The passage of PL-94-142 (The Education for All Handicapped Children Act) in 1975 mandated that children with disabilities, aged 6 to 21 years, were guaranteed a “free and appropriate education” in the “least restrictive environment.”1–3 The definition of “least restrictive environment” specifies that the first educational placement considered for children with disabilities is with their peers of the same age who are nondisabled, in their neighborhood schools, with the supplementary supports and services required to benefit from this environment.4,5 Since 1975, this law has been amended, renamed in 1990 as the Individuals with Disabilities Education Act (IDEA) and expanded to include greater numbers of children and to emphasize transition into independent living and the workforce.2
Related services included in this mandate, such as physical and occupational therapy, are necessary for the law's success. Over the last 30 years, changing educational philosophy as well as motor learning research has led to the recommendation of a more functional, inclusive, and collaborative related service delivery model. The APTA defines “best practice” as services that “assist a child with a disability to benefit from special education; therefore physical therapists primarily should work in the classroom or other places in the school/community that support the student's special education program.”3 Motor learning theories encourage a focus on functional activities that a child would perform on a daily basis, when the activity would naturally occur.6–8 Skills practiced in isolation are less likely to be retained, are less motivating for the student,9 and provide no opportunities for the student to learn from their peers,8 or for related service personnel to educate classroom teachers and other staff.10,11 Research also indicates consistent, daily practice of functional skills, whether encouraged directly by the therapist or by other school staff, can result in improved skill development and/or retention of learned skills.9–12
Previous research indicates the use of a combination of related service delivery models including direct/isolated, direct/integrated, indirect, and consultative.8,12 See Table 1. Direct/isolated services are provided one-on-one, separately from a child's peers. Research indicates this approach has limited educational relevance, having not been shown to affect overall skill development, or transfer back to the classroom,9 and can also be disruptive to a child's educational process.5,9,13Direct/integrated services are one-on-one, but provided in the classroom or other natural environment. Research supports this model because of the direct link to daily activities.3,8,14 Teachers are supportive of this intervention style as long as it is not disruptive to their classroom routines.8,9,13,14Indirect services focus on teacher/aide training with the therapist remaining responsible for outcomes.9,11,13 The therapist provides “skillful supervision,”9 must possess good teaching skills,13 and is responsible for deciding when the individual has retained all necessary information.9 Indirect services require “considerable expertise and take time, but are invaluable to ensuring coordination of services.”1Consultative services entail collaboration with teachers or other staff.8,11,12 Successful and beneficial consultation requires that the therapist and teacher both agree there is a need9,13 and view each other as “equals”13 in the process.
In several previous studies, therapists indicated that the “ideal” service delivery method was not always the method they used or were encouraged to use on a daily basis.8,12 Kaminker et al12 found that only 25% of therapists felt the direct/isolated service delivery model was the most effective, but 40% continued to use it as their primary method of intervention. Effgen and Klepper6 also found that therapists may adhere to the service delivery model that they prefer versus the model(s) most applicable to the needs of the child. “Best practice” guidelines have supported the use of a combination of all approaches with the greatest emphasis on direct/integrated services guided by functional assessments. Researchers also found that therapists express frustration with eligibility, intensity, and frequency decisions,12,13,15 but little guidance was found within the literature regarding which assessments were in use or should be used, especially for the preschool, middle-school, and high-school populations.
Overall, school-based related services should help support educational goals and facilitate access to the least restrictive educational environment.3 Giangreco aptly stated, “Students do not go to school to receive specialized services; rather, they are provided with individually determined specialized services so that they can participate in schooling.”4(p345)
The purpose of this study was to compare current patterns of practice with “best practice” recommendations noted in both the literature and in recommendations by professional organizations and state published guidelines. Two hypotheses related to years of clinician experience and size of the school district were developed to expand on previous research efforts related to these 2 topics.16,17 Prior research has been focused on therapist education programs and the preparedness of entry-level clinicians, but not on comparisons of practice patterns of these clinicians with therapists who are veterans in school-based practice. Researchers have also investigated barriers to optimal service provision unique to rural areas16 but have not compared practice patterns in these areas with more urban/suburban districts. The authors hypothesized that recent graduates would use more inclusive/integrated practice patterns and clinicians in rural districts (ie, small population density) would demonstrate less inclusive/integrated service provision.
The authors developed survey content based on the research questions and a literature review. The initial draft of the survey was completed by 10 pediatric physical therapists with school-based experience, with revisions made after feedback. Reviewers were asked to identify misleading or confusing questions and provide suggestions of any additional topics they felt should be addressed. The final draft of the survey contained 36 questions of multiple choice (n = 16), open-ended (n = 2), and Likert scale format (n = 18). An e-mail link to the survey was included in the monthly newsletter sent to members of the APTA's Section on Pediatrics (n = 4800); in a separate e-mail to the School-Based Special Interest Group (n = 406); and also to personal contacts of the researchers who are school-based clinicians (n = 9). Potential participants were provided with 2 e-mail reminders and a period of 2 months to complete the survey. Data were collected from August-October 2011. The low number of respondents limited data analysis to descriptive methods only.
Of 245 respondents, 227 completed more than 50% of the survey, resulting in an overall return percentage of 4.7% of the members of the association. Data from those completing less than 50% of the survey were omitted. For the context of data reporting, “n” represents the number of respondents to a specific question.
The majority of respondents reported greater than 15 years of practice as a physical therapist or physical therapist assistant (77%; n = 175/226) and greater than 15 years of experience as a school-based therapist (47%; n = 106/214). See Figure 1.
Of the respondents (n = 225), 33% (n = 79) had a bachelor's degree, 32% (n = 75) a masters degree, and 29% (n = 68) a doctorate of physical therapy. In addition, 6% (n = 13) of respondents reported other degrees such as MD, DScPT, EdD, MA, PhD, and DPT in progress. Of 223 respondents, the majority (74%; n = 173) indicated they did not hold any specialty certifications.
A total of 44 states were represented in the sample (n = 225). See Table 2. North Carolina (9%, n = 20), Virginia (8%, n = 18), and New York (6%, n = 14) were the states with highest participation. Of 225 respondents, the majority (47%, n = 109) indicated they worked in a “large suburban (>25 000 residents)” school district. See Figure 2.
Of 225 respondents, 88% (n = 198) reported they were members of the APTA.
Years of Practice and Impact on Inclusive/Integrated Practice
Of 193 respondents, 85% indicated 5 to more than 30 years of experience whereas only 14% (n = 33) indicated 1 to 5 years and 0% less than 1 year.
Size of District and Effect on Inclusive/Integrated Practice
Of 179 respondents, 79% indicated practice within urban, large suburban, and small suburban districts, whereas only 21% (n = 48) indicated rural district practice. Seventy-two percent of 48 rural district respondents felt their services were inclusive/integrated.
Provision of related services
Of the 5 most common service provision settings indicated in the survey, 88% of respondents chose playground, 88% selected classroom, 79% selected physical education class, 69% chose private therapy room/area within school, and 51% chose cafeteria. The settings of “Hallway” and “Gym/Stage” reported in the “Other” category were kept separate from “Private Therapy Area/Room” because of difficulty determining the type of services provided in those settings (Table 3). Fifty percent of 225 respondents indicated that they spent 10% to 25% of their time on training/education of teachers and instructional assistants. See Figure 3. Overall, 80% of 224 respondents felt their service provision would be defined as inclusive/integrated, and the majority of respondents felt that integrated services were beneficial. See Table 4.
Knowledge of Law and State Guidelines
The majority of respondents indicated familiarity with the sections of IDEA regarding provision of related services, as well as comfort with explaining the role of educationally relevant physical therapy services to administrators, educators, and parents. Whereas the majority felt that special education teachers and administrators were familiar with IDEA, they did not feel that general education teachers and administrators had the same knowledge base and understanding. See Table 4.
Use of Standardized Tests/Assessments
The School Function Assessment (SFA) was the only school-specific, functional standardized test noted in the research18 for use by physical therapists and is only validated for students in kindergarten through sixth grade. Some districts have developed their own evaluation criteria, but no validation studies were found in the literature. Within the survey, respondents rated their use of 9 common pediatric standardized tests with preschool, elementary, and middle-/high-school students using a 7-point Likert scale. Respondents were also allowed to add other tests and measures not suggested. The raw data reported is based on the scores from the categories of “frequently,” “very frequently,” and “always.”
The Peabody Developmental Motor Scales, “Other,” and the SFA were the 3 most commonly used categories with preschool students. Thirty-five additional tests were noted in the “Other” category, with the Gross Motor Function Measure (GMFM) and Test of Gross Motor Development-2 receiving the most frequent mention.
The SFA, the Bruininks-Oseretsky Test of Motor Proficiency, and the “Other category” were the 3 most common categories of tests noted for assessing elementary school students. In the “Other” category, there were 32 additional tests noted with the GMFM and the Test of Gross Motor Development-2 again receiving the most frequent mention.
The SFA, the Bruininks-Oseretsky Test of Motor Proficiency, and “Other” were the most frequently noted categories of tests used with middle- and high-school-age students. In the “Other” category, 26 additional tests were noted with the GMFM and nonstandardized, district or therapist developed observation checklist receiving the most frequent mention.
Perceived Barriers to Inclusive/Integrated Services
Ninety-six percent of therapists (n = 218) indicated that barriers to progress continued. The most frequent barriers (Table 5) cited by respondents are discussed as follows.
Thirty-seven percent of respondents indicated that teachers were not supportive of integrated services. Multiple reasons were cited, including classroom distraction, teacher preference for “pull out” services because they don't feel the student is “getting real therapy” if that does not occur, lack of acceptance of or lack of time to implement suggested modifications and the expectation of all interventions being “direct, hands on support.” Although therapists indicated lack of teacher support being a primary barrier to improving inclusive/integrated services, they did indicate in a separate portion of the survey that they felt teachers are supportive of suggestions and adaptations, and provide follow through. (Table 4).
Therapist Workload/Difficulty Scheduling
Thirty-two percent of respondents reported that personal workload and scheduling difficulties were limiting their ability to provide integrated services. Large caseload, travel between many schools, limited recess and physical education offerings, and busy and inflexible school schedules in middle and high school affected service provision at the “optimal” time.
Sixteen percent of respondents reported that parental expectations of “pull out” services were limiting to inclusive/integrated services. Therapists indicated a lack of parental support for the inclusive/integrated model or limited understanding of the role of related services. Despite expressing concern over parental support, the majority of respondents indicated in a separate portion of the survey that parents are knowledgeable regarding the role of related services within the Individualized Education Plan (IEP) team and as suggested by IDEA (Table 4).
Therapist-Perceived Classroom Distraction
Fourteen percent of respondents indicated that either the classroom is too distracting for their student to attend to activities or report inclusive/integrated related services are too distracting to the class. One therapist stated, “the activities I perform with my students are typically very disruptive to the classroom environment.” However, several therapists indicated they often began skill instruction in isolation with gradual integration of the skill into the classroom and other more distracting environments.
Therapists Do Not Feel Inclusive/Integrated Service Is Appropriate or Not Always Appropriate
Thirteen percent of respondents had concerns about inclusive/integrated service. Many indicated that “gross motor training” and “strength, balance, and endurance activities” cannot be integrated into a regular classroom and they felt pressure from administrators to work on “strengthening.” Several reported that student needs cannot be met in a general education classroom, inclusive/integrated service was “not practical,” was “out of the question,” and that services were “less intense” or “less effective” when integrated. Others indicated that disruptive student behavior or inadequate cognition for curriculum limited their ability to provide inclusive/integrated services for some students.
Lack of Administrative Support/IEP Team Support
Eleven percent of respondents reported that administrators and IEP teams limited inclusive/integrated service because of pressure to provide direct services. Respondents also indicated IEP plans were not inclusively written.
Support Staff Concerns
Ten percent of respondents indicated concerns regarding (a) the lack of support staff, (b) underqualified support staff, and (c) limited cooperation from support staff in regard to inclusive/integrated services. Despite these concerns, in a separate portion of the survey, the majority of respondents felt that school personnel are supportive of suggestions and routinely follow through with recommendations (Table 4).
Years of Practice and Effect on Inclusive/Integrated Practice
The authors hypothesized that more recent graduates would practice more inclusively. Because of a low response rate from recent graduates, a relationship could not be determined. Less-experienced clinicians may not have felt qualified to participate in the survey because of lack of experience or they may be overwhelmed adapting to their current workload. More research is needed to determine how the practice patterns of more recent graduates compare with more experienced clinicians.
Rural District Effect on Inclusive/Integrated Practice
The authors hypothesized that clinicians practicing in more rural school districts would practice less inclusively. Possibly clinicians were confused regarding the definition of “inclusive/integrated services.” For example, a “rural district” respondent who indicated practicing inclusively also felt “services in the classroom are out of the question due to the activities we provide.” The small number of responses from clinicians in more rural areas and the noted confusion with defining inclusive/integrated services limited analysis of the research question. The low response from rural therapists could be related to workload or lack of participation in the Pediatric Section of the APTA, which would have limited access to the survey. More research is needed to determine if rural district location affects inclusive/integrated service provision.
Defining Inclusive/Integrated Service Provision
The high percentage of respondents that indicated use of “private therapy room” and/or “gym,” “stage,” or “empty classroom” suggests that direct/isolated services may still be occurring more than is preferred or beneficial. Many respondents also had conflicting answers when open-ended responses to “barriers to inclusive/integrated practice” were compared to how they perceived their personal practice. More research is required to determine how therapists are defining inclusive/integrated practice as well as what percentage of time therapists are using private therapy areas and for what specific activities.
Training and Education
The majority of respondents indicated they only spend 10% to 25% of their time providing training and education to staff/team members. No specific reference to the “ideal” amount of personnel training was found, but motor learning principles as well as “best practice” guidelines support a strong emphasis. Clinicians are present during only a small portion of a student's cumulative time at school and the potential is for even greater functional improvement if all personnel are able to improve a student's access to their educational environment and collaborate to reach functional goals.19 Teacher and staff acceptance of clinician recommendations is closely related to their understanding of the role of school-based therapy service, therefore education of staff/teachers not only addresses student goals but also provides them information regarding the guidelines governing our practice. Greater emphasis on training benefits the student as well as the entire team and could improve the knowledge base and experience of general education teachers regarding inclusive/integrated services. The authors feel that multiple factors could affect the amount of time clinicians spend on training, including (a) therapist workload; (b) scheduling difficulties, especially with general education teachers; (c) therapist perception that teachers and support staff are unwilling to follow through; (d) therapist willingness to train others; (e) therapist understanding of the importance of staff training; and (f) staff and teacher willingness to learn activities they deem the physical therapist's responsibility or that they don't feel they have time to perform or supervise. More research is needed to determine ideal parameters for training and to problem solve strategies to increase the prevalence of training.
The majority of respondents felt that special education teachers are knowledgeable regarding IDEA guidelines, but they did not feel that general education teachers were also prepared. The most commonly indicated barrier to inclusive/integrated practice related to teacher attitudes and acceptance. Respondents did not make a distinction between special education and general education teachers, but the overall conflicting results indicate that more research is needed to determine how teacher understanding translates to actual provision of services.
The survey data indicated significant variability in the assessment tools currently used. The IEP team must determine if a particular related service is “vital to the students' participation in their educational program,”5 whether the support service relates to an IEP goal,14 whether team member skills overlap,14 or if classroom personnel truly need support.5,13 It is essential that personnel refrain from basing their decisions to provide related services on motor skill development or mere presence of disability.7 Placing primary emphasis on developmental skills assessment, either by therapist choice or from pressure by the parents or IEP team members hinders the development of functional goals and makes integration of services in classroom settings more difficult. Many students within the educational system may not have “age appropriate” gross motor skills and also may not need physical therapy support. The authors feel that development of a functionally based assessment, specific to educational settings and addressing age groups from preschool through high school would be a beneficial focus of additional research. This assessment would improve continuity of services between districts; assist clinicians and IEP teams with decisions related to eligibility, frequency, and goal writing; and provide valuable education to school staff and parents regarding the intended focus of school-based physical therapy services.
Unanswered Survey Questions
The 3 questions most commonly not answered by respondents were (a) selection of assessments used with middle-/high-school students (n = ∼25); (b) years of school-based practice (n = 13); and (c) role in equipment selection and purchase decision (n = 11). Although we cannot know the exact reason(s) for the lack of responses, the authors feel that lack of applicability to personal practice, respondent's misreading of questions, and the position of question within the survey may have played a role.
Limitations of Study
The study had multiple limitations with the most significant being the low response rate of 4.7%, compared with the 40% average response rate for e-mail surveys.20 Other limitations included (a) length and broad scope of survey topics; (b) majority of survey participants were APTA members, who provided a bias toward clinicians better versed on current research and who have more access to special interest groups and continuing education courses; (c) no distinction between physical therapists and physical therapist assistants; and (d) misleading wording or misreading of questions (as indicated by e-mails received during the survey completion period and discovered during analysis of survey data). Because of the possibility of confusion invalidating data, the authors chose to omit data from 3 questions in the analysis. The data concerning standardized tests were the exception, as the authors felt the raw data accurately represented the wide variability in assessments that are currently being used in schools.
Further research would be beneficial in the following areas: teacher/aide training, assessment tool development, exploration of clinicians' definition of “inclusive/integrated practice,” practice patterns compared to years of experience, practice patterns in rural versus urban/suburban districts, and prevalence of private therapy room use.
Despite the low response rate, the survey did provide valuable information regarding current practice patterns. Although many therapists reported their practice to be inclusive/integrated, the data indicated inconsistencies in therapist definition of “inclusive/integrated services.” A high percentage of “private therapy room” use, limited time spent training teachers and support staff, and variability in assessment tools was also noted. Respondents indicated the most prevalent barriers to progress with inclusive/integrated service were teacher acceptance and therapist workload. This project provides further information regarding patterns of “best practice,” resources for clinicians interested in modifying their current practice patterns, and information for clinicians and educators regarding the challenges faced when providing school-based physical therapy services.
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