For fifteen years, I worked and taught in the multidisciplinary clinics at Children's Hospital evaluating youngsters for school difficulties.  We used a model that employs developmental pediatricians, psychologists, and educational specialists working together as a team. Since 1996 I was the Associate Director of the Young Adult Team - the Middle & High School age division of those clinics.  What follows reflects my own personal opinions & positions regarding LD & related topics based on the above experience.  It does not necessarily represent the position of Children's Hospital, YAT, or any other member of our staff.

LD's are neurologically based - they are caused by poor "wiring" in the brain.  They are usually something a child is born with for no reason, although they can sometimes run in families or be caused/exacerbated by other factors (see below).

LD's are not related to maturity or motivation.  A child will not simply "outgrow" an LD - it is not "developmental" in the sense that teachers or schools often use this word.  Simply waiting or retaining a child in a repeated grade is seldom useful.  Moreover, it is also not helpful to "blame the child" for his or her disability.  They cannot be expected to overcome it through sheer effort alone.  Younger LD children are usually very motivated.  Older LD children who may have lost their motivation have done so specifically because they have become frustrated, discovering over and over again that simply trying harder does not help.

Learning Disabled children, regardless of their age, require a change in teaching technique to make the way a problem subject is being taught more closely match their "wiring" or "learning style".  Indeed, LD's might be better thought of as a "mismatch" between learning and teaching styles.  The child with an LD needs to be taught strategies for overcoming their area(s) of weakness - in other words, for "translating" an unfriendly teaching style into one which works better for them.

Regardless of what words you use for them, ND skills are things nobody teaches you in school, yet you need them to do school work!  They include memory, attention, motor coordination, visual processing, receptive & expressive language, sequencing, organization, and logic.  Other ND skills exist which are less important for academic success in American society, such as musical aptitude, sensory integration, empathy, intuition, and social cognition.

One of the great debates in modern psychology is whether or not "intelligence" is anything more than the simple sum of all these ND skills.  If it is, modern IQ (cognitive) tests don’t measure it.  Cognitive tests measure a number of ND skills, lumping the results together into a few numeric scores to generate an IQ profile.  Other kinds of tests may look at one or another ND area in detail (e.g. Speech & Language for receptive and expressive language; Occupational Therapy for fine motor coordination & sensory integration, etc.).  Neurodevelopmental examinations are tests measuring most educationally relevant ND abilities, but rather than lumping them together like an IQ test, an attempt is made to split them apart into individual categories.

Although most of us have near-average IQ’s, very few of us have near-average abilities in all ND areas across-the-board. Most of us have significant strengths & weaknesses.  Our strengths balance out our weaknesses in a way that brings our overall IQ towards average.  Moreover, most of us utilize our strengths to overcome our weaknesses quite "naturally", without any assistance from parents, teachers, or the "outside world".  People who do this so that their weaknesses do not impede their learning or job performance are, quite simply, normal.  LD is defined not merely by the existence of an ND weakness, but by an inability to overcome that weakness without help.  Only when a weakness gets in your way or becomes an obstacle to your success does it become a "disability".  Similarly, while many of us have significant strengths in one or another area, very few of us utilize those strengths to do anything particularly unusual or special.  "Giftedness" is not merely the existence of a strength, but the use of that strength to do something remarkable.

Many factors influence whether a weakness becomes a disability or not.  (And, conversely, many of the same factors influence whether a strength becomes a "gift".)  These include not only what other particular strengths & weaknesses coexist, but also such things as social environment, family structure, financial resources, emotional health, and probably even just-plain-luck.  School quality & the match between teacher and a particular child’s learning style/personality also play a role.  Sometimes a particular child will appear to have an LD in one school and not in another, simply by virtue of the school’s differences in teaching style.

While a weakness may or may not represent an impediment to learning in different situations, because they are neurologically based ND weaknesses themselves cannot be "cured" or directly remediated.  Altering the teaching environment in a way that de-emphasizes the impact of a child’s weakness while calling more consistently upon his or her strengths is therefore the foundation of Special Education (SPED) assistance for LD children.  Specialized LD teachers can accomplish this.  Regular teachers with good "instincts" can do it just as well. It can happen in either SPED or regular classrooms.

Finally, no discussion of LD's or giftedness would be complete without reference to two other things - Mental Retardation & Genius.  Most people have strengths that are somewhat above average, and weaknesses somewhat below average, so that the whole thing averages out, well, near average.  Mental Retardation is when even someone’s strengths are below average for their age, and their weaknesses far below, such that the whole thing averages out to be far below average.  Genius is the opposite - even a Genius’s weaknesses are above average for age, and his/her strengths are very far above average, so that the whole thing averages out far above normal.

<Click here for a graph illustrating what I mean>

In sum, most of us have strengths & weaknesses that neither get in our way nor enable us to excel.  Someone whose weaknesses impede normal learning has a Learning Disability.  When strengths lead to special accomplishment, that’s Giftedness.  Someone with Mental Retardation has weaknesses in all areas, while a Genius has nothing but strengths.

• EARLY RECOGNITION: It's important to recognize many children with LD's were first identified with "developmental delays" of one sort or another during infancy, toddlerhood, or the preschool years.  While the chance of "outgrowing" a developmental delay (weakness) in this young age group (or having it respond favorably to direct "therapy") is much greater than it is at school age or beyond, many developmental delays in young children evolve into LD's later in life.  Thus, it can be said that many LD's are first diagnosed by specialists who work with very young children: Early Intervention Programs, Speech Pathologists, and Nursery School teachers.
  

• IQ TESTING: The oldest, simplest, most widely accepted way of diagnosing an LD is with an IQ test.  Two criteria are commonly used - one being a discrepancy of more than 15 points between the Verbal and Performance IQ scores, the second being a great deal of "scatter" or discrepancy between individual subtest scores within either the Verbal or Performance sections.  While either of these findings suggests LD, they can be found at times in people who are functioning normally.  Therefore, one must add the criteria of an actual delay in learning to these IQ observations in order to fashion a rational diagnostic method.  This approach is the one most commonly used by school systems in states other than Massachusetts, under the federal PL 94-142 and the Individuals with Disabilities Education Act (IDEA).
  

• ACHIEVEMENT TESTING: A third, quite straightforward, way of diagnosing LD, popular in Massachusetts public schools, dispenses with IQ/abilities testing altogether.  Instead it focuses on reading, writing and arithmetic.  In this scenario, a detailed battery of Individual Achievement Testing is carried out.  Some (arbitrary) cut-off point is established for the amount of delay in a particular subject that is considered acceptable.  If a child is delayed beyond the cut-off point, they are considered disabled and are given services.  If their delays are not that severe, they are not considered disabled.  This approach is appealing to some school systems because it's cheap to administer & easy to understand.  It seems outwardly "fair".  It skirts the question of "why" the delay exists, which could be seen as either an advantage or a disadvantage.  This approach can be criticized as avoiding making the diagnosis of LD altogether, but rather simply giving help to those who are behind regardless of cause.  
  

• UP TO POTENTIAL?: A slightly more sophisticated version of the previous approach compares achievement test results not to the grade expectations or cutoff, but rather to the subjective impression of the child’s "potential" in the opinion of teachers & parents.  Thus, a 2-year delay in math might be considered more problematic in a child who seems "bright" than in a child who seems "average".  Carrying that logic one step further, however, one wants to objectify the impression of potential using something like an IQ or some other abilities test, which brings to the next method.
  

• MULTIDISCIPLINARY ASSESSMENT:  Many medical centers (and some school systems) combine the above approaches.  They use Individual Achievement Testing alongside Abilities Testing - either an IQ test or Neurodevelopmental Examination.  The latter is more often used in medical settings for two reasons: First, it allows better "teasing apart" of the various developmental strengths & weaknesses than an IQ test, so that one can be more specific about what the LD is based upon.  Second, a physician (Neurologist or Developmental Pediatrician) usually administers the Neurodevelopmental, bringing valuable medical perspective to the team.  In any case, it is necessary to find weaknesses in abilities along with concomitant delays in achievement, and to be able to reasonably connect the two, in order to make a diagnosis of LD under this model.  While the achievement-abilities combo should be seen as a "minimal" multidisciplinary team protocol, other tests & specialties can be and often are added - for instance, projective psychological assessment to look for emotional problems, OT or Speech evaluation, etc.  All these things add to the depth of any evaluation, and thus lead to a richer and more complete understanding of the child.
  

• "NEUROPSYCH" TESTING:  A final way of diagnosing LD's is the "neuropsychological" or "neuropsychiatric" evaluation.  This is a very detailed battery that combines multiple tests administered from a neurological point of view, often by a psychologist under the supervision of a neurologist or, alternatively, by a psychologist with specific neurological training and background.  The tests used combine abilities tests, achievement tests, and some neurological assessment.  Such evaluations are often very helpful in painting a detailed picture of the child’s strengths and weaknesses and can be particularly useful when "normal" SPED techniques have been tried and failed to help a particular child.  For initial diagnosis, however, a full neuropsychological evaluation can sometimes be "overkill" and yield more information than is practically useful.  

First, psychological problems can mimic LD's.  Therefore, an evaluation looking for emotional difficulties such as depression, anxiety disorders, and adjustment problems should really be done alongside any LD evaluation.  While almost always included as part of a team evaluation in a medical setting, schools or private "LD specialists" often omit this.  In older children, it can often be difficult to tell "what came first, the chicken or the egg" when evidence of both LD and an emotional problem is found.  In many ways this is a false dilemma, however, since in such situations it is necessary to address both problems simultaneously in order to "break the cycle & help the child".

Another factor  to think about when student is having difficulty is the standards of the school system compared to the child's abilities.  While it is nice to think of "national norms" in terms of things like reading acquisition, the truth is there are many communities across America that deviate from the norm considerably both in the average academic attainment of their students and in the content of their curriculum. This can affect students in a number of ways.  First of all, when a child moves from one community to another, trouble can arise if the curriculums are too different in either direction.  Some such children essentially skip a grade, find themselves behind, and start having trouble where before they had none.  This can be misconstrued as an LD at times. Conversely, children who move to a "slower" district can sometimes develop behavioral difficulties because they become bored and under-challenged.  Another artifact produced by this variability between community curriculums has to do with a bright child who nonetheless has an LD.  Such a child is far more likely in an accelerated curriculum to be identified and given some help.  Such a child in a slower curriculum setting is apt not to be seen as having a problem.  Conversely, a child of low-average intelligence who is unfortunate enough to be living in an accelerated community may be misidentified as having a LD when he really has none.  The simple fact is that moving can be both disruptive and helpful for different children.  A good match between the child and his school system is often times more important than all the SPED assistance in the world.

• SCHOOL: The advantages of school testing are that it is usually free, it is often a pre-requisite for receiving extra help or specialized services from the school even if other private testing has been done, and the validity of school testing is seldom questioned by school personnel.  Disadvantages of testing by the school are several.  The background, training and, quality of evaluations provided by the school varies greatly.  Some are very good, but others may be lacking.  It can be difficult for parents to evaluate the qualifications of personnel on the school staff.  Moreover, personnel who are working for the school virtually always have a certain "conflict of interest" when evaluating children for LD's.  A person working for the school can’t simply give an objective opinion about what would hypothetically be in the child’s best interest, but has to temper his or her recommendations with knowledge of the school’s available resources as well as the needs of the student’s classmates.  Moreover, a second kind of conflict comes about when a child has been receiving services from the school for some time.  In this case, testing which demonstrates a lack of progress reflects poorly on the school’s interventions, services that may sometimes have been delivered by the evaluator him/herself.  The extent to which an individual evaluator in the school system allows these conflicts of interest to influence them varies greatly, but it can be hard for a parent to tell the extent to which it has occurred.  The results of school testing may be very valid, but they are always suspect on this basis.  
  

• PRIVATE: The advantages and disadvantages of private testing are in many ways the converse of testing carried out by the school.  Private evaluators work for the parents and are free to give their best professional/expert opinions about what would be best for a particular child without bias or conflict of interest.  While the quality of private evaluators also varies widely, parents have more freedom of choice in selecting an evaluator and are usually more able to investigate a particular evaluator’s background, training and credentials.  The disadvantage of private evaluations is that they are often quite expensive.  This can sometimes be mitigated by health insurance, although many health plans will not cover investigations of this sort. It is also possible to sometimes get the school system to pay for private evaluations (see below) although this has disadvantages in terms of the delay it entails as well as sometimes engendering some bad feelings between the school staff and the parents.  Often times, parents end up having to pay this bill themselves.

When looking for private evaluators, there are many different sorts of professionals that one might utilize.  These include Education Specialists (Reading Specialists, Tutors, LD Specialists, etc.), Psychologists, Speech & Language Pathologists, Neurologists, and Developmental Pediatricians.  In general, no one specialty is better than any other for these kinds of evaluations, although none of them are able on their own to "cover all of the bases".  Therefore, a team evaluation is almost always best.  Ideally, the team should include psychological, medical, and educational components.  Unfortunately, team evaluations in the private setting can be hard to find and often require a trip to a teaching hospital to obtain.  There can also be long waits for such evaluations. Financially, they are often bargains (compared to their individual components obtained separately), however, and the results are the most comprehensive, accurate and reliable.

• SCHOOL & PRIVATE SIMULTANEOUSLY: An ideal situation can be for parents to obtain private testing at the same time that the school is proceeding with their own evaluation process.  This is best because it has the effect of "leveling the playing field".  When its time to meet with a school to agree on an Individual Education Plan (IEP), parents who allow the school to do all the testing are at a disadvantage - the school plays the role of "expert" and the parents have little choice but to accept what they are told.  On the other hand, parents who go into such a meeting with their own testing already completed have their own idea of what is wrong and what needs to be done which may or may not jive with the schools plans and perceptions. The situation then turns into something more closely resembling a negotiation between equals.  

Certain LD's are common enough & have had enough written about them to have acquired special names of their own, however.  The two oldest names actually pre-date the current LD literature, although we now understand them to be examples thereof.  The first of these is Attention Deficit Disorder, which has been known and written about since the earliest years of the 20th century (see separate article).  Theoretically and intellectually, ADD (or ADHD) is no different from any other LD except in the fact that we have medications that can help it (by improving the functioning of the brain wiring).  

Another LD with "roots" long before the current era is Dyslexia.  Dyslexia has been known and written about since the 1800’s.  It was a severe Reading Disability characterized by certain distinctive neurodevelopmental weaknesses including visual processing, sequencing, and language issues.  Not every Reading Disability is Dyslexia, however.  

Other named LD's have been more recently described.  These include Dysgraphia, which is a difficulty performing any pencil/paper types of tasks due to difficulties with fine motor control and visual motor integration.  They also include Dysarthria, which is a speech impediment based upon difficulties with oromotor control.  The term Dyscalculia is sometimes used to describe a severe Math Disability mirroring Dyslexia in certain ways.  Finally, the term "Non-Verbal LD" (NVLD or NLD) has been in fashion lately to describe children who have strong skills when performing work verbally (listening and talking) but have difficulty with all sorts of academic tasks based upon weak visual processing, sequencing, and memory skills combined with difficulties with executive functions and social interactions.  

There are also a number of medical/neurologic conditions defined by symptoms unrelated to learning, but which are often accompanied by an LD as well.  These include Cerebral Palsy, Traumatic Brain Injury, Epilepsy or Seizure Disorder, Tourette’s Syndrome, Narcolepsy, many Genetic Syndromes, as well as syndromes involving patients who in the past have experienced Head Trauma, Shock, lack of Oxygen, near Drowning, or who have undergone brain surgery or chemotherapy for cancer.  Finally, anything that causes hearing loss, (mild or severe), especially early in life, including recurrent/chronic ear infections, can pre-dispose to LD later.  This can remain true even if the hearing loss has been corrected if it was present for a significant period of time early enough in life.

The most important thing in this age group is to pay attention to any delays in their development and address them with appropriate therapies and interventions as early as possible.  Neurodevelopmental weaknesses are never as responsive to therapy as they are in infancy and the preschool years.  This may be the one time in life where it actually may be possible to reduce the severity of such a weakness rather than just teach strategies for overcoming it.  With this knowledge in mind, "Early Intervention" has developed as both a field and as a legal mandate over the last 25 years.  Federal law requires that Early Intervention services (which may include Speech Therapy, Physical Therapy, and other developmental interventions) be paid for by health insurance.  Children from birth until age 3y are eligible.  They can qualify either because of actual developmental delay, or because of situations (e.g.  prematurity or a particular medical diagnosis) which put them at higher risk for having developmental delays and/or LD later.  Early Intervention has been proven to reduce the degree of later disability, and is available in most areas of the country.  Children can be referred to Early Intervention by their parents, physicians, day care providers, or teachers. Government picks up the tab for people who lack health insurance.

Interestingly, the "conflict of interest" in the Early Intervention world tends to run in the opposite direction as it does for Special Education in the older age group.  Public schools providing SPED services (age 3 & up) tend to operate on a fixed budget and need to divide their resources among all the children who need them.  In contrast, Early Intervention has a guaranteed funding source due to it’s federal mandate for insurance coverage.  Early Intervention programs tend to be private, non-profit corporations, at least in this part of the country.  A director simply hires more staff when they find more children with needs.  Indeed, the way they grow their program is precisely by finding more such children.  Given the importance of Early Intervention, this is probably good.  It does lead to something of a rude awakening for parents when their children reach age 3, however.  Very often, children who were felt to have significant needs by their local Early Intervention program, when "handed off" to the public schools at age 3, experience severe cutbacks of services due to the differing financial and political circumstances of the two programs and resulting differences in criteria of "need".

Despite the above, perhaps the most successful SPED model ever developed by public schools is the "Integrated Preschool" designed to serve the 3-4y age group.  Nurses, Early Childhood Specialists, Speech & Occupational Therapists, Physical Therapists, and Psychologists in addition to Teachers staff such preschools. Generally a mixture of special needs and normal children are enrolled.  They were the original example of "inclusion models" and can boast a fantastic success record at "turning around" many children with significant early developmental delays. Especially around this geographic area, the public Integrated Preschools are glowing examples of the best that Special Education has to offer.

One final note about early developmental delays.  It is in this age group that developmental delays are most likely to be indicative of an underlying medical problem.  Although the majority of developmental delays are NOT medically based, the younger they are when they present, the more likely there is to be a medical diagnosis underlying them.  Therefore, all children who present with developmental delays in the early years ought to have a full medical evaluation as part of their assessment.

Many LD children are first noticed when they start falling behind in the early elementary years or have difficulty acquiring basic skills.  Children who did not appear developmentally delayed prior to school entry but who show problems early-on, once they enter school, are far less likely to have medical problems, Mental Retardation, Autism, or other diagnoses and are far more likely to have mild or subtle learning problems.  Luckily, most early elementary teachers are both alert and sympathetic to such children.  In most school districts across the country, the tendency is to recognize these problems are not the child’s fault and to offer assistance once the need is recognized.

Another fortunate thing for the early elementary LD child is the fact that they themselves usually do not yet realize they are different in any way.  If there are no associated underlying emotional problems, they tend to be well-motivated, well-liked, and well-behaved - all of which helps the people helping them a great deal.

The fact is that things often get harder during the Middle School years (5th - 8th grade) - for LD and non-LD students alike. The nature of academic demands changes radically.  All of a sudden, a child is reading to learn, rather than learning to read.  Also, they are expected to show what they know in writing at great length, organize their own work, keep track of assignments, and stick with long-term projects.  These new demands call on strengths (and emphasize weaknesses) that were less important in early elementary school.  Some children with LD can even start having difficulty for the first time at this age.  In particular, children who are bright but have Attention Deficit Disorder or organizational difficulties are particularly prone to stumble in the middle school years.  For them, it is like the structure they depended on is suddenly removed, and they lack the internal skills to replace it.  Unfortunately, such children are less likely to be greeted with the sympathy, support and assistance that younger children are.  Too often, teachers take their prior good performance as "proof" that they are capable, and instead tend to blame the child.  Most school districts tend to be far more reluctant to begin SPED services for a child in this age group who has never had them before than they are in earlier years.

Another thing that happens in middle school is children become increasingly aware of their differences.  Children with LD's who are receiving assistance often increasingly feel stigmatized by this.  They become resistant to accepting the help, their peers can tease them and their self esteem can suffer.  Behavioral problems can result.  This makes school personnel even less likely to look sympathetically upon their problems.

In sum, there is a common believe that LD's are a phenomenon of early elementary school that, if helped appropriately, should resolve by late elementary school.  Nothing could be further from the truth.  Children who require SPED assistance in early elementary school often continue to require that assistance through middle school and beyond, and will suffer if it is withdrawn from them.  An additional group of children first manifest their LD's in this age group are every bit as deserving of help. Unfortunately this age group is far less likely to be given that help, and far more likely to be "blamed" for something which is outside of their control.

Adolescents with LD's do not do well with traditional pull-out or inclusion services.  They usually prefer to receive private tutoring and they can benefit from certain accommodations to their difficulties such as untimed tasks and tests, and reduced homework loads.  Things actually get better at the college level.  There are many colleges across America with specialized LD programs that are quite good.

The thing to be avoided, which is all too common in the adolescent age group, has been referred to as "developmental output failure". This is essential a vicious cycle in which a child’s LD becomes a self-fulfilling prophecy.  The child has not been given enough help in the early years and by the time he or she reaches high school, has become convinced that success is not possible.  As a result, they indeed ARE unmotivated - due to learned frustration and expectation of failure.  People around them (parents & teachers) who tend to blame it on "poor character" reinforce this.  In order to break this cycle not only SPED assistance but a great deal of support, encouragement, and active efforts to help the adolescent experience success & competency are necessary.

The first thing that is important to understand about these laws is why they were originally written.  Prior to the late 1970’s, many children in this country with severe disabilities (Mental Retardation, Down’s Syndrome, etc.) were simply "warehoused" rather than educated.  They were placed in separate classrooms or in separate institutions and given custodial care, little more than baby-sitting.  Little or no attempt was made to teach them anything.  At that time in our history, LD's were not even thought about, hardly a "blip on the radar screen" for politicians or public schools.  

The laws currently applied to Learning Disabled students were not written for them.  They were written with the much more severely handicapped in mind.  They were written to end warehousing of the mentally retarded.  They said two things - First, that an attempt to educate these children must be made to some reasonable degree (see below).  Second, that to the extent possible, these children should be "mainstreamed" (the legal phrase used for this was "educated in the least restrictive setting possible").  The law in this regard has largely succeeded.  Today we have a society, not just in the public schools but throughout our culture, in which handicapped persons of all stripes are far more integrated than they once were.  Nobody argues but that this is a good thing.   However these laws, written to end the warehousing of severely disabled individuals but subsequently applied to LD students as well, have worked much less well for the Learning Disabled population.  (See "Who Qualifies" and "Inclusion vs.  Pullout" below).

A few years ago, the regulations in Massachusetts governing Special Education (SPED) were revised.  The revisions generally favored school districts and their budgets at the expense of families whose children had special needs.  They focused on "who qualifies", tightening up those requirements and giving schools more control over spending.  This was justified by supporters of the changes by pointing out that Massachusetts has one of the highest percentages of children in SPED of any state in the country.  In my opinion this really missed the important points, however.  It is very hard to "codify" a system of SPED qualification - each situation is different, calling for individual case-by-case judgment with lots of parental input.  It would be much better to debate WHO PAYS and WHO DECIDES rather than "who qualifies".

The major flaws in current SPED law, it seems to me, are:

• It puts responsibility for evaluation and deciding "who needs what" in the hands of the very same people who are responsible for delivering services and administering SPED budgets, creating the conflict of interest described earlier.

• It mixes up the two separate issues of clinical need and who pays.   Public school staff have no legal way of saying to a parent, "Yes we think your child would benefit from that, but we can't afford to pay for it."  Thus, when a service has to be denied for budget or staffing reasons the school is forced to make the often dishonest case that the child doesn't need or wouldn't benefit from it.

• It sets up a "competition" at the local level between regular & special education budgets, so that serving SPED kids better means sacrificing the quality of regular education programs.

To solve the first problem, I would propose establishing a procedure for state "accreditation" of private LD evaluation centers (which would allow standardization of and state input into what sorts of testing and diagnostic criteria are used).  I would then take evaluation, needs determination, and IEP writing out of the hands of local schools altogether, and give it to the evaluation centers.  They could evaluate the child and write up their objective findings/recommendations in an IEP-like format that could be taken to the local school to be "filled" much like you take a prescription to the drugstore.

In order for the above to work, however, local schools need a guaranteed source of funding to fill these "prescriptions" which doesn’t threaten the remainder of their programs and budget.  We need to have an honest conversation about who should pay for what.  Guaranteed funding for such services already exists under age 3, in the form of law requiring Health Insurance to cover all services (and the state to pay when children have no insurance) determined to be necessary and delivered by certified Early Intervention programs.  We need to extend these same guarantees throughout childhood - or find some other separate SPED funding mechanism.  Many ways to do this could be proposed, for example, requiring Health Insurance to pay for the evaluations and any OT, PT, Speech Therapy, Communication Technology, medical or psychological care needed, while having state reimbursement available to local schools for increased educational costs in SPED kids.  The latter might include funds for things like tutors, specialized staff or staff training, LD teacher salaries, alternative textbooks, educational software, and other specialized classroom equipment/supplies.

I would encourage anyone who cares about these issues in Massachusetts to contact their state legislator or the  Mass.  Dept.  of Education.  Tell them simply that giving schools more control and tightening eligibility will not fix the problems, that they need to SEPARATE NEEDS DETERMINATION FROM SERVICE DELIVERY and ESTABLISH GUARANTEED FUNDING SEPARATE FROM REGULAR EDUCATION when they "reform" Special Education.

Click here to read a letter on this subject written by Dr. Ansel to the Mass. Dept of Education at the time they were considering the above regulation changes.

Click here to go to the web site of the best law firm in Massachusetts specializing in SPED law.

In Massachusetts, the CORE evaluation process is supposed to be completed within 90 days (although it is unclear whether this means 90 calendar days, 90 school days, or 90 business days).  It is the school’s prerogative to determine how the evaluation is completed and what it consists of.  It can include any testing which they deem appropriate, and that testing can be carried out by school employees, private professionals under contract, or anybody else whom they designate.  There is no single standard battery of tests either mandated by law or universally agreed upon by school professionals.

Once whatever testing process deemed appropriate by the school is complete, the next step is to have a meeting.  This meeting is normally attended by the SPED director of a school, the child’s parents, some of the child’s teachers, and any other interested parties (often including some of the evaluators, although this is not required), and also often involving Guidance Counselors, Speech Therapists, or other school staff who may be involved with a child.  Doctors (Neurologists, Developmental Pediatricians, Psychiatrists) who may have evaluated the child rarely attend such meetings, mostly because it is difficult to get health insurance to cover the cost of such attendance.  That is unfortunate since their presence would certainly be helpful.  The purpose of the meeting (which in Massachusetts is called a "CORE meeting") is to present to the parents and the rest of the Team members the results of the testing as well as a proposed Individual Education Plan (IEP).

An IEP can call for almost anything.  At one extreme, it could simply say that the child has no special needs and will be returned to the regular education setting with no SPED services.  At the other extreme, it can say that a child needs to and will be placed in a substantially separate setting outside the mainstream designed for their particular LD.  The majority of IEP’s designate some level of need and some type of service between these two extremes.  These services could include tutoring, small classrooms taking a different approach to teaching, Speech or Occupational Therapy, counseling, or almost any other thing which might be necessary.

Parents have several options following a CORE meeting.  It is important for them to be aware of these options going into the meeting, since often times the school staff will not fully explain them or will emphasize one and de-emphasize the others.

• One option is to accept the IEP in full. This should only be done if parents are totally satisfied that both the conclusions of the evaluation and the planned services are appropriate.  Accepting the IEP in full has the affect of "locking in" that plan for the next year - the school is under no obligation to change or renegotiate it sooner.  
  
• A second option is to reject the IEP in full. This should only be done in rare circumstances.  It is the equivalent of a parent saying, "I do not feel my child has special needs, I want no services, and I want my child returned to the regular education classroom".  At that point, parents give up all rights to their child receiving any SPED services for another year.  
  
• A third option amounts to a "line item veto". Parents can choose to accept portions of the IEP and reject others.  This should be done only by parents who know very specifically what they want and why, usually with some outside expert advise.  
  
• A fourth option is simply to delay a decision.  Parents have the right to take the IEP and think about it or consult with anyone who they choose outside of the school, and delay a decision for up to a month after the CORE meeting.  This would be a good option if, for instance, you wanted to have one of the providers at our office review the IEP before you sign it.
  
• Finally, parents have a right to delay a decision pending an independent evaluation, and they used to**  have the right to request the independent evaluation be provided (paid for) by the school.  In this instance, the outside evaluation needed to occur at a place mutually acceptable to both the parents and the school system.  Obviously because outside evaluations are very costly and they mean that the parents are not trusting the results of the school testing, school officials were rarely pleased when this option is chosen.  It also must be borne in mind that, although the school was paying for an independent evaluation, they were under no obligation to heed it’s recommendations.  Usually, once an independent evaluation obtained in this way was completed, a second CORE meeting will be held.  

(** This right is one of the things that was seriously curtailed by new regulations in Massachusetts adopted by the DOE in 1999 - now paying for "second opinions" or outside assessments is usually the parent's (or their health insurer's) responsibility, unless a hearing before a DOE panel finds the school's evaluation to be "inadequate".)

If the school and the parents cannot reach agreement over an I.E.P., there are mediation procedures in place that can be resorted to at a state level.  Parents who find themselves in this situation will usually want to have the assistance of someone familiar with the process such as a child advocate (available privately or through the Federation for Children With Special Needs or through the a variety of internet sites) or perhaps even a lawyer.

If the mediation process fails, the parents can take the school system to court.  Fortunately, most families never reach this predicament.  A more common scenario is the IEP which is agreed upon by parents and the school but which either is not fully implemented or isn’t implemented to the parents satisfaction.  The truth is, what exists "on paper" in an IEP and what actually goes on in the classroom rarely correspond exactly.  These things always depend on the motivation, training, experience and instincts of the teacher(s) involved.  Another common scenario is the IEP does not seem to be working and needs to be re-thought and re-written.  When parents and teachers agree that this is the case, usually, there is not a problem, but if the parents think this and the school does not, a dispute can occur.  

Normally, IEP’s are re-written once every year.  A repeat CORE evaluation is mandated once every three years for those who continue to receive SPED services.  Evaluations sooner than three years can be conducted by the school at their own prerogative but are not required.  They can also, of course, be obtained privately at any time by the parents.  Once again, however, schools are under no obligation to pay any heed to independent private evaluations.  

A final word is in order about reading IEP’s.  Generally, IEP’s can be divided into three sections.  The initial section (first few pages) describes the child in question.  It is important to read this carefully as it reflects the school’s understanding of what is wrong.  It is important that a parent be satisfied that a school understands their child.  Distortions or omissions from this section should be considered serious things that ought to be corrected.  The middle section of an IEP, ranging from one to more than 20 pages, consists of individual "instructional goals". Within these pages are the specific techniques which are supposed to be used by the teachers, their purpose, and goals for educational attainment by the child during the next year.  As the year goes on, there is often a large discrepancy between reality and what is written in this section.  That usually does not matter very much.  Although the most detailed, this is also usually the least important part of the IEP.  The final section of the IEP is a statement of services and overall level of service.  This summarizes such things as how many hours or minutes per week of tutoring, LD assistance, Speech Therapy, etc.  a child is to receive and in what location.  In Massachusetts, this service level has traditionally been "**coded" or categorized in a system of 502.x.  The code is as follows: (** This is another feature that was done-away with by regulation changes in 1991 - supposedly to "increase flexibility" for schools but the real impact has been to make it harder for parents and outside professionals to judge the level of service actually being provided.  I encourage parents to ask schools what 502.x level an IEP would have been under the old system.)

• 502.1 meant monitoring by the Special Education Dept.  but with no direct services.

• 502.2 meant some direct service but the majority of the child’s time is in the regular education setting.

• 502.3 meant a substantial amount of direct services encompassing the majority by not all of the child’s time.

• 502.4 indicated full time placement in a special setting (or it’s functional equivalent in an inclusion model).

• 502.5 meant an outside private placement in an alternative educational institution.

• 502.8 was a special temporary diagnostic placement.

This final service-delivery specification page should be closely scrutinized for accuracy, as it matters more than any other portion of the IEP.  It constitutes the "bottom line" regarding how much the child is to receive, where, and by whom.  There are also sections here for specifying whether any alterations to the normal disciplinary code and/or graduation requirements apply to this particular child.

There is no data showing whether learning outcomes are better or worse with inclusion vs.  pull-out.  Remember the idea of "least restrictive environment" was put into the original laws in order to end "warehousing" of severely handicapped children.  It was NOT based on any knowledge about children with LD's.  Most LD research suggests that the more intensive the services a child receives, and the more specialized for their specific LD, the better the outcome will be.  This is probably true regardless of whether the services are delivered in an inclusion or pull-out mode.  There can be good and bad inclusion programs just as there are good and bad pull-out programs.  The good programs of either model will tend to be the ones that have the smallest student/teacher ratio, the most highly qualified, trained and specialized personnel, and to which the most resources (financial & otherwise) are devoted.  It is therefore not possible to state a general rule about whether pull-out or inclusion is better.

Every child is an individual, however.  For certain individuals, one model or the other may be preferable.  In general, parents are in a good position to judge this themselves.  If a child is feeling (or apt to feel) particularly stigmatized by having to leave the classroom for SPED assistance, moving in the direction of an inclusion model may be very beneficial.  Alternatively, if a child needs structure or is highly distractible (not doing well when other children in the room are engaged in different activities), that child might do better with pull-out.  Children whose delays involve all academic areas, and are so severe that virtually everything going on in the classroom is "over their heads", also are not good candidates for inclusion.  They will be made to feel inferior, and may even begin to feel a need to confabulate to cover up the inadequacy.  Such children do better when grouped with other children (same or different age) who are functioning at a level close to where they are.  In this way, instruction can be directed at their level and they do not feel so different.

Another issue to think about in regard to pull-out vs. inclusion involves the issue (alluded to above) of whether what is actually going on day-to-day with the child matches what is written in the IEP.  Oftentimes in an inclusion model, especially when a single SPED teacher is having to service several students with differing educational needs simultaneously in a mainstream classroom, the specific methods/goals of the IEP for a particular child can get "lost".  In these situations, pull-out can sometimes be a remedy.

Finally, it must be recognized that a big part of the benefit of "inclusion" accrues not to the disabled or special needs children, but rather to their "normal" peers.  There is no doubt that normal peers benefit from exposure to disabled children in terms of learning tolerance and developing helping skills.  Such benefits surely have a value to society, but at whose expense? They should not be given precedence over the educational needs of the individual child.

In an ideal world, all school systems would have the flexibility to provide children with services in either an inclusion OR a pull-out model. Selecting which is best would be a collaborative effort between parents & school staff, individualized for each child.  The truth, however, is that many school systems utilize exclusively one or the other model as a matter of "philosophic belief". This is unfortunate and something that we all should be working to change.

• Categorical: Most states in the nation use the categorical approach. Under this approach, certain diagnoses qualify, others don’t.  At the most basic level, children in these states are "coded" as either Learning Disabled, Emotionally Disturbed, or Medically Handicapped.  If the children do not have a diagnosis that falls into one of those categories (by state or city criteria), they are not eligible for services.  In these states, political battles over eligibility tend to revolve around which diagnoses are included in these lists.  For instance, a common controversy is whether Attention Deficit Disorder "qualifies" at all, and if it does, which category it fits under.
  

• Functional:  Until recently in Massachusetts, the "functional" approach was used instead.  Here, the specific diagnosis really does not matter.  Indeed, in their CORE evaluations Massachusetts school systems still usually "shy away" from applying labels or making diagnoses at all.  Instead, it is determined how far behind a child is in certain areas.  If their problems are deemed to be severe enough (by local criteria) for whatever reason, services are rendered.  Since 1999 Massachusetts has begun moving towards the Categorical approach, requiring a qualifying diagnosis.   Because of the functional tradition in the state, however, these requirements are sometimes rather loosely applied.

The functional approach has the advantage of making services somewhat easier to obtain (as evidenced by the fact that Massachusetts has one of the highest SPED delivery rates in the nation), but it also has disadvantages.  In particular, children in states where this approach is taken often remain undiagnosed longer.  Parents may feel that they don’t know why their children have the problems they have.  This can be as frequent a reason for seeking independent evaluations or second opinions in such states as disputes over what the needs actually are.

Optimal benefit basically holds that a child deserves to receive whatever services would enable them to develop, grow, and learn to the fullest extent of their potential.  For example, if a child has an above-average I.Q.  and ought to be functioning several years above grade level, but isn’t due to an LD, this view would say bringing the child to grade level is not enough.  He or she ought to be brought to the level they should be at by virtue of their potential.  Such a child functioning "at grade level" would still be viewed as "delayed".  Most parents naturally fall into the optimal benefit camp, at least when discussing their own children.  What parent doesn’t want the best for their child?

Most school officials, politicians, and even many parents (if thinking about somebody else’s child) adhere to the "adequate progress" is good enough point of view.  They would argue that the optimal benefit standard is too idealistic, expensive, and even discriminatory.  That if every child received the "ideal" services to bring them to their "full" potential society would be unable to afford the expense.  It would break the budget of most school districts.  They say if one allows an "optimal benefit" standard it creates a competition for services in which the playing field is not level.  The children who actually receive the "optimal service" end up being the ones whose parents are best able to advocate for them - meaning parents who are educated and have financial resources. Children with perhaps greater needs but less resourceful parents under such a system get less.  Advocates of this viewpoint believe all children should be entitled to a certain "adequate" level of service that enables them to progress, but not necessarily to the "optimal benefit".

The problem with "adequate progress" is how to decide what’s adequate.  Very often, the standard used is functioning within one (or two) "standard deviations" of grade level norms.  In practical terms, this means being less than a year delayed in the first few years of elementary school, less than two years delayed in late elementary to middle school and less than 3-4 years delayed in high school.  Other ways of measuring adequacy include "slow but steady progress", or, for children who are not felt to have the potential to work up to grade level, some arbitrary determination of what their potential might be.

In practice, most of the country adheres to the adequate but not optimal standard, although loosely.  In cases where parents are very forceful advocates, certain children do manage to obtain more.  There was a time back in the 1980’s when Massachusetts was one of the most "optimal benefit" oriented states in the nation, although this has changed markedly in the last decade despite language in our state law which supports that concept.