Components of CET Components of CET Sole purpose

Components of CET

Components of CET Sole purpose for or against autism Independent Team One Report Trans-disciplinary approach Concise meeting time 4 Squares (Domains) Not Standardized Score Based Report Shared with the parents ahead of time Qualitative Sensory not assumed Three person team Objective – don’t know kids All doing Observations in all settings Home visits (all three go) Showing deficit does not have to be academic Report follows MET criteria

CET Components • Components that can be immediately implemented • Components that can be implemented in a reasonable amount of time but that need some planning. • Components that have major barriers for our district / ISD.

Beyond CET Customizing Implementation Kelly Dunlap, Psy. S. Stephanie Dyer, Ed. S.

Implementation = Herding Cats

CET = Standardize the Process Beyond CET = Customize the Implementation • Factors in Customization – Players – ISD / District Structure – Competency of Staff in ASD Evaluation – Political / Cultural Variables – Buy In / Support

Acronym Deciphering Tool • • • SE = Special Education ASD = Autism Spectrum Disorder MARSE = Michigan Administrative Rules for Special Education REED = Review of Existing Evaluation Data MET = Multidisciplinary Evaluation Team IFSP = Individual Family Service Plan IEP = Individualized Educational Program SAS = Supplementary Aids and Services P&S = Programs & Services FAPE = Free and Appropriate Public Education LRE = Least Restrictive Environment • • • • AIB = Autism Insurance Benefit DSM = Diagnostic and Statistical Manual of Mental Disorders PDD-NOS = Pervasive Developmental Disorder – Not Otherwise Specified ADOS = Autism Diagnostic Observation Schedule ADI = Autism Diagnostic Interview CMHP = Child Mental Health Professional PCP = Person-Centered Plan IPOS = Individual Plan of Service ABA = Applied Behavioral Analysis EIBI = Early Intensive Behavioral Intervention ABI = Applied Behavioral Intervention ABLLS = Assessment of Basic Language and Learning Skills VB-MAPP = Verbal Behavioral Milestones Assessment and Placement Program

Current Players at the Table Special Education AIB Private Insurance Medicaid / MIChild Criteria ASD / MARSE ASD =DSM disorders of autistic disorder, Asperger’s or PDD-NOS Plan for Evaluation REED/30 -day timeline ------------------- Who Evaluates MET Licensed psych or physician CMHP Using What Tools Prescriptive for Child / Purpose “autism diagnostic observation schedule” (e. g. ADOS-2) Must include ADOS-2 Developmental Family History (e. g. ADI-R) Determination of Impairment / Diagnosis IFSP / IEP Team Determines Impairment Diagnosis of Condition Eligibility for Services IFSP / IEP Team Treatment prescribed or ordered by evaluator CMHP + Medicaid Agency final approval Service Plan IFSP / IEP Types of Services Treatment Plan developed by IPOS developed through board certified or licensed PCP process provider IFSP=Early Behavioral Health, Pharmacy, Intervention services; Psychiatric, Psychological, IEP=SE, RS, and SAS Therapeutic ABA (EIBI and ABI)

Referral / Evaluation Considerations • Context of Referral: – Request for Initial Evaluation, or – Already eligible, but not ASD (e. g. ECDD/SLI) • Potential Challenges – Pressure to accept outside diagnosis and proceed to an IEP with ASD eligibility • IDEA/MMSEA Considerations to Remember: – Always consider information provided by parent (REED) – AIB diagnosis • Not typically done by a team • Possibly using different tools • Using different criteria – Special Ed evaluation done for dual purposes of eligibility and IEP development

Autism Council SUBCOMITTEES Early Intervention Adult Services Workgroups Screening and Assessment / ASD Eligibility Determination Education

Resources • • • START’s Centralized Evaluation Team (CET) Training (CET): (M. Ziegler, D. Schoemer) “Exemplars” (e. g. Kent, Ottawa, Char Em Evaluation Guidelines) CDC ACT (Autism Case Training) http: //www. cdc. gov/ncbddd/actearly/ACT/class. html • • • CCRESA Progression & Feedback “Beyond CET” Training: S. Dyer Collaborative Conversations: • • C. Lord, B. Ingersoll, S. Pastyrnak, OAISD AIM (Autism Internet Modules) http: //www. autisminternetmodules. org • • National Association of School Psychologists National Research Council

National Research Council “There is no single behavior that is always typical of Autism and no behavior that would automatically exclude an individual child from a diagnosis of Autism. ”

So, where do we start? 3 Steps: 1. Ensure high quality special education eligibility evaluations…. (Clean up our own backyard!) 2. Utilize “Gap Analysis”: What additional information do schools need, when given an outside evaluation, to address special education ASD eligibility? 3. Move toward true collaborative evaluation

Improve Quality of ASD Evaluations

Improving School Processes • All staff need to be competent at ASD screening / evaluation • Current Issues: – Not recognizing there are THREE required eligibility areas – Not recognizing that “educational impact” can be in one of THREE areas (e. g. academic, behavior, social) – Use of tools with no observational data – Not understanding terms: • • Pervasive Marked Qualitative Adverse Impact

High Quality Evaluation • ASD Evaluation Process ü Key Components ü Evaluation Methods & Tools • ASD Eligibility Criteria ü Rule 340. 1715 ü Deep Understanding • Other Considerations / Individual Challenges

TEAM Evaluations are conducted as a team! ☺ Collaboration ☺ One voice ☺ One contact ☺ One report Minimum: Psych, SSW, SLP…

Collaborative Team Approach

CET Components Selected

4 Critical Components 1. Evaluation Checklist Meeting 2. Evaluation Components 3. Results Review Meetings 4. Team Report

KEY COMPONENT #1 Evaluation Checklist Meeting • Attended by MET members (Psych, SSW, SLP) • Critical for coordination of scheduling (ie. IEP, RRM, observations…) • Discussion and assignments of evaluation components (evaluation checklist) • Allows time for training, questions, case study, problem solving

Evaluation Checklist ü Teacher interview ü Parent interview / home visit ü Observations ü CA-60 review ü ADOS ü Diagnostic Testing ü Report Writing ü Results Review Mtg ü Need / Impact Determination ü Schedule IEP ü Feedback to building team/coach/sped rep ü Parent interp ü IEP attendees

KEY COMPONENT #2 Evaluation Components • Parent/Family Interview(s) and Home Visit • Teacher/Service Provider Interview(s) • Observations (Multiple Times/Settings by all team members) • ADOS (Viewed/scored by TEAM) • Other Information as Determined by Evaluation Team

Evaluation Methods/Tools • Predominantly OBSERVATION and INTERVIEW • Not YES/NO, Black/White…Qualitative Evaluation • Autism Diagnostic Observation Schedule (ADOS): Not score, but observation opportunity • Specific diagnostic tests (communication, cognitive, social, sensory, adaptive) • Caution: Questionnaires? CARS?

Technical Adequacy • Sample • Reliability • Validity • EXAMPLE: ADOS-2: • Test / Re-test Reliability— 2 Weeks: • Classification changed for 9 of the 39 children (23%)

Assessment Tools Central Assessment Lending Library (CALL) https: //www. cmich. edu/colleges/chsbs/Psychology/call/pages/default. aspx/ • ASIEP-3: Autism Screening Instrument for Educational Planning • ADOS-2 (Autism Diagnostic Observation Schedule) • ADI-R: Autism Diagnostic Interview • CARS-2: Childhood Autism Rating Scale • GARS-2: Gilliam Autism Rating Scale • GADS: Gilliam Asperger Disorder Scale • KADI: Krug Asperger Disorder Index • PEP-3: Psycho-Educational Profile • ABLLS-R: Assessment of Basic Language and Learning Skills • VB-MAPP: Verbal Behavior – Milestones Assessment and Placement Program

Parent Interview • During home visit • At least two evaluation team members • Guided interview – Biggest concern – Describe interview process – Birth, developmental, medical history – Go through questions • Visit to child’s room if possible

Teacher Interview • Allow at least 45 minutes • Preferably two evaluation team members • Guided interview – Biggest concern – Describe interview process – Go through “teacher interview” questions – Academics – Explain rating scale if using one & set up return process

Observations • All team members need to conduct observations • Make sure all settings, times of day, contexts are covered • Allow room in schedule for additional observations • Powerful…allows for considering function of behavior (“eyes on kid, eyes on kid…”) • Dig down below the surface

Understanding Behavior Positive Behavior Intervention Support Perspective • Behavior serves a FUNCTION • Behavior is influenced by: – internal events such as physiological condition (e. g. , earache) – emotional state (e. g. , anxious, scared) – factors outside the immediate context, including relationships, activity patterns, and lifestyle issues. • Behavior is related to and governed by its CONTEXT: – ENVIRONMENT Horner, R. , 2000

Possible Function? When peers try to talk to her, Mariah turns away, does not respond verbally, and pulls her sweater over head; peers move away. When the teacher gives her corrective feedback about her work, Mariah turns away, does not respond verbally, and pulls her sweater over head; the teacher sits next to her, rubs her shoulders and says comforting words.

• Marci was observed grabbing toys and objects from others and appeared unaware that the other child was using or playing with the object. Marci was observed tickling peers under the chin while giggling, moving from one peer to the next. None of the children appeared to be enjoying this, but Marci did not seem to recognize their displeasure. • Marci was observed pulling at girls’ ponytails and accessories; Marci has not been noted to pull hair other than in pony/pigtails or when there accessories present. Marci was noted to state, “I want to poke her in the eye” and “I want to kick her” in a very unemotional manner not directed at anyone. Despite her statement, Marci has not attempted to do the things that she says.

Marci was observed grabbing toys and objects from others and appeared unaware that the other child was using or playing with the object. Marci was observed tickling peers under the chin while giggling, moving from one peer to the next. None of the children appeared to be enjoying this, but Marci did not seem to recognize their displeasure. Marci was observed pulling at girls’ ponytails and accessories; Marci has not been noted to pull hair other than in pony/pigtails or when there accessories present. Marci was noted to state, “I want to poke her in the eye” and “I want to kick her” in a very unemotional manner not directed at anyone. Despite her statement, Marci has not attempted to do the things that she says.

Marci was observed grabbing toys and objects from others, while yelling, “I had it first!” and pushing peers away. Marci was observed tickling peers under the chin while giggling, moving from one peer to the next. None of the children appeared to be enjoying this, but Marci kept saying, “Am I bugging you yet? ” and “Isn’t this so funny? ” Marci was observed pulling at girls’ ponytails and accessories; she will say, “I don’t like your hair like that-it looks stupid. ” Marci was noted to state, “I want to poke her in the eye” and “I want to kick her” while being redirected from an argument with a peer. Marci has previously shoved, kicked and poked this girl when she doesn’t do what Marci wants her to do.

KEY COMPONENT #3 Results Review Meeting • Only Eval Team present (Psy, SSW, SLP) • List all 12 criteria on board • Color code information (teacher, parent, eval team) • Ask BIG question in each area: Is there a qualitative impairment in socialization? . . . • Discuss each criterion; check criterion that has been reached • Report writer (on computer)

Data Analysis?

Determining Eligibility • Start with the child, not the characteristics • Integrate quantitative & qualitative information • Within qualitative assessment, discover whether student meets criteria for Autism Spectrum Disorder • “Preponderance of the evidence”

Results Review Meeting cont… • Process – All data sources – Determine eligibility / DECISION – If eligible as ASD, determine how the ASD is impacting progress in gen ed in the areas of socialization, independence, communication, transition, self-regulation… • Feedback/recommendations provided to building team, parents, coach, sped rep

Of primary concern is Johnny’s level of independence. Due to difficulties in pragmatic language and communication, sensory modulation, and socialization, Johnny’s independence is limited. In order to participate with the routines and activities of the classroom, Johnny currently requires considerable physical and verbal prompting from adults. His independence is significantly impacted in the following areas: • Transition (task to task and place to place) • Group participation • Direction following • Self care • Interactions with peers • Outside play • Inside play with free choice time • Spontaneous conversation

KEY COMPONENT #4 Report Writing Process • Use template! (Follows the MET criteria) • Information from RRM provided basis for report; recommendations and consistent message developed at the RRM • Report writer determined when assigning tasks from the evaluation checklist • Very defendable; easy to understand; excellent feedback from staff, parents, special ed reps; creates consistency; eliminates redundancy!

Critical Report Considerations • Build a case for your conclusion (e. g. you shouldn’t get to end and question eligibility recommendation) • Avoid “cut and paste” process (makes it challenging to cohesively build a case) • Use Persuasive Writing Skills • Customize to MET form • Explain what does NOT align (e. g. standardized scores, parent reports of behaviors, etc. )

EXAMPLE SOCIAL: Based on survey information and observations, demonstrates a range of nonverbal behaviors such as smiling when happy, frowning when sad, pointing to orient another to something, and looking nervous when he does something wrong. For example, on one occasion during direct observation, . On another occasion, On yet another occasion, These are a just a few examples of the good use of nonverbal behavior uses to communicate in social situations. During direct assessment, was able to describe an event using a full range of facial expressions, body postures, and gestures including pointing, shrugging his shoulders, and nodding. Although reports indicate that struggles with matching facial expressions with mood (e. g. face will be straight when he is actually happy) and using a full range of non-verbal, in school observations and direct assessment, these behaviors were noted to be qualitatively (DEFINE) impaired compared to peers.

EXAMPLE SOCIAL: also is attentive and responsive to the social environment and engages in the give and take of social interactions that define reciprocity. is reported to have two good friends in the general education classroom and a number of friends in the special education classroom. was observed during recess to play soccer with a group of about six other students and despite some disagreement among them around rules, they sustained the game for the majority of the recess time. is also reported and observed to initiate and even seek out peers to engage with and likes to show toys and school work to both peers and adults. , however, indicates that does not show or share at home unless it is in an interest areas, although in school, is reported and observed to share a full range of information including sharing about events outside of school like vacations. During direction observation, showed and shared on a number of occasions. For example,

QUICK CHECK: ASD is characterized by: qualitative impairments in ___________, qualitative impairments in __________, and __________.

The Triad of ASD: Qualitative Pervasive Characteristics of ASD DEEP UNDERSTANDING • Social Skills -- Reciprocity • Communication • Restrictive, Repetitive, and Stereotyped behaviors: – Insistence on Sameness – Idiosyncratic Behavior – Imposition on Environment

Eval Team Practice

Other Considerations • Eligibility before age 8 • Re-evaluations • Others

Gap Analysis What needs to be done when an outside evaluation is provided?

Considerations • We still have obligation to address MARSE eligibility criteria (ex: ADHD) • What do we know from what they provided? Diagnostic information/rating scale scores Developmental history ADOS score • What do we still need to know? What does child look like across settings? Impact on social, behavioral, academic Additional parent/teacher info specific to triad Communicate with evaluator

Proceed with Process • Checklist Meeting • Evaluation Components (completion of identified “what we still need to know” items) • Results Review Meeting • Team Report

What if there is disagreement? (e. g. one says “yes” and one says “no”) • Remember, different purposes (diagnosis versus special education eligibility and IEP development) • Adherence to strong evaluation process, report is defendable • Commitment to communication • Make sure to meet student needs Implementation of Universal Supports Use of SW-PBIS practices

ONCE ELIGIBILITY IS DETERMINED— IMPACT OF NEW PLAYERS ON THE IEP PROCESS CHALLENGES & SOLUTIONS

Challenges & Solutions • Expect Requests for School Observation – Context of the Request: • Part of AIB evaluation to develop a treatment plan / IPOS • To identify potential generalization opportunities • To monitor progress • Potential Challenges: – Moves from observer to participant (e. g. intrusion into the instructional process for the individual child or the whole classroom) – Liability Issues • Administrative Considerations to Remember: – Requests should be processed per the school visitation policy – Observers need to be cognizant of privacy rights of other children and remember that this is an observation of the child, not the teacher! – Observers are non-participants

IEP Challenges & Solutions • Expect more input on PLAAFP & Goals: – Remember---PURPOSE of the IEP: Determine impact of ASD on access and progress in general education – Behavioral Health Treatment Plan / IPOS may focus on developing discrete skills identified from an alternative curriculum or ABLLS-R / VB-MAPP – COLLABORATE; COLLABORATE • Where there is agreement, embed in the IEP • Where these is disagreement, focus on the PURPOSE of the IEP

What is FAPE? IDEA 2004 An educational program that is individualized to a specific child, designed to meet that child's unique needs, provides access to the general curriculum, meets the grade-level standards established by the state, and from which the child receives educational benefit. 20 U. S. C. § 1401(9). Ed Benefit = progress over time (IEP goals, curriculum, social, communication, behavior, etc. ) To provide FAPE, schools must provide students with an education that prepares the child for further education, employment, and independent living. 20 U. S. C. § 1400(c)(5)(A)(i)

Defining LRE: Fed Language “To the maximum extent appropriate, children with disabilities…. are educated in the general education classroom with children who are not disabled…” …. and that special classes, separate schooling, or other removal of children with disabilities from regular education environment occurs only if the nature or severity of the disability is such that education in regular classes with the use of supplementary aides and services cannot be achieved satisfactorily. ”

IEP Challenges & Solutions • Expect more input on Programs / Services: – The IEP must always offer FAPE in the LRE – Methodology Request • All requests MUST be “considered” • Generally, methodology is at the discretion of the special education service provider • Determine if the methodology is needed for the child to receive FAPE – AIB services may supplement but not supplant FAPE • MSA: “These supports may serve to reinforce skills or lessons taught in school, therapy or other settings, but are not intended to supplant services provided in the school or other settings or to be provided when the child would typically be in school but for the parent’s choice to home-school the child. ” --MSA Bulletin 13 -09

Request for Push-in AIB Services Parent / Therapists’ Reasons Special/General Education Issues Raised • • Parent’s inability to get the child to the outside therapist’s location; Desire on the part of therapist to generalize skills learned in 1: 1 treatment / intervention; Push in therapist could build capacity of school staff and save $ on 1: 1 parapro • IDEA / MMSEA/Gen Ed Considerations • 1: 1 Therapy (EIBI) = defacto request for a reduced school day (geography issue: classroom is therapist’s office) • ABI—supporting generalization of skills / capacity-building: • • District’s obligation is to provide FAPE in the LRE (can’t bargain away FAPE or LRE); Reduced school day would rarely constitute FAPE; • Services included IN the IEP should be limited to those needed for FAPE. • Liability issues / Who monitors implementation of the portions of the IEP provided by individuals the district does not supervise? Potential labor law issues (e. g. supervision, subcontracting of union work) • Potential FAPE issue (consider if should be in the IEP as SAS and if so, must be provided at no cost to the parent) Including AIB treatment/intervention during school day risks insurance co. challenge that district should be payor. What happens when child no longer eligible for AIB service OR state funding of AIB reimbursement ends?

Requests for Pull-Out AIB Services Parent / Therapists’ Reasons / Request • Therapist does not offer after school or evening hours; Special / General Education Issues Raised • Developing a reduced day IEP; IDEA / MMSEA / Gen Ed Considerations • Same as for Push-In AIB Services • IEP Team must offer FAPE: Is therapy (e. g. ABA) needed for FAPE? Or methodology that is generally left to the discretion of the district if the student is progressing? • Refusal to develop a • Request IEP team to reduced day IEP or write develop a reduced therapy in the IEP day IEP or write the may result in potential • Legal Alternatives that parents AIB therapy in the IEP truancy issues may want to explore: so the child will not be • Home-school marked absent • Temptation is to write the • Register as home-school; service in the IEP to parents provide core avoid truancy issues instruction and Ss receive • • auxiliary services (ISP), but not FAPE; Register as home school & explore shared-time for non-core classes Online classes

Move Toward Collaborative Evaluations

Purpose of a Collaborative Approach • Current Changes (e. g. AIB, Autism State Plan) • Eliminate Redundancy • Ensure Families are Provided Resources / Contacts • Treatments • Services

Challenges • Ethical Issues – Report sign-off and letterhead – Quality/ethical guidelines • “Turf Issues” Who’s the lead? Private vs. public issues • In-house Team Issues – MET teams • Limited guidance in literature • TIME

Conversations with Collaborative Partners 1. What are those common pieces that both groups need? 2. What about mutual releases of information? 3. Invitation of collaborative partner to REED or evaluation checklist meeting? How can different players be at each other’s meetings?

4. Respecting professional expertise 5. How many different people does the child see during the evaluation process? 6. What happens when parents get conflicting information? 7. What pieces are sensitive? • • • Cognitive information Reporting only ADOS score Recommendations out of context

SUMMARY 1. “Clean up our own backyard”: Improve quality of ASD evaluations 2. Understand “Gap Analysis”: What is it that schools need to address ASD eligibility when given an outside evaluation? 3. Move toward a true collaborative evaluation

Don’t let the barriers paralyze you…

Next Steps • Brainstorming with team • Brainstorming with other ISD teams • Talk with neighboring ISD/Districts or your Regional Collaborative Network (RCN) • Email Dave, Kelly, Maureen, or Stephanie • Access START’s formal Technical Assistance Process (in development)