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Opening Doors

Rehab services help integrate children with special needs into mainstream school settings

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When a child with special needs goes to school, who thinks about whether he is able to ride the bus, climb the stairs, communicate with his peers, and write his name? These challenges are best addressed by the physical and occupational therapists and speech language pathologists who work in a school setting.

By definition, children with disabilities require special education and related services that can include transportation services as well as OT, PT and SLP. The disabilities range from visual and hearing impairments to autism spectrum disorder, Down syndrome and traumatic brain injury.

Special education services may be necessary if a student has a disability that adversely affects his educational performance. In 1975, Congress passed Public Law 94-142 (Education of All Handicapped Children Act), now codified as Individuals with Disabilities Education Act (IDEA).

Under this law, school districts are required to provide a "free appropriate public education" to each qualified student with a disability, regardless of the nature or severity of the disability.

IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities.

"The basis of physical therapy in this setting is to give children access to education. The students are provided with support that allows them to participate fully in the home, school and community with their peers," explained Julie Almeida, PT, president and chief executive of Bristol County Rehabilitation Services Inc. of Middletown, RI.

The Newport County Regional Special Education Program was formed to provide the full continuum of special education services for children with disabilities in the towns of Middletown, Portsmouth, Little Compton and Tiverton, RI. Under contract with the program, Bristol County Rehab specializes in the delivery of physical and occupational therapy services in the public school setting.

Working with the speech language pathologists employed by Newport County Regional Special Education Program and various other team members, the PTs and OTs endeavor to keep children with physical and mental impairments in the public schools.

Leveling the Playing Field

"We support regular education," Almeida shared. "Students with disabilities learn from their peers, so if we can keep them in their home schools and communities, then we do. That's where rehab comes in."

Student evaluations are performed when requested by the parents, school staff, outside agencies and/or other medical professionals. These student evaluations help the rehab team make decisions regarding the continuation of services, the beginning of services or the discharge of services.

"We treat students ranging from age 3 to 21 so there is a great variety throughout our day," explained Shanan Brissette, PT, DPT, Bristol County Rehab.

"We incorporate our services into the educational setting as much as we can whether that is a movement group in the preschool class or supporting a student within a PE setting."

In a typical day, the PTs and OTs travel from school to school and classroom to classroom to support the students' physical mobility issues

Team Work

During the 2011-2012 school year, the OTs provided direct service to 335 students and the PTs provided direct service to 121 students.

"We use a team approach and the therapists are part of the team," explained Leslie Brow, assistant director, Newport County Regional Special Education Program. "We look at the student as a whole, even outside of the classroom. The therapists assist students walking on stairs, getting on and off the bus and accessing playground equipment."

The therapists hold one-on-one therapy sessions with the children who have more physical needs. "These sessions look like typical medical rehab sessions, but because we're working with kids, we have to make the sessions fun and inventive," Dr. Brissette said.

"Every child is unique so we need to consider his background and figure out what he enjoys," stated Megan Silvia, MS, OTR/L, Bristol County Rehab. "If there is one student who loves lions and will do anything lion-related, then we focus on that to motivate him. Other students respond if we bring sports into an activity. A lot of preparation and planning goes into our sessions."

According to Almeida, rehab services cannot stand alone. "We have to collaborate with other departments and educational experts," she said. "The kids require other specialized support whether it's special education, speech therapy or adaptive physical education."

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(Back row l to r): Bristol County Rehab therapists Megan Silvia, MS, OTR/L, Julie Almeida, PT, and Shanan Brissette, PT, DPT, gather in the preschool classroom at Fort Barton School in Tiverton, RI.

"I provide functional communication therapy to children with a wide variety of needs," said Lindsay Z. Jacobs, MS, CCC-SLP, Newport County Regional Special Education Program. "My goal is for them to be able to communicate their wants, needs, likes and desires to different communication partners throughout the day."

Jacobs runs individual and group therapy sessions and co-treats with physical and occupational therapy in the classroom. She runs social skills groups with the school psychologist.

"We have a number of students who have great knowledge of language and vocabulary; however, they have a difficult time expressing themselves, formulating their thoughts and articulating their message so that it's intelligible to all listeners," Jacobs observed. "We use many tools to help them communicate successfully."

In order for some children to access the curriculum, the PTs may need to obtain gait trainers, walkers and standers. "We collaborate with the classroom teacher and consider the child's classroom schedule," Almeida shared. "Is he going to PE, circle time or writing time? We follow the child's classroom schedule and embed ourselves in that."

The therapists use adaptive equipment so the students can remain with their peers, whether they are in a mainstream or a self-contained classroom. The PTs provide adaptive chairs and bean bags to support the students' posture during classroom activities.

The therapists generally work with a particular student on multiple activities at once. While Dr. Brissette may be helping a student onto a bean bag, she is also trying to keep him focused on the activity in the classroom.

Silvia mainly focuses on fine motor, visual motor and visual perceptual skills with the students. "One student worked on a word search to improve his visual perceptual skills," she shared. "Then he completed a craft project that involved tracing a shape onto a piece of paper and then cutting the shape out. The cutting is a bilateral skills task and the tracing is a visual motor task."

According to Silvia, the students may think they are simply doing a craft project but the activity addresses multiple skills. "We do our best to make the activities fun and enjoyable," she said.

Silvia told ADVANCE that the therapists work very closely together. "Having a multidisciplinary approach is beneficial to the students," she shared. "We keep the lines of communication open to discuss which approaches may be working with one student but are not working with another."

When a child uses an augmented communication device, the goal is for her to become a more sophisticated user so she may access a much larger vocabulary and participate in academic tasks. Proper use of these communication devices often relies on an interdisciplinary approach.

"OT, SLP and PT work together with the augmented communication devices because access is an important consideration and one of the first things we look at," Jacobs said. "How is the student going to access the device? Is it going to be through the use of her fingers touching something? If it is, then we need to make sure she has the fine motor skills to touch the button. The OT addresses this before I teach her how to use the device."

According to Jacobs, some students use eye gaze to control the devices. "For students who access the device switches with head control, PT determines the optimal position for the student," she explained.

For children with greater and more specific needs, the therapists focus on lower level and simplified motor activities. "We make the tasks more practical and try to work on tasks they will be doing when they are older," Silvia explained. "The task may be to put coins in a piggy bank because they may need that skill when they're older to put coins in a vending machine. The tasks may not seem complex, but we are working on the foundation skills."

Identifying Needs

In addition to the time spent with the students, Bristol County Rehab staff members often consult with the classroom staff, the principals and office staff, Newport County Regional Special Education staff, vendors and most importantly, parents.

The staff meets with parents and school representatives at least once a year at the annual individualized education plan (IEP) meeting.

"We look at the child's school functioning to determine if their ability to access the curriculum is being affected," relayed Brow. "We have to monitor RI eligibility criteria so we hold meetings with the IEP team, the clinician and the local educational advocate to see if a student is eligible."

"The IEP drives what we do," Almeida explained. "We may set an annual goal for a particular child to use a stander for two hours a day."

To achieve that goal, the PTs will collaborate with the teacher, OT and SLP to determine the child's tolerance and endurance level. The teacher assistants then track the time the student remains in the stander.

The use of adaptive equipment requires classroom staff training. "We need to train the teachers who work in that classroom about how to use a stander throughout the day and how to lift the children, when necessary," Dr. Brissette said. "We train the staff to carry over the goals we have identified for the students."

The staff consults with the teachers on how to provide accommodations for the student within the classroom, according to Brow. "In order to meet student needs, we frequently hold inservices for teachers," she said. "Last week, for example, a child returned from surgery so we did an inservice with the nurse, teaching aide and teacher. The rehab team assessed the desk height, doorway width, table height and accessibility of the bathroom."

In the school setting, it may take a full school year or even several years to see a child progress on a certain goal. "We enjoy seeing the kids grow and progress over a period of time," Silvia told ADVANCE. "It's very rewarding when they hit a milestone." 

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com


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