I’ve been thinking about and worrying about our first IEP meeting with the school in a couple of weeks. In April Henry will be transitioning out of Early Intervention and hopefully will be getting services in preschool at our local public school. Everything I’ve heard about these meetings sounds intimidating and it’s kind of mind boggling how many people are there. From our side there will be Henry, my husband and I, and the SLP, OT and developmental teacher from Birth23. I believe at the minimum the school will have their SLP, OT and PT attending. I came across another mom’s post to apraxia-kids facebook page about IEP’s and apraxic children and found the link she shared most helpful. It’s provided by apraxiaeducation.org. It’s a very long article, so I’m going to post below the information that applies mostly to our situation at the moment…maybe it will be useful to some of you too. You can always click on the above link to see the information in it’s entirety.
Addressing Apraxia of Speech in the IEP
So what else does Apraxia affect in the school setting? As a motor planning disorder, Apraxia can:
• Delay or alter the coordination of fine motor movements related to handwriting, using scissors, opening up a school locker, opening classroom doors, and completing fasteners on clothing – an important component of becoming independent in the restroom.
•Make it difficult for children to generalize a skill that they have learned in one setting, such as atherapy room, into another setting, such as a classroom or playground.
• Cause any type of sensory integration dysfunction that affects classroom behavior, attention, focus, and the ability to transition easily from one activity to another4.
• Affect gross motor movements needed for accessing playground equipment, maintaining balance on classroom chairs, and navigating stairways, especially when there are a large number of other children on the stairs at the same time. Low muscle tone, called hypotonia, is common in Apraxic children, and can affect the quality of motor movements as well as balance and coordination.
• Affect visual-motor skills needed for visual tracking and refocusing rapidly from the board to the desk and back again, depth perception, or for using both eyes together to make sense of what they are reading or writing5.
So what does that mean for the IEP?
While no one professional can address all of a student’s needs related to Apraxia, the IEP team as a whole can put in place a combination of services and supports to help a child succeed in the classroom and throughout the school environment. An ideal IEP addresses all areas of the child’s needs, and includes several goals and objectives to focus on all those areas, including communication, fine motor development, sensory integration needs, academics, and gross motor skills if needed. If your child’s IEP only includes speech and language goals, look back at his or her Multi-Factored Evaluation to see what other needs were identified, and ask for those to be included in the IEP goals and objectives.
Special Education Services are the actual teaching strategies and techniques provided to your child by a certified special education teacher, for a specified amount of time. This is IN ADDITION to or IN PLACE OF the general education classroom and teacher for your child’s grade. For example, if your child struggles with reading, then they have additional reading instruction from a special education teacher, or they may replace their regular classroom reading instruction with separate reading instruction from a special education teacher, often in a separate classroom. Sometimes, they may have both.
Related services are added to an IEP to support the goals and objectives, and should not be completely disconnected from what is happening in the classroom. A child’s Speech and Language Therapist, Occupational Therapist, and Physical Therapist should be spending adequate time in the classroom setting as well as in a therapy room, in order to help their student generalize skills outside of the therapy room and back into the classroom to promote classroom success. Therefore, related services should be happening in more than one physical location.
Accommodations are changes made to a child’s classroom, teaching methods, schedule, or assignments, that allow them to succeed in the same general curriculum as their peers at school. They are NOT services provided to the child. For example, a child who has difficulty reading and processing written information, may have extended time for classroom work and tests as an accommodation in the IEP. A child who takes longer to navigate stairs may have the accommodation of being dismissed from each class 3-5 minutes early in order to have time to safely travel on the stairs to his or her next class. A child who cannot write in an efficient or legible manner may have a scribe for writing assignments, especially tests, as an accommodation. A child with limited attention may have shortened homework assignments, such as completing odd number math problems instead of all of them. (A child who ONLY needs accomodations but no related services or educational needs, does not need an IEP. Instead, they would have a 504 plan.)
Modifications are changes made to the general curriculum itself, so that a child who can’t understand the general curriculum can continue to learn. However, the child is NOT learning the same general curriculum as his or her peers, and may eventually experience deficits in their knowledge that cannot be regained. So, modifications should be considered only after the child is not successful in the general curriculum with accommodations and special education services.
How do all of these things get added to the IEP?
Since the IEP stems directly from needs identified in the evaluation, a child’s Multi-Factored Evaluation is the place to start. The evaluation should target all of these areas, in order to identify ALL of a child’s educational needs. If those areas are not included as part of that evaluation, then it is much more difficult (if not impossible) to justify an IEP goal to address that area later on. Therefore, it is crucial that the Multi- Factored Evaluation (called an ETR in Ohio) assess fine motor, gross motor, vision, hearing, academics, and speech AND language separately from one another, in order to gain the most comprehensive view of the child’s educational needs as possible.
If your child’s school does not have someone experienced with Apraxia to complete one or more areas of the evaluation, then ask for an independent evaluation in those specific areas from someone who is experienced. For example, if your child uses sign language or an Augmentative Communication Device, then the Speech Language Pathologist who evaluates your child should have experience and knowledge of that communication method. In some areas, schools do not employ staff who are qualified to assess that area. For example, visual-motor skills need to be assessed by a qualified optometrist or ophthalmologist, or by a teacher certified in the area of visual impairment, through a functional vision assessment. It is NOT the same thing as a vision screening completed by a school nurse.
You should also provide evaluations and reports from private therapists who work with your child, as well as from the physician(s) who diagnosed and is monitoring your child’s Apraxia, to be included in the Multi- Factored Evaluation. However, it is important to remember that just because you provide these reports, does NOT mean that your school district has to accept them in the evaluation itself. If you and your district disagree on whether or not a private report from a therapist or physician should be part of the Multi-Factored Evaluation, then you have the right to DISAGREE with the results of the evaluation, and to either ask for an independent evaluation at the district’s expense, or file for due process. Understanding your parent rights at this stage is very important!
Once you are satisfied with the Multi-Factored Evaluation, you are ready to move forward with the IEP.
Content Areas for IEP goals & objectives
Expressive Communication: Speech AND Language
Communication goals are very individualized, and can be separated into “Speech” and “Language”. Many Apraxic children’s IEPs focus only on Speech, and don’t consider Language as a separate issue. However, if a child can produce a sound or word (speech) but can’t use it in a conversation (language) outside of the therapy room, they are not communicating – they’re only parroting what they’ve been taught to say. Thus, BOTH are important in an IEP.
Speech goals are usually developed and monitored by the Speech Language Pathologist (SLP). Speech goals may include specific phonemes that a child needs to work on, which vary from one child to the next. They may include oral motor activities to promote speech, including activities to promote the use of the top of the tongue for certain consonants (t, d), lateralizing the tongue (side to side movement), or using both lips together for bilabial sounds (b, p, m). They may include practicing phonemes in different positions of words (beginning, middle, end), or combining consonants and vowels in different ways to expand on a child’s baseline skills. As the child progresses through the phoneme and then the single word level, speech goals should focus on producing sounds in connected speech (several words together), which is usually where Apraxic children’s speech breaks down and becomes unintelligible. Speech goals depend on the child’s present levels of performance, which the SLP would present in the IEP as the child’s baseline.
Language goals aren’t usually developed or addressed solely by the SLP, while speech goals typically are. Goals for language should not be neglected, since the foundation for learning depends on the ability to communicate with intent rather than just to repeat random syllables. Communication leads to social interaction, which is a big struggle for so many Apraxic kids. In a program that uses both English and American Sign Language, a language acquisition goal may also include sign language. For example, there may be a goal for a child to spontaneously communicate their wants and needs to an adult, and then later to a peer, in 2-3 word sentences, in voice, sign, or both. Or, a child may have a goal to respond to a request for play from a peer, and later to initiate a request for play from a peer, for a minimum of 2 exchanges, and then later progressing to 3 or even 4 exchanges, again in voice, sign, or both.
Other language goals may focus on labeling common classroom items, both upon request and then spontaneously, which the classroom teacher would monitor rather than the SLP. The therapist and teacher may jointly focus on expanding a child’s language usage from 1-2 word phrases to more complex sentences of 3-5 signs or spoken words. Putting words into the correct order in a sentence is also an area of need for some children, as is using appropriate pronouns such as “I” instead of “me”.
Caution: Language goals that specify a certain number of words or signs to be added per year can be tricky, especially without a solid documented baseline to start from. In addition, if they are not worded correctly, then a child may get credit for just copying a word or sign, or only producing the word upon request, instead of spontaneously using those words in conversation (which would, again, be the GOAL of communication). Therefore, this kind of a goal statement may be more appropriate as an objective under a larger language acquisition goal, than as a stand-alone goal in and of itself. Apraxic students need to learn to communicate with each other, not just repeat what is signed or spoken to them, so the best IEP goals and objectives in this area focus more specifically on HOW they will use their newly acquired language in the classroom with teachers, peers, and other adults (therapist, cafeteria staff, etc.), rather than just adding a set number of new words.
In light of the importance of both Speech AND Language, Apraxic students should receive speech and language therapy that focuses both on specific Speech goals, as well as Language goals for communicating their wants, needs, and knowledge of the curriculum, as well as for developing social communication with peers. Again, speech and signs are only communication if the child is able to use them in language, both to interact and to communicate!
Fine motor goals for Apraxic children often focus on developing a tripod pencil grip for writing, writing their name (tracing, then copying from a model, then progressing to writing independently), using scissors to cut with in 1⁄4 ‘’ of a line, and to cut out a circle while using one hand to cut and one hand to rotate the paper. The latter is an example of a bilateral manipulation tasks (using both hands together), which many Apraxic kids struggle with, and should not be ignored in an IEP if the child has this need. A slant board and weighted pencil or pencil grip are often beneficial to an Apraxic child, as they are often better able to write on an inclined or vertical surface than they are on a horizontal surface. These are accommodations that can be added to the IEP, even without having Occupational Therapy as a related service.
Another area of fine motor focus in the classroom is crossing midline, because reading and writing go from left to right and therefore cross the midline of the body. If a child can’t cross midline, they will really struggle with learning to write. Since so many Apraxic children have a great deal of difficulty crossing
midline, this is something that always should be assessed in the Multi-Factored Evaluation. While most Apraxic children with fine motor delays receive Occupational Therapy, classroom activities such as Brain Gym and yoga also help with this skill, and can be implemented in the classroom for all children, not just the Apraxic student. As so many fine motor activities take place in the classroom as part of the regular school day, fine motor goals in an IEP are typically set by an occupational therapist and the teacher together, and monitored by both.
If the child has sensory needs, adaptations may need to help with this, such as the use of a sensory diet, classroom breaks to use sensory diet stations or to get a drink of water, wedge cushions for floor sitting, chewy items to give them oral motor input, a “fidget” (a small item they can hold to help them focus during circle time or large group activities), or adaptive seating that gives them more proprioceptive input to their bodies (therapy ball seating, a chair with side support and/or foot rest, etc.). Some children may need to be allowed to change classes a few minutes before the other students, so that crowded classroom hallways are not overwhelming for them. These are all accommodations rather than goals, and do not require a student to be receiving Occupational Therapy in order to be included in the IEP.
Some children do need IEP goals for their sensory needs, often in order to “pace themselves”, since they may rush through their work and make mistakes. Others need IEP goals to help them improve their focus or attention so that they do not get easily frustrated and give up on a task. Some children become so frustrated or overwhelmed by their sensory needs, that they develop classroom behaviors that are mis- labeled as behavioral problems rather than as a sensory integration dysfunction. An Occupational Therapist (OT) can design strategies and supports to help a child with sensory needs, and both the OT and the teacher should implement those strategies in the classroom and other school settings. As children get older, they often learn to manage their own sensory needs more effectively, and their need for OT may decrease or be eliminated outside of a consultative capacity. Again, sensory strategies to assist Apraxic children can still be continued in the IEP as accommodations, even after direct OT is no longer needed as a related service.
If a child has some behavior problems that are interfering with learning, those should be addressed also. These are typically tied in with the sensory integration piece, and have OT services attached to them. It’s rare to see an Apraxic child whose behavior is not tied at least in part to sensory integration or frustration with communication. Once those issues are addressed, their behavior problems tend to decrease dramatically or disappear altogether. If not, then a child may benefit from a Functional Behavior Assessment by the school psychologist, followed by IEP goals, objectives, and sometimes services (i.e. counseling) to address the needs that are identified through the assessment. These are highly specific to each child.
Many Apraxic children have difficulties with their functional vision. This is NOT the same as visual acuity, which is what most children have their vision tested for (near-sightedness or farsightedness, or astigmatism). Functional vision is how a child uses their eyes together (binocular vision) and for everyday tasks such as tracking from left to right (used for reading), refocusing rapidly from near to far and then back again (from the paper on their desk to the board and back again), depth perception (stairs, playground equipment, etc.), and locating objects in their field of vision (pencil on their desk, numbers on a page, etc.). In short, functional vision is how the child uses his or her vision to perform routine tasks in different places and with different materials everyday7.
So how do you know how your child does this? A functional vision assessment looks at this area. It should be performed by an optometrist or ophthalmologist trained in this area, or by a teacher certified in the area of visual impairment. Glasses may be prescribed, such as prism glasses, to help correct some of these issues. Accommodations can be made, such as limits on the distance between the student and the teacher, enlarged font, contrasting colored paper, and decreased distractions in the child’s visual field. The recommendations that the eye doctor makes from this assessment should become part of a child’s multi-factored evaluation, and thus be incorporated into the IEP as they apply to a school-based setting.
Any IEP should include any or all of the above components that are applicable to the Apraxic child. If they are not an area of need at the time of the IEP, they should be re-considered every year as the IEP is updated. This can be documented in the present levels and/or profile to establish that there is not a delay or a concern for that area, based on teacher and therapist evaluations. If private therapists make recommendations about school accommodations or services, those should be given to the school immediately, and an IEP team meeting held as soon as possible to incorporate those recommendations into the IEP.
If at any time the parent feels that these areas are not being considered or addressed as needed, they should speak up and tell the district – never assume that the teachers and therapists are the only experts on educating the child. Educators work with children with all kinds of needs, and Apraxia is just one of those needs. They cannot be expected to know everything there is to know about every disability. They rely on information from other sources, including parents, to supplement their own knowledge and experience. The parent is a vital part of the IEP team, knows their child the best, and is generally their child’s first and best advocate. If the parent does not speak up on behalf of the child’s needs when the child is too young to do so for themselves, then their child may not receive all of the assistance and/or services needed to be successful in school. Apraxic children CAN learn, but they learn best when their IEP looks at the whole child, not just speech.
7 Colenbrander, August. (2010). “Assessment of functional vision and its rehabilitation”. Acta Ophthalmologica. Volume 88, Issue 2, p. 163-173.