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Pediatric Physical Therapy:
Research Report

Consensus Among Experts in Pediatric Occupational and Physical Therapy on Elements of Individualized Education Programs

Dole, Robin L. PT, EdD, PCS; Arvidson, Kristin MS, PT; Byrne, Eilish MS, PT; Robbins, Jodi MS, PT; Schasberger, Britta MS, PT

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Author Information

Institute for Physical Therapy Education (R.L.D.), Widener University, Chester, Pa; Spaulding Rehabilitation Hospital (K.A.), Boston, Mass; Children's Hospital at Stanford (E.B.), Palo Alto, Calif; Roanoke County School District (J.R.), Roanoke, Va; and Special People in the Northeast (B.S.), Philadelphia, PA

Address correspondence to: Robin L. Dole, PT, EdD, PCS, Institute for Physical Therapy Education, Widener University, One University Pl., Chester, PA 19013. Email: Robin.L.Dole@Widener.edu

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Abstract

Purpose: The aim of this study was to establish consensus among a sample of expert occupational therapy and physical therapy practitioners on characteristics necessary for individualized education program (IEP) objectives to be educationally relevant, measurable, and appropriate in content.

Methods: The Delphi technique was used to survey 38 board-certified clinical specialists from New Jersey, Pennsylvania, and New York. Nine physical therapists and 29 occupational therapists agreed to participate.

Results: The results of a three-round survey process revealed six characteristics of measurability, six characteristics of educational relevance, and seven characteristics related to content that were agreed on by 75% or more of the respondents.

Conclusions: While IDEA is being readied for its next reauthorization, knowledge of these characteristics may be helpful to related service professionals in their participation for developing higher quality IEPs.

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INTRODUCTION

The Individuals with Disabilities Education Act (IDEA) ensures that all children, regardless of ability or disability, receive a free and appropriate public education. The law also provides for any related services that are required to support that education. 1 To meet the requirements of IDEA, related service professionals in the fields of physical and occupational therapy are encouraged to collaborate with teachers, psychologists, parents, and school administrators in the writing of educationally relevant and measurable goals and objectives. Although this collaboration is desirable in theory, it is difficult to implement in practice. 2,3

If professionals who develop a plan for a child's education are not working as a team, the end result may be fragmented service delivery guided by discipline-specific goals and objectives. 3,4 Such goals and objectives may not relate well to an overall educational plan for a child. Although some information is available in the literature to aid therapists in determining what constitutes an educationally relevant individualized education program (IEP) goal and how to write objectives that can be easily measurable to demonstrate progress, 5–8 therapists continually seek methods to improve these skills.

The special education and related services literature echoes the spirit of IDEA, indicating that IEP goals and objectives should accomplish the following: 1) be focused on the child's educational experience, 2) be written in measurable terms, and 3) require specific content as stated in the law. A review of the literature relating to IEPs and related service interventions, however, provides several insights into the problems that IEP teams have faced when writing educationally relevant and measurable goals and objectives.

Several authors have noted that IEP goals and objectives are often not linked to assessment. 9–11 Gallagher and Desimone 9 reviewed studies pertaining to the analysis of IEPs over a 15-year time period and concluded that IEP goals and objectives were too often poorly written, without functional relevance, and lacked required elements. Additional factors contributing to poorly written IEP goals and objectives relate to the child's educational setting and level of disability. In a study of IEPs for children receiving special education, Hunt and Farron-Davis 12 found that goals written for the regular classroom were of a higher quality than goals written for the same children when they were in a special education classroom. Downing's 13 investigation of IEP goals revealed that the majority of goals reviewed describe something done to the child or for the child rather than what the child will do or learn to do, and contained few criteria for measurement. In Downing's study, children with severe disabilities were more likely to have goals of lesser quality than children with mild disabilities.

Problems of poorly written goals and objectives, however, have plagued special education practices for some time. This is illustrated in two investigations of IEPs, one from 1978 only three years after the legislation concerning the education of children with disabilities was instituted, and one published in 1990, when the law was reauthorized for the third time. Alper 14 studied 265 IEPs from several school districts in the state of California, and Smith 15 analyzed 120 IEPs of children with behavioral disorders and learning disabilities. In each of these studies, problems with implementation of special education were attributable in some way to IEP goals and objectives that were poorly written or inconsistent with other information contained in the IEP.

The investigations described above reviewed the educational goals pertaining to special education, in general, without specific reference to related services. In fact, few researchers have investigated the quality of IEP goals and objectives that address related services provided to children receiving special education. In one study, Giangreco et al 4 found that IEP goals were more discipline specific rather than collaborative. Goals were also written in generalities, which addressed objectives for the service provider and not the child. In a later study expanding on these problems, Giangreco 2 found that related service professionals often functioned independent of the team and made isolated decisions regarding services for children with disabilities. Goals written by professionals who were functioning independently or in isolation were also less likely to reflect the educational relevance required by the law.

Although some authors have hypothesized that therapists, who are traditionally trained in a medical model, may find it difficult to participate in writing IEP goals and objectives that are educational, 5,8 others argue strongly that the dichotomy of “medical versus educational” focuses of intervention are purely mythical. 7 Regardless, in recent years there has been greater attention paid to the importance of educationally relevant and measurable IEP goals and objectives. This is evident in the revisions made to IDEA in 1997. 16 Even with this additional emphasis, therapists may still find themselves searching for assistance in developing high quality IEPs. In light of the difficulties that may face related service professionals when helping to develop high quality IEPs, the purpose of this study was to develop a consensus among experts in pediatric occupational and physical therapy on the essential characteristics of IEP goals and objectives. The focus was on determining which characteristics were most important for an IEP objective to be measurable, educationally relevant, and contain the necessary content to comply with IDEA. At the time of this study (1997–1999) IDEA had just undergone its 1997 reauthorization, and therapists were not yet accustomed to these new regulations; therefore, the focus was on the quality of IEP objectives. The findings, however, may be just as applicable to the writing of quality IEP goals as well as objectives.

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METHODS

This study was designed to define a set of characteristics that experts in the fields of school-based occupational and physical therapy would agree are essential for well-written IEP objectives. After a review of the current literature, the authors decided to focus the study on three major areas: measurability, educational relevance, and overall content in the writing of IEP objectives.

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Design

To obtain a consensus among occupational therapists (OTs) and physical therapists (PTs) regarding IEP objectives, the Delphi technique was employed. This method was chosen because it affords the inexpensive and remote collection of field experts’ opinions concerning a particular topic. 17 The Delphi technique typically consists of the identification and selection of a panel of experts in the area being studied, the development and distribution of at least two questionnaires, and the collection and analysis of consensus data in the final round. 18 Before the subjects were recruited, the study was submitted and received approval from the Widener University Institutional Review Board.

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Subjects

A purposive, nonprobability sample of experts was obtained from the fields of physical therapy and occupational therapy. These two disciplines were chosen because they are included in the realm of related services, and the establishment of “expert” status could be determined through a valid external method. Participants were chosen from the available population of board-certified pediatric specialists in the tristate area of New Jersey, Pennsylvania, and New York. The base criteria for specialty certification for each discipline at the time of the study are presented in Table 1. In addition to specialty certification, all subjects in this study were required to have the equivalent of at least three full-time years working in a hands-on capacity within a school-based setting. It would have been desirable to also include the discipline of speech and language pathology in this investigation; however, at the time of the study there was no similar external method for determining expert practice in school-based practice.

Table 1
Table 1
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An invitation letter and informed consent describing the study was mailed to all tristate area therapists who were board certified in pediatrics by either the APTA or AOTA credentialing process. The population of clinical specialists at that time contained almost three times more OTs (n = 90) than PTs (n = 33). The relative imbalance between OTs and PTs was retained in actual number of participants from each discipline (29 OTs, 9 PTs) and therefore was a representative sample.

Because of the length and nature of this investigation, attrition was to be expected. Of the panel of 38 experts who originally responded to the letter of invitation, 34 responded to at least one questionnaire and a total of 21 participated in all three rounds. The average age of the participants was 41.6 years (range 30–65). The majority of participants’ highest earned degree was at the master's level (n = 27), with a mean of 15 years of pediatric experience (range = 10–23). Each therapist also had some form of advanced training, such as Neurodevelopmental Treatment certification, Sensory Integration and Praxis Tests certification, or Neonatal Individualized Developmental Care and Assessment Program certification. The initial sample and the resulting respondents contained a relatively equal representation of therapists from New Jersey and Pennsylvania, with a smaller number from New York.

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Survey Procedure

Four weeks after signed informed consents were received, an initial survey questionnaire was sent. On the basis of an analysis of the available literature, the researchers developed the initial survey, which was reviewed and revised based on input from two survey experts. The survey was then pilot tested with two pediatric therapists who were not a part of the study. This revised survey was then sent to the participants, who had four weeks to return their completed surveys. Responses to the survey were used to formulate the next survey and the process continued toward the development of consensus. Approximately six weeks were needed for completion, receipt, analysis, and design of each set of surveys, between each survey round. The participating experts eventually completed a total of three rounds of surveys to come to consensus. In this study, consensus was defined as at least 90% agreement, and near consensus was 75–89% agreement on the aspects considered important for IEP objectives in the areas of measurability, educational relevance, and necessary content.

The first-round survey consisted of five open-ended statements related to IEP goals and objectives. To ensure consistency of response, operational definitions (based on the law and a dictionary) were provided for the following terms: IEP, goal, objective, measurability, educational relevance, and content. The opening statement asked the selected experts for an explanation, from a clinical perspective, on their perception of the difference between an IEP goal and an IEP objective. This was followed by three similarly phrased statements that asked respondents to list factors that they considered important for IEP objectives to: 1) exhibit measurability, 2) exhibit educational relevance, and 3) exhibit the necessary content to comply with the law. A final question allowed participants to provide any additional information they felt was appropriate. Because of the distinction between IEP goals and objectives with respect to time period for achievement, scope, and the version of IDEA applicable at the time of data collection, the authors of this study chose to focus primarily on the elements involved in writing IEP objectives.

On receipt and analysis of the responses from the first round, development of the second-round survey commenced. With each of the three rounds of surveys, the results of the previous survey were analyzed for themes and then presented to the expert panel in the next survey. With each subsequent survey, the panel was also asked to state their agreement or disagreement with the information that was presented. Respondents were free to add, edit, or delete information as the process moved toward agreement on a set of characteristics that best fit the concepts of measurability, educational relevance, and necessary content.

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RESULTS

First-Round Survey

The responses from the first survey yielded valuable information about the panel's perception of the difference between an IEP goal and objective. This was necessary to determine whether all respondents were in agreement as to these differences. The goals were consistently described as being for a longer time period, more general, related to the academic environment, and involving overall improvement in function or behavior. Goals were typically viewed as not needing to be measurable. This is in contrast to the language of IDEA 1997. Because this study took place before the regulations of IDEA 1997 had been widely published and implemented, it is not surprising that these experts interpreted the content of an IEP goal in this manner. IEP objectives were consistently described as components of the goal, the measurable steps toward a goal, applying to shorter time periods than goals, and used for objective and measurable behaviors.

When responding to the question-soliciting characteristics necessary to ensure the measurability of IEP objectives, the panel collectively provided 68 separate responses, which were consolidated into 18 thematic characteristics to be presented on the second survey. The same procedure was done with the responses to the questions on educational relevance (33 responses consolidated to 20 characteristics) and content (>100 responses consolidated to 20 characteristics). The process of consolidating the responses was done by identifying common themes from within the responses. Two researchers reviewed the responses separately to identify themes in the responses by using qualitative analysis procedures. The researchers then reviewed the information collaboratively to confirm the development of these themes. Examples of how the actual responses were consolidated into a unified characteristic are presented in Tables 2 to 4.

Table 2
Table 2
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Table 3
Table 3
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Table 4
Table 4
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Second-Round Survey

For the second-round survey, a total of 58 characteristics, which were formulated from the responses in the first-round survey of IEP objectives, were presented in list form. This included the 18 characteristics related to measurability, and 20 characteristics each related to educational relevance and content. Participants were then asked to rate these characteristics on a five point Likert scale indicating the level of importance each characteristic had with respect to the measurability, educational relevance, or necessary content of IEP objectives. The scale provided the following options for rating: Important (I), Somewhat Important (SI), Neutral–Neither Important nor Unimportant (N), Somewhat Unimportant (SU), and Not Important (NI). Characteristics that received high levels of agreement or consensus (at least 90% of respondents rated the characteristic as I or SI) were identified for inclusion in the third-round survey. In addition, the items that reached near consensus, defined by this study as 75–89% agreement, were also included in the third-round survey. This was done to allow the experts to further clarify their thoughts on the importance of these items and to determine if they should be included in the overall consensus.

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Third-Round Survey

The results of the second-round survey helped to limit and focus the number of characteristics that would be included in the third-round survey. From the second-round survey, a total of nine characteristics associated with measurability, 10 characteristics associated with educational relevance, and eight characteristics associated with content were identified for inclusion due to strength of consensus on these items. These 27 characteristics were then presented one more time in the third-round survey. At this point the experts were asked to state only agreement or disagreement with each characteristic. A rating of “agree” indicated approval of the characteristic as necessary for an IEP objective within the concept area in which it was presented (measurability, educational relevance, or content). A rating of “disagree” indicated that the expert did not think the characteristic was a necessary quality for an IEP objective within the concept area it represented. The participants were also instructed to compare the characteristics within and across each main concept area to check for redundancy and to comment on whether such redundancy was appropriate. Participants were also free to state whether a characteristic needed editing or revision for clarity. The final results of the third-round survey are presented in Tables 5 to 7. Because of the high level of agreement among the characteristics in the second- and third-round surveys, the study was completed and consensus achieved after the third round.

Table 5
Table 5
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Table 6
Table 6
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Table 7
Table 7
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DISCUSSION

This study utilized the Delphi technique to formulate a consensus among experts in the related services of physical and occupational therapy on the important elements of IEP objectives. The Delphi technique was an appropriate and successful choice for this study as regional experts could be surveyed remotely and could participate in consensus development. Although there was attrition during the time of the study, is not unusual when this technique is employed, 18 and the authors do not believe that it unduly affected the outcome of the consensus.

The Delphi process aided the expert panel in identifying several characteristics that were important to IEP objectives. This consensus in many respects is in accord with what the literature defines as best practice. A discussion of the results and the relationship to the literature follows, with respect to each concept area represented in this study.

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Measurability

The experts felt strongly that an IEP objective should relate to or describe a functional skill or observable behavior (100%). The inclusion of a functional skill in IEP objectives was so important to these experts that it was found to be relevant to all three of the concept areas studied. Weisenfeld's 19 1987 investigation of the IEPs of children with Down Syndrome revealed a lack of functionally related objectives in the areas of language, motor, social skills, and basic academics. Only the self-help–related objectives exhibited functionality, yet even in this area, many of the skills were practiced and measured for success outside of the relevant context or environment and with materials that were considered “artificial” rather than “authentic.” A more recent investigation reveals that little has changed in the past 15 years. Pretti-Fronticzak and Bricker 20 studied 86 participants across five states. When examining IEPs for children in preschool, they found very few goals and less than one-half of the accompanying objectives included statements of function and context.

With regard to measurability, therapist concensus in this study indicates that IEP objectives should use an identified method for measuring achievement (100%), utilize valid and acceptable measurement tools (90%), specify the level of assistance or cueing needed (90%), identify specific criteria for achievement (81%), and be able to be measured reliably by others besides therapists (81%). These characteristics are consistent with what is expected of annual measurable goals and short-term objectives, as outlined in IDEA.

The importance of relying on specific criteria and methods for measurement rather than on one's personal opinion or informal observation is illustrated in the work of Fuchs et al. 21 They found that special education teachers who relied heavily on their informal observations to assess progress and achievement of IEP objectives were highly inaccurate when compared to the student's actual performance. If goals and objectives are not evaluated effectively, there will be little evidence to facilitate writing objectives that are more relevant and easily measurable. When participating in writing IEP objectives and in evaluating progress toward those objectives, therapists should be very careful to incorporate valid and objective methods of measurement.

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Educational Relevance

According to IDEA, IEP goals and objectives must be directly linked to an educational benefit. The experts in this study consistently stated that objectives should relate to the school environment to be considered educationally relevant. Giangreco 2 suggested that related services must be educationally relevant to be considered effective components of the IEP. He also suggested that an examination of goals and objectives could serve as a means of evaluating the effectiveness of related services.

The experts reached consensus or near consensus on the importance of the school environment in the final round survey by agreeing that objectives should accomplish the following: enhance school function (100%), relate directly to school/classroom curriculum or goals/requirements (85%), assist in gaining benefit from educational setting/placement (80%), be associated with a general school activity (76%). One helpful rule of thumb for therapists may be that, if the skill cannot be observed or measured during the child's normal school day, it might not be relevant to that child's education. Orr and Schkade 22 found that OTs employing a student role adaptation model to guide their interventions, utilized goals and objectives that were more congruent with what teachers felt were the task demands of the child's classroom environment. Paying attention to the classroom environment during IEP development with objectives that directly relate to activities that occur in this setting can assist therapists in identifying key tasks for the focus of intervention.

Giangreco 2 recommends that the generalizability of a skill from one context to another may be a manner by which the effectiveness of a related service can be determined. Generalizability was one of the themes that emerged in the open-ended questions in the first-round survey, where the experts were asked to list the factors they thought were important for an IEP objective to exhibit measurability, educational relevance, and overall content. On the second-round survey, items such as: enhance skills outside of school environment in the educational relevance concept area, and generalize across settings in the measurability concept area demonstrated that the experts supported generalizability; however, those characteristics did not achieve the requisite levels of consensus or near consensus in this study.

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Content

In terms of the content that is necessary for IEP objectives to comply with IDEA, the experts overwhelmingly felt that objectives should relate to a functional skill (100%). In addition, experts thought that being child focused (95%) and including an action verb (76%) were additional criteria for an objective to demonstrate the proper content. O'Neill and Harris 8 proposed that objectives should focus on an activity or behavior that the child is to achieve, along with outlining the environment in which the activity occurs, the actions of the therapist and any equipment to be utilized. The experts in this study concurred, stating in the first-round survey that an IEP objective should contain the “action or behavior being measured and what material is being used,” and “how the task is performed, where and with what equipment, and with or without assistance and cues–verbal, visual, auditory.”

Another theme that emerged was that objectives should be connected to the achievement of long-term goals. This was evident in the content concept area with the item related to the long-term goal (95%), and in the educational relevance concept area with the item related to achievement of IEP goals (76%). This is congruent with the Notice of Interpretation of the Individualized Education Program, 23 which states that objectives should facilitate the child's achievement of educational goals because objectives can be defined as steps toward the educational goal. The experts also believed that for the objectives to meet the proper content requirement, objectives should be meaningful for all involved (80%). McEwen and Sheldon 7 recommend that focusing on goals that are meaningful to the child may be a more effective means of achieving the desired outcome. There is also a growing trend in special education toward “student-led” and “family-friendly” IEPs, 24–26 where the child and family are encouraged to take a more active role in developing the focus of the program. This philosophy would also embrace two items that the experts believed were very important to IEP development: objectives should be easily understood by all involved (90%–educational relevance concept area) and be well defined, specific, clear, and without jargon (100%–content concept area).

In searching the literature since IDEA's reauthorization in 1997, one notices an abundance of articles and position papers that provide information on how to improve the quality of IEPs, 27–33 but little evidence of the successful implementation of such strategies. 20,34 Pretti-Fronticzak and Bricker's 20 recent investigation of goals and objectives written before and after a two-day training session on writing quality IEPs indicates that team members are more adept at writing functional, measurable objectives than they are at writing high-quality goals. In their study, IEP goals and objectives were rated for quality with the use of the Goal and Objective Rating Instrument. Before training, only an average of 10-14% of the written goals achieved the quality indicators for functionality, measurability, or instructional context. IEP objectives were of higher quality, with 50-76% achieving the evaluative criteria. After the two-day training, the quality of both goals and objective rose, but still only 40-53% of goals and 64-85% of objectives achieved the quality indicators of the Goal and Objective Rating Instrument.

With the new reauthorization of IDEA, it is imperative to determine whether these best practices are being employed, and whether higher quality IEPs are associated with more efficient delivery of services and more successful outcomes for children.

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Limitations

There are a few limitations to the applicability of these results that should be considered. These relate to the researchers’ reliability in identifying themes in participants’ responses, and factors that influenced the size, type, and geographic representation of the sample of experts.

The process of consolidating the responses from the first-round survey into unified themes followed the procedures used by others who have employed the Delphi technique. 17,18 The researchers did not, however, employ specific reliability procedures to determine the level of agreement between the two researchers who analyzed the responses.

The expert panel that participated in this study had a much larger representation of OTs than PTs. This was due to the population from which this sample was solicited. At the time of this study, there were more certified pediatric specialists in the field of OT, and more OTs in school-based practice when compared to available data for PTs (membership data from APTA and AOTA). When one considers that OTs and PTs serve similar roles on IEP teams during the goal and objective writing process, the information gained from this study becomes vitally important to both disciplines.

The sample size in this study included PTs and OTs practicing in the tristate area of New Jersey, Pennsylvania, and New York, and so the results may not applicable across other geographic regions. Specific interpretations of the law and common practices vary across states, and might alter the significance of our results in other geographic areas. The authors of this study recommend that additional studies be conducted in other areas of the country and with other related service professionals who serve as members of the IEP team.

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CONCLUSIONS

The expert panel of pediatric OTs and PTs that participated in this study reached consensus on several important characteristics of IEP objectives. The importance of IEP objectives being related to functional skills was echoed across all three of the concept areas studied. These experts thought that IEP objectives demonstrate measurability through the use of an identified method of measuring achievement and the use of valid and acceptable measurement tools. For an IEP objective to be relevant to the education of a child, it should enhance the child's ability in school and be easily understood by all individuals who are involved with the child's IEP. The experts confirmed that for an IEP objective to contain the necessary and appropriate content outlined by the law, it should be free of professional jargon, child-focused, and relate to a specific long-term educational goal. It should also be realistic and achievable within the typical IEP time frame, or other time frame indicated on the IEP.

The literature indicated that all of these characteristics are important elements of IEP objectives. Our results demonstrate that these related service professionals agree with what is considered best practice in special education. Future research is needed to verify agreement on these characteristics with other professionals involved in the IEP process, including teachers, psychologists, nurses, speech and language pathologists, and parents. Although the available literature appears to point to the importance of these characteristics, there is little evidence that therapists and others on the IEP team are implementing these ideas. Related services professionals should demonstrate knowledge of and periodically review these characteristics when participating in IEP development. In addition, therapists should participate in evaluating their own team's IEP objectives to determine whether the essential characteristics identified in this study are present.

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REFERENCES

1. Education for All Handicapped Children Act of 1975, Public Law No. 94–142, Section 6, 89 Stat. 775, 1976.

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23. Assistance to States for the Education of Children With Disabilities and the Early Intervention Program for Infants and Toddlers With Disabilities; Final Regulations, Appendix A to Part 300–Notice of Interpretation of IEPs. Federal Register 1999; 64(Suppl 48): 12405–12454.

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Keywords:

special education/standards; occupational therapy; physical therapy; data collection/repeated rounds of survey; consensus

© 2003 Lippincott Williams & Wilkins, Inc.

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