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When a school placement is a bad fit, medication and therapy are unlikely to make much difference. In this episode, we will help you understand and assist your patients to optimize their success in the least restrictive placement.

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Published On: 10/03/22

Duration: 15 minutes, 40 seconds

Referenced Article: “School Inclusion: What You Need to Know ” The Carlat Child Psychiatry Report, January 2022

Joshua Feder, MD, and Mara Goverman, LCSW, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity

Dr. Feder: Inclusion can help children with developmental and learning challenges as well as typical students. But inclusion is more than a geographic placement. When a school placement is a bad fit, medication and therapy are unlikely to make much difference. In this episode, we will help you understand and assist your patients to optimize their success in the least restrictive placement.

Welcome to The Carlat Psychiatry Podcast.

This is another episode from the child psychiatry team. 

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

Dr. Feder: We have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.

Mara: Let’s begin by talking about what exactly school inclusion is. School inclusion refers to the practice of including students with disabilities in regular classes, rather than in separate special education classes. Inclusion is a legacy of the civil rights era, ending school segregation, consistent with current social emphasis on diversity and acceptance. The Individuals with Disabilities Education Act (IDEA) requires schools to provide a free and appropriate public education in the least restrictive environment—in other words, to mainstream students if possible. While it is not always possible to fully include all students, the goal of IDEA is to press schools to do their best to include students as much as possible in more typical school experiences.

Dr. Feder, can you talk about how school inclusion works?

Dr. Feder: So, the legislation legislation requires public schools to assist students with known or suspected learning or social disabilities. This usually begins with response to intervention or (RTI) in which the school tries out accommodations in general education settings, such as frequent check-ins between the student and teachers, help with organizing academic tasks, and seating with matched peers to support better social interaction.

Mara: What if the response to intervention is ineffective? 

Dr. Feder: If response to intervention isn’t helping enough, the school conducts an assessment, typically doing psychoeducational testing, observations at school, and speech and language including  pragmatics, occupational therapy including motor planning, motor tone, and sensory differences. The child may qualify for a 504 plan that offers some accommodations like specific seating to pay better attention, extra time on tests or quieter places to work. If that isn’t enough, the might write up an Individualized Educatoonal Plan (IEP) that can modify the curriculum and add additional services like speech and language therapy, OT, or even provide one on one assistance. Once parents sign them, IEPs are legally binding for the school. Sometimes an IEP calls for segregated placement. This usually occurs when the staff does not feel qualified to educate and support the student in a mainstream classroom. In such a case, future meetings include discussions of when and how the student can be placed in the least restrictive environment. That’s how the law presses schools to help kids join the mainstream community as much as possible so they get the same opportunities as everyone else for education and socialization. 

Mara: Would you say that inclusion is more helpful than segregated instruction for students with disabilities?

Dr. Feder: Yes, definitely. Outcomes for students in special education classrooms with more intensive services have not been as robust as hoped. By contrast, a recent study by Cole at Indiana University tracked students with disabilities through several years and found that students included for most of the day did significantly better on state tests than those not included. Similarly, a study by Gee et al in 2020 found that when placed in inclusive classrooms, learners with complex support needs did better academically and in other aspects including communication skills. 

Overall, the benefits of including kids with special needs in inclusive classrooms include acceptance by peers as equal members of the school community, greater enculturation and improved ability to function in society over their lifetime, more opportunities for academic achievement, increased opportunities for participation in clubs, sports, and other activities, and exposure to a more natural range of social behavior for all students.

Mara: What was the inclusion’s impact on “typical” students? 

Dr. Feder: Gottfried and colleagues reported  a“spillover” effect on the other students who do not have special needs. These include more frequent school absences, for example an average of ½ day per semester for each student. Another study found that mainstream students in inclusion classes had lower academic achievement in reading and math. This impact was greatest in reading scores for Black and Hispanic children in low-income districts. There are also concerns about increased externalizing behaviors among mainstream students, and how to help them respond adaptively when a student with special needs has behavioral difficulty.

However, this is a continuing area of study, and Roldán et al recently found that students without disabilities actually benefit from learning with peers with disabilities. A recent literature review concluded that while older mainstream peers have more risk for spillover, inclusion has an overall positive effect for all students and improves understanding and acceptance. 

Mara: Despite research supporting the benefits of inclusion for all students, it is still important to be aware of the common challenges. These challenges include bias, discrimination, and fear on the part of the other students and families, There is also difficulty in managing the sensory environment of a general education classroom as well as the creative execution of push-in services, such as occupational therapy or speech and language therapy delivered in the classroom. There are also safety or bullying concerns when there is inadequate supervision available in class or on the playground. 

The bottom line is that general education placement should not be viewed as a “geographic” process but one that is carefully considered and titrated to maximize success for all students.

Mara: Let’s move on to discuss how providers can best talk with patients and families about the educational options available to their child. Dr. Feder, since families frequently find it challenging to navigate through these options, what are some productive talking points to consider when meeting with patients and parents to talk about building a good plan for school?

Dr. Feder: You can ask, What have been the best moments in your child’s educational career? What made these moments special? Tell me some of your child’s education inclusion success stories like helpful projects or effective adaptations. Let’s think about how those can be replicated.

Or, what do you think are the child’s strengths and challenges? Most importantly, what is meaningful to them? Help me understand the most important goals you have for your child this year. Tell me how you want your child’s education to look this year.

Mara: Other talking points include: 

Tell me what you think your child might need to be successfully included in the classroom, whether in person or virtual. Think about areas of sensory, motor, visual, communication, and executive function. Consider noise-canceling headphones, headsets that amplify the teacher’s voice, specific seating, allowances for pacing during class, yoga ball chairs, fidgets, or extra time on assignments and tests.

Compared with virtual learning, do you see any ways in which in-person learning is helping or could help your child? Can benefits such as fewer transitions in the day, use of certain tech tools, or better mental health make learning more accessible? 

What barriers—cultural, practical, and others—might make inclusion difficult, and how can we work to overcome these barriers in a supportive fashion? For example, if a child wants to join complex playground games and is repeatedly left out or, worse, teased for playing poorly, school staff can supervise, work on basic skills with all the kids, and facilitate scrimmages. 

Dr. Feder: Once you have a good idea of what might work for the student, it’s time to look at how those measures can work at school. Given the need to optimize learning for the student while supporting mainstream peers and staff, consider these factors as you work with schools and families:

• Where will the student have a better chance of meeting their academic and social goals?
• Where will the student have more social opportunities?
• Can therapies be delivered in the mainstream classroom?
• For which specific activities can the student join the mainstream class? Sometimes a student requires a different environment for certain activities like test taking or for some more focused academic instruction.

Mara: Other factors to consider include:

• How can staff manage the mix of students to maximize success and minimize loss of academic or social learning for other students? Programs such as The Good Behavior Game can help teachers to foster cooperative learning.
• What support do mainstream children and their families require? Sometimes in-class inclusion programs such as Circle of Friends or Autism Is help the typical students and families learn acceptance, foster inclusion, and reduce bullying.
• What support will staff require to optimize the experience for all the students in the class? This may include specialized consultation and regular and frequent protected time for reflective problem ­solving.
• Is the pace of the classroom working for the child? 
• So often we need to give kids more time to process information – how can we make sure that the child has time to process questions and other information?
• What can we do make the transitions more comfortable from activity to activity?
• What can we do help the child navigate around the school safely and happily?
• How do we ensure that we anticipate changes in routines so that those are less disruptive? 

Dr. Feder: A good plan generally leads to academic and social progress for the student. But special education, including mainstreaming, is expensive. Often a school district doesn’t have the resources, so students make little headway. In their effort to show progress, schools may document small gains that mean little in terms of actual function, but a recent Supreme Court case ruled that minimal progress is inadequate progress. We need to be monitoring how things go. Expect to see substantive changes in kids from season to season and year to year. It doesn’t happen in a few weeks, but meaningful progress should not take years.

Mara: Remember this: special education accommodations must be made in the least restrictive way possible. The good news is that the bulk of research supports inclusion as beneficial for all students. 

Dr. Feder: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Mara: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.

As always, thanks for listening and have a great day!