school.  He was diagnosed by a local psychiatrist with ADHD and has been on appropriate doses of stimulant medication for one year.  He comes to clinic with a chief complaint of poor performance in school.  His parents note that he received a number of “unsatisfactory” grades on his most recent report card. His strengths are in art and PE.  He is very social and well liked by classmates.  He has several friends with whom he plays regularly after school.

QUESTION 1: List additional questions you would ask about Mark’s school performance.

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ANSWER:

Which subjects are most difficult? Which are his best?

When did Mark’s difficulties begin?

What makes Mark’s performance better?  (e.g., 1-on-1 attention, modifications of the curriculum or assignments, modifications of the amount of homework?)

What makes his performance worse? (noisy environment, requirements for writing, etc.)

What have the family and school done so far to address the problem (other than using medication for ADHD)?

 

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Mark’s parents tell you that:

Reading and spelling are the most difficult subjects.

Math is best.

Difficulties were first noted in the first grade.

If Mark’s parents read a story to him, Mark can answer questions about the content.  When he tries to read himself, he loses focus quickly and does not understand what he has read.

Mark does worse when another child with ADHD is seated next to him and when the assignments are long, with no breaks.

The school has done no assessments.  No interventions or services have been implemented.

QUESTION 2: Based on your questions, Mark’s parents ask for more information about his eligibility for services and interventions at school. What would you tell them?

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ANSWER: All children are entitled to receive a Free and Appropriate Public Education.  Mark may be eligible for educational accommodations or modifications under Section 504 of the Rehabilitation Act or for special education under the Individuals with Disabilities Education Act (IDEA). 

Link to Information on Educational Law for Children with Disabilities

 

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QUESTION 3: Mark’s parents would like to pursue the possibility of getting him extra help at school. What next steps would you take?

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ANSWER: Contact Mark’s teacher to better understand the issues firsthand. Advise parents to submit a written request for an initial educational evaluation,  to either the principal of the school or the Special Education Coordinator for the school district. Including a letter from the pediatrician or psychiatrist may be helpful.  Parents should follow up by phone within 1-2 weeks to check the status of the request. 

Link to Letter Reqesting Initial Educational Evaluation

Depending on the results of the school’s evaluation, Mark may qualify for either a Section 504 Plan or an Individualized Educational Plan (IEP).  A 504 plan specifies educational accommodations within the regular education setting for a child with a disability, in this case ADHD.  It is a flexible plan, does not have rigid eligibility criteria, and serves many children well.  However, it is not as formal as an IEP

Districts vary as to their procedures, with most beginning the accommodation process with an Student Study Team/504 meeting, and will call for a full IEP team meeting only if the cheaper and easier to implement 504 plan is unsuccessful.

Link to Decision Tree for Educational Plans

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Background: At Mark’s parents request, his school assembles a Student Study Team. 

The SST reviews reports from Mark’s present and past teachers, information provided by the psychiatrist who prescribes his medication for ADHD, and input from his parents on his strengths and difficulties.  No formal testing is completed.

When they return to clinic after Mark’s initial visit, his parents explain that he has a Section 504 plan that includes the following accommodations:

Mark will be seated in the front of the classroom

He will have a behavior modification contract, with rewards and praise for staying in his seat and completing his work

He will be allowed extra time to complete in-class assignments and tests, with short breaks during lengthy assignments. 

A teacher’s aide will read test and assignment instructions aloud. 

Three months later, Mark continues to do poorly in reading and spelling.  Math has become more difficult since the class has begun working on word problems.

Mark’s parents note that he now complains of abdominal pain in the mornings on school days.

QUESTION 4: What next steps would you recommend?

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ANSWER: Request a formal evaluation/IEP team meeting – to include specific assessment for learning disabilities.

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Background: The school conducts psychoeducational testing: 

Results of intelligence testing (WISC-IV) demonstrate that Mark has normal cognitive function.

Academic Achievement Testing (WJT Achievement –III) reveals weakness in subtests related to reading and spelling, consistent with a language-based learning disability

A multidisciplinary IEP team determines that Mark has an IDEA-eligible disability that is adversely affecting his educational performance.  He qualifies for special education.  The team and family meet to develop a formal IEP.  

Mark and his parents return at the beginning of third grade.  Over the past several months, he has received  specialized instruction in reading in the regular classroom as well as in a resource room ½ hour per day.  He has made progress and is now reading at a beginning 2nd grade level.  His parents ask whether it would be better to hold him back a year, “so that he doesn’t have to be in special ed.” 

QUESTION 5: What would you recommend?

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ANSWER:

Holding a child back does not provide specialized instruction

Some of the special education services that Mark is receiving occur in the regular classroom.

Mark has friends and is well liked in his current grade. Separating him from his peer may be disruptive and damaging to his self-esteem.

The child’s rate of development may be slow.  Simply holding him back one year will not address that issue

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