Effgen, Susan K. PT, PhD; Chiarello, Lisa PT, PhD, PCS; Milbourne, Suzanne A. OT, PhD
Long before the federal legislation PL 94–142, The Education of the Handicapped Children’s Act of 1975,1 physical therapists had provided services to children with disabilities in schools.2,3 This federal law did however have a major effect by expanding the right to a free appropriate education to all children with disabilities. The purpose of the law and its later amendments, including the most recent Individuals with Disabilities Education Improvement Act of 2004 (IDEA), is “to ensure that all children with disabilities have available to them a free appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living.”4[118 STAT. 2651, SEC. 601(d)(1)(A)] “Improving educational results for children with disabilities is an essential element of our national policy of ensuring equality of opportunity, full participation, independent living, and economic self-sufficiency for individuals with disabilities.”4[118 STAT. 2649, SEC. 601(c)]
IDEA is intended to help children with disabilities to achieve high academic and functional standards—by promoting accountability for results, enhancing parental involvement, and using proven practices and materials.4 The provision of physical therapy as a related service is to assist the child to benefit from the special education program as outlined in the child’s Individualized Education Program (IEP). Local educational agencies (LEAs) are mandated to provide the related service of physical therapy to assist a child to benefit from special education and/or to access the general education curriculum. The appropriateness and extent of therapy must be related to the academic and functional needs of the student with disabilities and ultimately the student’s ability to have full participation in society, live independently, and have economic self-sufficiency.
The educational needs of students with disabilities are best served in the least restrictive environment by using a variety of instructional strategies, with emphasis on collaborative team models that facilitate the student’s learning.5 Physical therapy services must be provided when specified in a student’s IEP or service plan as defined by IDEA 2004, or in an educational plan as defined by the Rehabilitation Act of 1973, Section 504, and its amendments.5
We believe that physical therapist professional development in school-based practice is fourfold and similar to professional development for physical therapists in early intervention6,7 First, therapists must develop competencies in the broad body of knowledge and skills related to pediatric physical therapy. Second, they must have knowledge of the professional, federal, state, and local rules, regulations and guidelines for practice in schools. Third, therapists must acquire the global knowledge and skills required to work in a school setting. Fourth, they must be mentored during on-the-job training and maintain a dedication to life-long learning to promote state-of-the-art, evidence-based practice. Personnel preparation in school-based services should be discipline specific as well as interdisciplinary to reflect collaboration required in schools.8,9
In 2003, the board of directors of The Association for Persons with Severe Handicaps (TASH), an international advocacy association serving people with disabilities approved a resolution for the Preparation of Related Services Personnel to Work in Educational Settings.10 They believe that personnel preparation must focus on evidence-based practices and promote reflective service providers and life-long learners. Their positions are in line with the purpose of this project to update competencies for therapists working in schools to guide professional development and promote best practice.
Professional development based on competencies is considered a sound approach to the organization, content, and process of professional development.11–13 This methodology of learning is characterized as individualized, flexible, self-directed, and measurable. Competency-based education recognizes the current knowledge and skills of the learner and promotes integration of new abilities with previous experience.7 Competencies can be used to define performance outcomes necessary to practice in schools. The American Physical Therapy Association (APTA), Section on Pediatrics competencies for physical therapists in early intervention14 have served as a standard for therapists, educators, administrators, and consumers to monitor the quality of service delivery. However, competencies for physical therapists working in school settings have not been published.
In 1985, the faculty of the Pediatric Physical Therapy Program at Hahnemann University in Philadelphia, Pa, received a grant from the US Department of Education, Office of Special Education to support the postprofessional training of physical therapists in school-based practice. Part of the grant activity included development of competencies for school-based practice.15 Those competencies were adopted by the APTA Section on Pediatrics in 1990 but were never published. This project was undertaken to update the competencies for physical therapists working in schools that reflect current practice standards, current legislation, and terminology. The development of the competencies was supported by the award of a grant from US Department of Education, Office of Special Education in 1998 to the faculty of the Pediatric Physical Therapy Program at MCP Hahnemann University. This grant also funded the development of a competency-based, interdisciplinary Specialty Certificate Program in School-Based Intervention.
A four-step process was used to define the competencies. First, the original School-Based Competencies document15 was reexamined with respect to current regulations, terminology, and evidence-based practice. Practicing school-based therapists from the Philadelphia Tri-State region (Pennsylvania, New Jersey, and Delaware) reviewed the existing competencies and provided recommendations for the content and terminology based on their current work experience. Second, multiple literature searches were conducted to identify other published standards of practice, professional guidelines, or competency lists for professionals across a variety of related disciplines including occupational therapy, speech-language pathology, and special education. The major documents reviewed included the APTA Pediatric Specialty Council’s Pediatric Physical Therapy Advanced Clinical Competencies16; Children’s Seashore House Goals and Objectives for Interdisciplinary Leadership Education in Neurodevelopmental and Related Disabilities17; draft competencies for pediatric physical therapists from the Maternal and Child Health Bureau’s University Affiliated Programs for Persons with Developmental Disabilities18; Recommended Guidelines for School-Based Physical Therapy in New Jersey19; University of Kansas’ Master’s Level Curriculum for Preparing Therapists to Serve as Consultants in the Public School Setting20; the American Occupational Therapy Association’s Training: Occupational Therapy Educational Management in School21; and Guidelines for Occupational and Physical Therapy in California Public Schools.22 A master matrix of competencies was developed from those reviewed.
Third, a series of four focus groups were convened with 44 school-based therapists from Pennsylvania, New York, New Jersey, and Virginia. Seventeen of these therapists had more than 10 years experience as a school-based therapist. The focus group key questions, structured to yield competencies, included the following: What are your roles and responsibilities as a school therapist? What knowledge and skills enable you to be effective as a therapist? and If you were mentoring a new therapist what skills and knowledge would you say are necessary for working in a school setting? The focus groups’ discussions were audio taped and transcribed. Content analysis procedures were used to examine the focus group responses. The complete methodology used with the focus groups has been described elsewhere.23
Fourth, these three data sources were triangulated and collapsed into one final list of competencies that reflected legislation, professional literature and the perspectives of therapists This list of competencies was then reviewed by 15 interdisciplinary pediatric professionals on the Specialty Certificate Program’s regional program steering committee, program faculty, and advisory board. Additionally, the competencies were reviewed by at least 10 members of the Practice Committee of the APTA Section on Pediatrics, representing experts in the field in the area of school-based physical therapy from the four major geographic regions of the United States. Subsequently, this list of competencies was used by 26 therapists practicing in schools for further feedback and refinement.
Triangulation of the data sources resulted in the identification of nine major competency content areas. Competencies for each of the nine competency content areas are seen as being equally weighted as they relate to practice. In Table 1 is the list of all of the content area competencies supplemented by example behavioral indicators. A brief, overall description of each of the nine competency content areas follows.
Competency Area 1: Context of Therapy Practice in Education Settings
It is important for therapists to have knowledge of the structure, goals, and responsibilities of the public education system to meet the educational needs of the children they serve. Therapists’ awareness of educational standards, curricula, and general and special education teaching strategies enable them to design and implement effective supports and services.24 Therapists’ familiarity with community resources and school extracurricular programs is necessary to promote children’s full participation in age-appropriate social and physical activities. Knowledge of federal, state, and local rules and regulations that affect delivery of services to students with disabilities is critical. This knowledge is of utmost importance because the rules and regulations of legislation, such as IDEA,4 are essential to the day to day functions of therapists in schools.
Competency Area 2: Wellness and Prevention
Physical therapists should assume a role in prevention as emphasized in the Guide to Physical Therapist Practice.25 Prevention efforts can range from education on fitness activities and back-pack safety to prevention of childhood accidents such as burns or head injuries. Screening for neuromuscular, cardiopulmonary, and general developmental dysfunction has been identified as one of the major roles for physical therapists serving preschool children.26
Competency Area 3: Team Collaboration
As noted by TASH, collaboration with students, families, teachers, and other service providers is critical.10 These indirect services require considerable expertise, time, and energy and yet are essential to supporting a child’s educational outcomes.27 Therapists form partnerships among family members, service providers, and the community to provide coordinated care. Therapists function as consultants to school personnel and families to promote the inclusion of the student in the educational experience. Coordination of services across the home, school, medical, and community settings is often lacking and families value the therapist’s role in assisting with this process. Therapists also supervise personnel and professional students to ensure quality care.
Competency Area 4: Evaluation and Evaluation
IDEA states that evaluation is to be used “to determine whether a child is a child with a disability … and to determine the educational needs of such child” 4 [118 STAT. 2702 SEC. 614(a)(1)(C)(i)(I)] and evaluators “… shall use a variety of assessment tools and strategies to gather relevant functional, developmental, and academic information, including information provided by the parent”4[118 STAT. 2704 SEC. 614(b)(2)(A)]; shall “not use any single measure or assessment …; and [shall] use technically sound instruments that may assess the relative contribution of cognitive and behavioral factors, in addition to physical or developmental factors.”4[118 STAT. 2705 SEC. 614(b)(2)(B&C)]
The use of the terms evaluation and assessment are different than noted in the Guide to Physical Therapist Practice.25 The Guide notes that examination involves a gathering of history data, systems review, and tests and measures; whereas evaluation is the making of clinical judgments based on a synthesis of the examination findings.25(p. 42–45) Physical therapists working in schools must integrate their professional examination guidelines within the context of the evaluation and assessment process described by IDEA. Therapists provide evaluations and assessments as part of an interdisciplinary or transdisciplinary team.28–30 They are skilled in interviewing and observing the child in his or her natural environment during routine daily activities. As part of the team process, therapists synthesize findings related to motor development and functional abilities within the context of all areas of development and the participation of the child in school, home, and community. Physical therapists analyze critically the child’s abilities to determine if impairments in the neurological, musculoskeletal, cardiopulmonary, or integumentary system are related to functional or developmental issues and if they affect the child’s ability to receive an appropriate education that will prepare the child for further education, employment, and independent living. During the evaluation and subsequent planning and intervention, physical therapists specifically address needs related to the physical environment, mobility, balance and safety, endurance, self-care, and access to and ability to manipulate materials.
Competency Area 5: Planning
Physical therapists should be actively involved in the development of the IEP for each child they evaluate or are serving. In collaboration with the team, they help determine how therapy might contribute to meaningful student outcomes,31 and measurable annual academic and functional goals.4[118 STAT. 2708 SEC. 614(d)(1)(A)(I)(cc)&(II)] Objectives, although not required for every child under IDEA 2004, would also be determined if the child requires alternate assessments or if required by state or local educational agencies. Therapists assist in determining therapy service recommendations, interventions, and the frequency, intensity, and duration of services based on their knowledge of peer-reviewed research and evidence-based practice. They contribute to developing a means for ongoing coordination and collaboration regarding the IEP, transition planning, and interagency activities.
Competency Area 6: Intervention
Intervention in a school environment is in many ways more complex than intervention in other settings. The therapist must be able to adapt the child’s environments to facilitate student access to and participation in student activities.32 Therapists’ expertise in assistive technology and environmental modifications is an asset for the educational team.33 The therapist must use various types and methods of service provision in intervention including direct, individual, group, integrated, consultative, monitoring, and collaborative approaches.28,29,34 There is no single best intervention delivery method; however, therapists should attempt to imbed therapy interventions into the context of student activities and routines and as appropriate use activity-based and play-based approaches that optimize learning opportunities within natural contexts.10,32,35 Therapists need to be familiar with instructional plans in order to recommend appropriate motor learning strategies. Therapists’ background as health care professionals and knowledge of medical and health issues enables them to address the body systems that promote children’s physical functioning. Competent therapists are reflective, critically evaluate their intervention approaches,36 and use evidence-based interventions.4
Competency Area 7: Documentation
Documentation of services is required by federal, state, community, payer, and professional regulations. Documentation serves as an excellent way to communicate with families, teachers, and other service providers and to record systematically progress toward achievement of the IEP goals and outcomes. Documentation serves as a mechanism to collaboratively monitor and modify a student’s IEP. Therapists require skills in communication, writing, and legal issues to become competent in documentation. Documentation allows the therapist to provide evidence of accountability and effectiveness of their services. Guidelines for Physical Therapy Documentation are provided by the APTA in the Guide to Physical Therapist Practice.25
Competency Area 8: Administration
School-based physical therapy is unlike most other environments where therapists work. Not only is service provision directed by federal, state, and local rules and regulations, but the school milieu has its own conventions. Therapists need to take an active role in the administration of therapy services to promote quality service delivery and educate teachers, administrators, and other service providers regarding the contributions physical therapists can make to meet the academic and functional needs of children with disabilities in school.
Administrative issues can overwhelm therapists and can become so time consuming that service delivery might suffer. Policies and procedures for work load management, documentation, team communications, professional development, supervision, reimbursement, safety precautions, and continuous quality improvement plans can provide a solid foundation so that therapists can maintain focus on the students. Therapists should be prepared to serve as a leader or manager as required in their setting.
Competency Area 9: Research
IDEA 2004 requires that special education and related services be “based on peer-reviewed research to the extent practicable.”4[118 STAT. 2708, SEC. 614(d)(1)(A)(IV)] This new requirement demands that therapists should be able to search and critically review the literature, and apply that knowledge of the peer-reviewed research to the selection of examination and evaluation procedures, determination of prognosis, selection of intervention strategies, and outcomes related to pediatric physical therapy. They should have knowledge of service delivery systems, child development, medical care, and educational practices. They should also participate in program evaluation and clinical research activities with appropriate supervision. Therapists require access to resources and reference materials so they remain current in their knowledge and are able to investigate topics related to their changing caseloads. Therapists can contribute to our professional body of knowledge by disseminating case reports and clinical research studies.
Synthesis of existing documents, focus group methodology, and a peer review process provided valuable information for updating and developing the current competencies for physical therapists working in schools. This triangulation of data sources ensures that the competency list is comprehensive and useful for professional practice.
The primary differences between the original 1987 competencies and the revised 2007 competencies include greater focus on transition and preparation for long-term outcomes; addition of the therapist’s role in advocacy, wellness, and prevention; and expansion of the intervention area to comprise adapting environments, methods of service delivery, and embedding intervention into student’s routines. These additions reflect a substantial change in the role of school-based therapists and how services are provided. The greater focus on transition highlights the important role that therapists play in preparing students for higher education, employment, and independent living.37,38 The addition of the therapist’s role in advocacy, wellness, and prevention exemplifies how the therapist can be a consultant and resource to the school system to promote the well-being of all children. The expansion of the intervention area to include adapting environments recognizes the value of accessibility and assistive technology to enable students with disabilities to fully participate in their educational program. Providing interventions within the context of the student’s activities and routines reflects our current knowledge of motor learning and embraces the importance of inclusion of children with disabilities in their school and community.
The competencies conform to the content areas specified for personnel preparation in school-based practice9,11 as well as the specific knowledge and skills physical therapists must demonstrate.9,10,25,26 These competencies go beyond those outlined for entry-level physical therapists in the Normative Model for Physical Therapist Professional Education.39 They conform to the Guide to Physical Therapist Practice25 and the International Classification of Functioning, Disability and Health language.40
The competencies presented in this paper can serve an important function for therapists, administrators, and educators by providing an overview of the knowledge and skills that therapists need to acquire to provide quality care for children with disabilities in schools. Professional development is critical to attain and maintain competencies in school-based intervention and pediatric physical therapy. Therapists need to utilize a variety of opportunities and resources available to enhance professional knowledge, skills, and attitudes. Physical therapists must be committed to life-long learning to remain competent practitioners. Therapists can attend and present at study groups, conferences, workshops, and continuing education courses and contribute to their profession and their schools by serving on committees and task forces. Professional advancement could include publishing on current issues, enrollment in postprofessional certificate or degree programs, and obtaining pediatric clinical specialization.
The TASH resolution for the Preparation of Related Service Personnel for Work in Educational Settings10 includes recommended guiding principles for the preprofessional and postprofessional preparation of service personnel that would facilitate research-supported practices and innovations and promote the development of effective service providers who are reflective life-long learners. Their recommended principles along with the specific competencies for physical therapists working in schools presented here should be considered by those who develop and provide preprofessional and postprofessional training and education.
The purpose of this project was to reexamine the 1987 competencies for physical therapists working in schools and to update their content to reflect present practice, legislation, and terminology. A process of triangulating the results of multiple literature reviews, focus groups, and peer review resulted in the identification of nine content areas with specific competencies in which physical therapists should have expertise if they work in school settings.
Physical therapists who work in schools require specific skills and knowledge to effectively serve children with a wide variety of disabilities encountered in school environments. The competencies can serve as a guide for professional education programs, are useful to guide professional development, and assist education administrators in knowing the areas of professional competency expected of physical therapists working in schools.
The authors acknowledge the considerable assistance of Pip Campbell, PhD, OTR, in all aspects of this project.
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