Students with TBI - Thriving Beyond Injury
Part 3 - Evaluation

Part 3 covers assessments, tests and activities used to determine whether your child has a disability, and to assess the nature and extent of the services your child needs.

Summary of Part 3

Your child with TBI may be ready for or may benefit from educational services sooner than you think. It is very important that you notify your school of your child's injury as soon as possible. When you and your child's medical team have decided that your child is ready for educational services, make a written request for a multifactored evaluation (MFE). See sample letter on page 48. Be sure to collect as much documentation of the effects of the TBI as you can. Ask for copies of tests and evaluations done by medical professionals for your own records. Having this information will help your school complete evaluation of your child without delay.

Documentation and Eligibility

One of the first things you need to do to get special education services for your child is to determine if he is eligible for services through any of the laws discussed in this book. The first step in beginning this process is to identify and evaluate your child as eligible for services. This process requires two determinations. The disability condition must be documented followed by the documentation of what is called adverse effect. Adverse effect is the negative impact of the injury/disability on your child's ability to learn and participate in school.

You can keep a journal about changes in your child's behavior, personality, mood, and abilities. Write down changes that you notice and when you notice them. Note any trends that you see in your child's functioning. For example, if your child's behaviors get worse at the end of the day, you should document this. This can mean that your child is tiring more easily because of the TBI or the behaviors can be in response to your child's late day routine. In any case, careful documentation of trends can assist your child's school in planning for services.

You should also keep copies of all important documents about your child's injury. These documents can include medical records, therapy records, information about medications, information about insurance, and any other relevant records. Consider keeping all of your documentation in a three-ring binder organized in sections. Having all of the necessary information in one, easily accessible place can save you time and can prevent loss of documents.

Your school should also document changes in your child's behavior. Changes should be documented to assist in determining whether your child needs special education services and whether the services being provided are responsive to your child's needs. A "Documentation of Behavior Changes" form includes information about the date and time of the behavior change, the behavior and circumstances, the IEP measures implemented, and responses and comments.

Any negative impact on your child's learning must be substantial and prevent your child from receiving FAPE if specialized services are not provided. There may be children with disabilities that do not substantially impact their ability to learn. For example, a child who uses a wheelchair but attends a fully accessible school building would have complete access to his educational environment and may not require any individualized services. A child with ADHD who takes medication which enables him to focus on and complete his school work may not require additional support.

A child with a mild TBI or one who has substantially recovered from a TBI may or may not initially require special education support in school. The TBI alone does not establish eligibility for special education services. There must be a substantial negative impact on the child's ability to function in school. As your child grows and develops, learning challenges may appear that substantially impact your child's ability to learn, thus qualifying him for special education services. If you notice a decline in your child's academic performance or social behavior, contact your school for an evaluation.

Child Find

The Ohio Department of Education is required to implement policies and procedures to make sure that efforts are made to identify, locate, and evaluate children in the state who have disabilities and who need special education and related services. Each school district, in consultation with county boards of developmental disabilities and community mental health boards, must identify and test children under the age of 22 with known or suspected disabilities. Additionally, public notices and awareness campaigns must be used in order to make people aware of special education services. This can be done through television radio and newspapers; posters and flyers; and speaking with community groups. For children 0 through 2, the Ohio Department of Health is responsible for child find activities. See Early Intervention.

Referral

A child may also be identified by a referral or request for evaluation. A school professional may ask that your child be evaluated to see if he or she has a disability. You may also contact your child's teacher or other school professional to ask that your child be evaluated. If the school decides not to evaluate your child, you must be notified of this decision and the reasons for the refusal.

If a referral is made to have your child evaluated, and school officials decide that your child should be evaluated, they will need to obtain your written consent before they proceed with the evaluation. You should provide your written consent as quickly as possible because your child's IEP must be written no later than 90 days after you provide your written consent.

Evaluation

Evaluation helps to establish that your child is eligible for special services. The evaluation must assess your child in all areas related to the suspected disability. This evaluation is called a multi-factored evaluation (MFE). The results of the MFE will be used to determine your child's eligibility for special education and related services and to make decisions about an appropriate educational program for your child.

Eligibility

The results of the evaluation will be reviewed to determine whether your child is eligible for special education and related services. The team will decide if your child is a "child with a disability" as defined by the IDEA.

IEP process

Once your child is determined to be eligible for services, the IEP team must meet to write an IEP for your child. This document describes the special education and related services necessary to provide your child with a FAPE.

Re-evaluation

Every three years or whenever necessary, your child will be re-evaluated to determine if he or she is still eligible for special education and related services. More frequent re-evaluation may be necessary for children with TBI because of the recovery process that occurs during the first couple of years after injury. The standard 3-year re-evaluation period under the IDEA generally is not adequate for children with TBI, whose disabilities are potentially more fluid than those of children with learning or other developmental disabilities.

The Evaluation process for children with TBI

If your school does not contact you through its child find activities and you suspect that your child may need special education due to a brain injury, you should contact your school and ask that an evaluation of your child be completed. You should contact your school as soon as possible and in writing. Sample letters to request evaluations follow.

Sample Letter: Request for Evaluation

Date (include month, day, and year)

Name of Your Child's Principal
Name of Your Child's Special Education Coordinator
Name of School
Street Address
City, State, Zip Code

Dear (names of Principal and Special Education Coordinator),

I am writing to request that my child, (name), be evaluated for special education and related services. (Name) sustained a traumatic brain injury (TBI) on January 10, 2002. I enclose documentation of the injury and medical treatment.

I believe (name) may have a disability because of the TBI. I do not yet know how the TBI will affect his progress in school, and I believe he may need special services in order to learn. (Name) is in the (level) grade at (school name). (Teacher's name) is his teacher.

Specifically, I am concerned because (follow with a few direct examples of problems at school). We have tried the following to solve the problems: (follow with anything extra you or the school has done to address the problems).

This letter is my formal request and consent for a multifactored evaluation for (name). Please provide me the name and telephone number of the person who will be forwarded this letter and who will be coordinating the multifactored evaluation.

Thank you for your prompt attention to my request. I look forward to hearing from you within five school days of the date you receive this letter.

Sincerely,
Your Signature
Your Name
Street Address
City, State, Zip Code
Daytime telephone number
E-mail address

cc: your special education advocate or attorney, if working with one

Sample Letter: Request for IEE or Neuropsych. Evaluation

Date (include month, day, and year)

Name of Your Child's Special Education Coordinator
Name of School
Street Address
City, State, Zip Code

Dear (name of Special Education Coordinator),

I am writing to request an independent educational evaluation (IEE) for my child (child's name). I am requesting this evaluation because (state why you disagree with the evaluation conducted by the school and what part of the evaluation you will address through an IEE).

Please provide me with a copy of your criteria on IEEs and information about where an IEE may be obtained.

Once I have decided upon an independent evaluator, I would like to discuss with you how to facilitate billing and payment for the evaluation.

I look forward to hearing from you within five school days of the date you receive this letter. Thank you for your help.

Sincerely,

Your Signature
Your Name
Street Address
City, State, Zip Code
Daytime telephone number
E-mail address

cc: specialists or other staff

The school is required to conduct a multi-factored evaluation of your child within 60 days of your consent for evaluation or notify you that they do not think an evaluation is necessary and why. To ensure that your child's evaluation is completed as quickly as possible, provide your consent for evaluation in the letter requesting evaluation.

Differentiated Referral Process

Ohio schools are required to document that they have implemented a differentiated referral process prior to beginning a multi-factored evaluation (MFE). This process is designed to address a concern that a child may have a disability. The intent of this process is to ensure appropriate referrals and to prevent the misidentification of children who do not have disabilities.

The process starts when someone, who has knowledge of a child, shares with the school a concern that a child may have a disability. School personnel will respond with a variety of activities which could include reviewing records, interviewing staff, and pulling together an Intervention Assistance Team (IAT), defined in the box on page 36. The record review could include attendance, grades, discipline, group testing results and IAT notes if a referral has already been made . You and the teacher(s) may be questioned or asked to complete surveys about school work, social skills or other areas of concern. You may be asked to share test results, evaluations or reports from community professionals who work with your family. You may also be asked to give school personnel permission to speak with community professionals for additional information.

Once this information has been gathered, the process could move in several possible directions:

• a referral to the IAT if the IAT is not already involved
• a referral to other school or community resource such as community counseling/rehabilitation center or a medical provider
• a referral to a school-based resource such as a remedial reading program or a math tutoring group
• a referral to complete a MFE.

If a decision is made to work with the IAT and/or refer to counseling/rehabilitation resources the school will want to have some time to see if the interventions make a difference or whether different resources are needed. This can be a crucial time for a child who has sustained a TBI. Even though the brain is still healing, it may also be important to maintain the neurological functioning with specific types of educational activity, even during hospitalization and rehabilitation. In consultation with your child's physicians and the school, you should discuss whether and how long the intervention process should be used for your child. If the recommendations support the provision of more formalized services, you should ask that a MFE begin immediately.

Intervention Assistance Team (IAT) Defined

A school-based problem-solving group that assists teachers with intervention strategies to address the learning needs and challenges of students. For example, a building Intervention Assistance Team (IAT) may begin with the building principal and the 3rd and 4th grade teachers coming together once every two weeks to share concerns about particular students who are struggling in school. The group will ask what has already been tried and suggest further ideas or resources the teacher may want to try. Usually a plan is written down to track the progress of the plan and document what has been tried. Many IATs routinely include parents and other school personnel such as the guidance counselor, school psychologist, or related service provider to bring additional ideas and resources to the problem-solving effort. The work of these building teams can establish the ground work for a referral for a multi-factored evaluation, if efforts made to help the student are not successful.

Components of Evaluation

All children suspected of having a disability will be evaluated by a school district to determine eligibility for special education. Your child will be evaluated by a multi-disciplinary team comprised of individuals with expertise in different areas affecting your child's educational performance (domains). This team can include school personnel, your child's private therapists/physician, and other individuals necessary to assist the team. Different individuals will be responsible for conducting the various components of your child's evaluation. The evaluation will include specific instruments as well as structured observations and procedures to determine your child's strengths and needs.

As a member of the team, you should ensure that your child is evaluated in all areas that are affected by his or her traumatic brain injury. You should talk to the person who is going to test your child to find out whether they are going to test/evaluate for the following issues: attention, memory, information processing, communication and language capacity. You should also discuss whether they can address the issues unique to children with TBI.

For example, a child who acquires short-term memory problems from a TBI may have pre-injury memory which is not affected by the TBI. The injury may only affect the ability to remember new information. The assessments used to test memory must be able to distinguish between overall memory and pre and post injury memory problems.

For example, if you suspect that your child's vision has been affected by a brain injury, you should request that a vision assessment be included in the MFE. There are many different ways that vision can be affected and there are corresponding methods to evaluate a suspected vision problem. It is important that an individual familiar with traumatic brain injury assist the team in determining the appropriate assessments necessary for evaluation. If your school psychologist or other evaluator is not going to test your child for specific TBI problem areas, you should determine whether to pursue a neuropsychological or other evaluation.

Neuropsychological Evaluation

For most children with TBI, the MFE alone will not provide the necessary information to address all educational needs. Generally, children with TBI will need a neuropsychological evaluation to assist the team in determining educational planning and services. A neuropsychological evaluation differs from the MFE. The MFE focuses on academic achievement and skills needed for academic success. This evaluation generally tests your child in areas such as intelligence, academic achievement, language, psychological adjustment, and adaptive behavior.

The neuropsychological evaluation diagnoses learning or behavior disorders caused by altered brain function or development. These evaluations assist in better understanding your child's functioning in areas such as memory, attention, visual-spatial skills, coordination, language, problem solving skills, and personality. This information will help you and your child's teachers, therapists, and physicians provide treatments and interventions to assist your child with learning.

The specific skills assessed and the length of the neuropsychological evaluation will vary depending on your child's age, the severity of your child's injury, and where your child is in the recovery process.

Many schools have difficulty understanding and using a neuropsychological evaluation because its recommendations are generally stated in terms not used by schools in their evaluations. The MFE generally provides standardized scores or numbers to assess a child's abilities. For example, the MFE might determine that a 5th grader has an I.Q. of 90 and reads at the 2nd grade level. The neuropsychological evaluation may indicate that the child has damage to the brain which causes visual perception problems which are interfering with reading. The neuropsychological evaluation is often vital to assisting a child with TBI in the classroom as it can provide the reasons for the child's difficulty and assist the team in determining how to address the difficulty through modifications in teaching method, materials, content, and environment.

A typical neuropsychological evaluation may assess:

• general intelligence
• academic achievement
• executive skills (organization, planning, inhibition, flexibility)
• attention
• learning and memory
• visual-spatial skills
• motor coordination
• behavioral and emotional functioning
• social skills

This evaluation typically includes an interview with you about your child's history, observation and interview with your child, and testing. The testing portion of the evaluation involves paper and pencil activities, answering questions, and sometimes the use of a computer. Parents are usually not in the room during testing although they may be present with very young children. The time required for the evaluation depends on the age of your child and your child's needs.

The neuropsychological evaluation is conducted by a pediatric neuropsychologist. Pediatric neuropsychology is a professional specialty concerned with learning and behavior in relationship to a child's brain. A pediatric neuropsychologist is a licensed psychologist with expertise in how learning and behavior are associated with the development of the brain, as well as how learning and behavior are affected after brain injury.

Because the MFE conducted by your school and the neuropsychological evaluation look at your child in a different way, you will have to work with your child's team to understand the value of the neuropsychological evaluation in educational planning for your child. Your school may have never considered a neuropsychological evaluation in education planning and will need information and support in understanding your child's evaluation. For the benefit of all team members, consider inviting (or including by conference call) your child's neuropsychologist to the IEP meeting to explain the results of the evaluation.

Both the MFE and the neuropsychological evaluation rely on standardized tests and comparisons to group norms. However, the traditional MFE focuses on academic achievement and a limited range of cognitive abilities. In contrast, the neuropsychological evaluation tests a broader range of cognitive abilities in more depth. A neuropsychological evaluation focuses on a child's pattern of strengths and weaknesses and the process of thinking/learning, but also on how those relate to brain functioning and the nature of a brain injury (i.e., how a child's ability to learn is affected by or related to the injury). Thus neuropsychologists will focus on areas of functioning (e.g., attention, memory, executive functions) that typically are not paid much attention or formally assessed in an MFE, but that have substantial implications for educational progress.

The neuropsychological evaluation is also different in that a neuropsychologist has specific training and experience in brain injury, and can relate evaluation findings to what is known about brain injury and its effects on education. School psychologists and MFE teams typically have limited experience with or knowledge about TBI. So while a part of the difference between a MFE and a neuropsychological evaluation is the tests or evaluation procedures that are used, perhaps an even bigger difference is the professional training and knowledge of the professionals doing the evaluations. For more information on standardized testing see IEE (Independent Educational Evaluation)

When: Timing of Evaluation

If your child has a moderate to severe brain injury, it is often apparent that your child needs an evaluation to determine if special education services will be needed in school. With mild brain injuries the need for evaluation is often not clear and the effects of the head injury may not be apparent at the time of injury. Typically the effects of mild TBI do not worsen over time. If they do, there may be other issues present, such as psychological issues or family stress. However, deficits may become more apparent over time as various higher level cognitive functions develop or emerge, or fail to develop or emerge as academic demands increase.

If your child has sustained any brain injury you should seek medical attention, you should document the injury (see next section) and monitor any changes in your child's behavior, progress, or functioning. For example, changes in your child's personality (irritability, temper, patience) or your child's ability to concentrate, remember, or follow directions, could be the result of a brain injury. Keeping track of these changes can help you recognize that an evaluation for special education is necessary.

In consultation with your child's physician and other providers, you should decide when your child is ready to be evaluated and to resume educational activities. Your physician will be able to determine when your child is medically stable to participate in evaluation and educational activities. Your child will benefit from peer support and socialization, and the resumption of normal routines.

Early Intervention

Very young children (birth through age two) with TBI can receive services through The Individuals with Disabilities Education Act (IDEA), Part C, which provides financial assistance to states for the purpose of providing core services to infants and toddlers with disabilities. The purpose of these services is to enhance the development of infants and toddlers with disabilities and to minimize their potential for developmental delay. The goal of the program is to maximize the child's potential for independent living as an adult.

The focus of early intervention services is to increase the capacity of families to care for their children with disabilities and potential delays. The services are provided through a coordinated network of service providers. The services are driven by the needs of the family and child and are documented through an Individualized Family Service Plan (IFSP).

The Ohio Department of Health, Bureau of Early Intervention Services, is the state agency designated by the governor to administer the E.I. Program. In Ohio, the early intervention program is a part of Help Me Grow, a program that provides developmental services so that children start school healthy and ready to learn. For more information about the E.I. Program see the OLRS publication First Steps. If you have a young child with a TBI you should call 1-800-755-GROW for help and to get your child evaluated for services.

Preschool Child with a Disability

Children with TBI who are ages three through five could be eligible for special education preschool services. A preschool age child is determined to be eligible for services based on "documented deficits" in specific areas of functioning, not by the diagnosis of a particular condition such as TBI. The areas of functioning addressed include:

• Motor
• Cognitive
• Adaptive behavior
• Social / Emotional
• Communication
• Hearing
• Vision

For a preschool child with a traumatic brain injury, eligibility will be determined by documenting the areas where the TBI affects the child's functioning. For example, the injury may have affected the child's speech and walking. The child could be identified as a preschool child with a disability with documented deficits in the areas of speech and motor development. The existence of the TBI itself will not determine eligibility for special education services, but the way the TBI has affected the child's functioning will be the determining factor.

Since Ohio law does not require all preschool children to go to school, children may be served in a variety of settings where they would be if they did not have disabilities. This includes center-based special or typical preschool programs, Head Start programs, daycare centers, and in their home environment. For sources of information about special education services for preschool children, see Resources.

For very young children, the results of testing may be relatively normal. This is because very young children do not have as many skills and as great a range of skills as older children. For example, a one year old child's speech skills are significantly limited. The child may only approximate letter sounds. That child is not expected to have good communication skills and there may not be a great difference between pre and post injury in the child's ability to talk. With an older child who has good communication skills and a large vocabulary, the results of a TBI can be significant. A child can go from speaking in complete sentences prior to injury to not speaking at all after injury. This significant change can be captured by testing. You should consider your child's age and discuss with your physician/provider whether and what testing would be appropriate.

Parent/Child Role in Evaluation

Your child can provide the team with valuable information about how the brain injury affects him or her. Your child may be able to explain to the team what services and supports would best assist him or her to function in school as well as possible. Examples of assistance that can be provided to your child include extra time to complete work, shortened assignments, true-false or multiple choice format tests rather than short answer/essay, opportunity to respond orally, and copies of teacher's notes. You should be sure to ask the neuropsychologist to include appropriate recommendations in your child's neuropsychological evaluation.

As the parent, you have information about how your child has changed in the home and community environments. This information should be shared with the team, especially information about what has been successful in accommodating those changes to assist your child. You may also have evaluation information (from the hospital or private therapist) that will assist the team. It is important that all relevant information about your child's brain injury be shared with the school team.

IEE (Independent Educational Evaluation)

If you disagree with an evaluation that your school has conducted you can seek an independent educational evaluation (IEE) at public expense. If you want to pursue an IEE you should request a copy of your school's IEE policy. This will tell you the qualifications your professionals must meet and any other requirements you must meet to seek the IEE at the school's expense. The school's policy can suggest possible IEE evaluators but cannot require you to use one of the suggested evaluators or limit your choice of evaluator. If the school recommends evaluators you should give serious consideration to those recommendations. The most beneficial IEEs are done by individuals that both the parent and the school view as impartial, competent and qualified. Your school will be more likely to accept and use recommendations from an evaluator in which they have confidence. In any event, seek individuals who have experience is making recommendations to school teams.

At any time you can seek an IEE at your own expense. The school must consider the results of any IEE you provide but is not required to follow any or all of the recommendations. Your school can only refuse to pay for your IEE if they pursue an impartial due process hearing (see Part 6 - Advocacy, Negotiation and Rights) to prove that their evaluation is valid. To facilitate payment for your IEE, it is helpful to reach agreement with your school about evaluators and payment arrangements before pursuing the IEE.

IDEA versus 504 Eligibility

Most children with moderate to severe brain injuries will be eligible for special education and related services under the IDEA. Some children with mild brain injury may not be eligible under the IDEA but under a different federal law. The Rehabilitation Act of 1973 (commonly called Section 504 in education) is a federal law that provides the right to educational accommodations and FAPE to children who do not meet IDEA eligibility. The definition of disability under Section 504 is more inclusive. While IDEA looks at categorical eligibility determinations, Section 504 looks at whether a child has a substantial limitation in one or more major life activity (learning, walking, seeing, breathing, etc.).

If your child is not entitled to services under IDEA, you should request that the team consider whether your child is eligible under Section 504. Your district is required to have procedures and policies that address Section 504 in the school setting. This determination may or may not require additional evaluation.

Categorical Identification/Inappropriate Labels

The original federal special education law (P.L. 94-142, The Education for all Handicapped Children Act) became law in 1975. Since then, the law has undergone several changes and is now called the IDEA. Because traumatic brain injury is a relatively new eligibility category under IDEA (1991) and Ohio law (1997) there is little guidance for schools and parents regarding how to identify and evaluate children with traumatic brain injuries.

This often results in children with traumatic brain injuries either not being identified or being identified and served under different categories. While some children with TBI can be appropriately served under a different category, problems often arise. These problems can include:

• perception of the child is based on inappropriate label
• unique needs not addressed including behavior, learning and memory issues
• other adjustment problems/changing needs over time

Once all portions of your child's evaluation have been completed, someone on the team (usually the school psychologist) will complete an evaluation team report (ETR) that summarizes the results of your child's evaluations and assessments. This report is reviewed by the team in a meeting where a determination of eligibility is made. At the ETR meeting you should advocate for a TBI eligibility identification for your child if TBI is your child's primary disability.

Special Evaluations for Vision and Hearing

Children with TBI are at risk for having problems with vision and hearing. Problems with vision and hearing can range from blindness and deafness to mild perception problems. Your child's eyes and ears may not be damaged by his TBI, but his brain may have difficulties processing vision and hearing information. This processing problem can result in vision and hearing problems.

If your child has vision and hearing problems, it is important to have your child's vision and hearing evaluated to determine if there are problems and to recommend ways to address the problems. Your child can receive accommodations and modification that can help. In addition to a neuropsychological evaluation, you should ask your school to make sure that your child receives a test from an audiologist for hearing, a test from a pediatric optometrist and/or a pediatric ophthalmologist for vision, and a test from a low vision specialist to determine how your child uses his vision in day to day situations.

There are tests available for children who have severe TBI. These tests can be conducted in a way that does not require the child to make intentional responses to the test. These are useful to test children who have no means of communicating.

For more information on resources for children with vision and hearing problems, see Ohio Center for Deafblind Education, 800-229-0844. The Center offers free technical assistance to parents and parent support services and training in the area of deafblind education.

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