Academic journal article Exceptional Children

A National Perspective of Competencies for Teachers of Individuals with Physical and Health Disabilities

Academic journal article Exceptional Children

A National Perspective of Competencies for Teachers of Individuals with Physical and Health Disabilities

Article excerpt

Teachers instructing students with physical and health disabilities need specialized knowledge and skills to provide these students an appropriate education and a safe educational environment (The Council for Exceptional Children [CEC], 1996). This requires both knowledge and skills in the area of educational strategies and modifications and in the area of health maintenance. With the changing certification (or licensure) criteria across the nation and the decline of personnel preparation programs specific to physical and health disabilities, the extent to which teachers are prepared to appropriately instruct this increasing population of students is questionable. This study examined teachers' perceptions of their knowledge and skills in physical and health disabilities, as well as the special education directors' perceptions of the teachers' skills. Support from state Departments of Education was also examined as well as the extent to which physical and health disabilities competencies are included in university teacher education programs.

The area of physical and health disabilities includes three populations of students teachers typically encounter in the schools. These populations consist of students with (a) orthopedic impairments, (b) other health impairments (including complex health care needs and technology dependent students), and (c) multiple disabilities (in which a physical or health impairment is present). (See Table 1.) Orthopedic impairment refers to

TABLE 1
Defining Physical and Health Impairments

               Physical and Health Impairments

Orthopedic Impairments            Other Health Impairments
Orthopedic impairments caused     Chronic or acute health
  by congenital anomalies           problems
Orthopedic impairments caused     Complex health care needs
  by disease
Orthopedic impairments caused     Technology dependent
  by other causes

               Physical and Health Impairments

Orthopedic Impairments            Multiple Disabilities
Orthopedic impairments caused     Concomitant impairments, with
  by congenital anomalies           one impairment being an
                                    orthopedic or health impairment
Orthopedic impairments caused
  by disease
Orthopedic impairments caused
  by other causes
   a severe orthopedic impairment that adversely affects a child's educational
   performance. The term includes impairments caused by congenital anomalies
   (e.g., club foot, absence of some member, etc.), impairments caused by
   disease (e.g., poliomyelitis, bone tuberculosis, etc.), and impairments
   from other causes (e.g., cerebral palsy, amputations, and fractures or
   burns that cause contractures). (Department of Education [DOE], 1992, p.
   44802).

Other health impairment refers to "having limited strength, vitality, or alertness, due to chronic or acute health problems such as heart condition, tuberculosis, rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia, or diabetes that adversely affects a child's educational performance" (DOE, 1992, p. 44802). The term "other health impairments" can also include students who are technology-assisted or who have complex health care needs. These students may be dependent upon such technology as mechanical ventilators, oxygen, and tube feeding (Knight & Wadsworth, 1994). Multiple disabilities refers to concomitant impairments (such as mental retardation-orthopedic impairment), "the combination of which causes such severe educational problems that they cannot be accommodated in special education programs solely for one of the impairments" (DOE, 1992, p. 44802).

There is an increasing population of students who have physical and health disabilities. On a national level, 60,604 children were identified under the category of orthopedic impairments in the U.S. Department of Education's 18th Annual Report to Congress on Implementation of Individuals with Disabilities Education Act (IDEA U.S. Department of Education, 1996). This is a 6.6% increase of students with orthopedic impairments from the preceding year. In the area of other health impairments, 106,509 children were identified. This is an increase of 28.2%. The 89,646 students identified as having multiple disabilities is a decrease from the preceding year, but from reviewing the data it is impossible to know how many of these students have physical or health impairments as one of the disabilities and which percentage of these changed from the preceding year (DOE, 1996). Overall, the number of students with physical and health disabilities is increasing and it is not expected to decrease given the advances in medical technology to keep smaller babies alive, provide surgical interventions, and prescribe advanced treatments. Increasing numbers of qualified teachers are needed to educate these students.

Students with physical and health disabilities often have multiple educational, technological, and health care needs that are specific to their conditions. Teachers who educate students with physical and health disabilities require specialized knowledge and skills to provide an appropriate education. Some of the necessary knowledge and skills were delineated for various segments of the physical and health disability population such as: (a) physical and health disabilities (Ammer, Best, & Kulik, 1994; Heller, Alberto, Forney, & Schwartzman, 1996; Tyler & Colson, 1994), (b) chronic illness (Johnson, Lubker, & Fowler, 1988), (c) students with complex health care needs (Heller, Fredrick, & Rithmire, 1997; Lowman, 1997), (d) technology dependent students (Knight & Wadsworth, 1994; Porter, Haynie, Bierle, Caldwell, & Palfrey, 1997), and (e) terminally ill students (Schnieders & Ludy, 1996). A comprehensive list of knowledge and skills for all beginning special education teachers of students with physical and health disabilities was delineated by CEC in their International Standards for the Preparation and Certification of Special Education Teachers (CEC, 1996). These standards include specific competencies in the following:

* Philosophical, historical, and legal foundations.

* Characteristics; assessment, diagnosis and evaluation.

* Instructional content and practice.

* Planning and managing the teaching and learning environment.

* Managing student behavior.

* Communication and collaborative partnerships.

* Professionalism and ethical practices.

Under each of these categories are competencies specific to students with physical and health disabilities.

To address the specialized needs of students with physical and health disabilities, some states have specific certification in this area. California, for example, recently reasserted the need for a credential in physical and health impairments (Best, Davidson, & Kopriva, 1996). Creating or maintaining a separate certification in the area of physical and health disabilities is supported by CEC's Division of Physical and Health Disabilities (DPHD; Heller, 1997). However, these actions occurred in the context of a national trend toward generic or noncategorical certification, which would delete physical and health disabilities as a separate category. Some states considering a move towards a more generic form of certification no longer require specific certification in physical disabilities. Professors in universities that prepare teachers in this field must then consider the valid need for training programs in physical and health disabilities. Questions arise as to the extent to which teachers are trained in the knowledge and skills necessary to appropriately instruct students with physical and health disabilities. The issue is of major concern since a student's well-being, even life maintenance, during school hours might be overseen by a teacher with no training in recognition of, or intervention for, medical problems.

The purpose of this study was to examine how special education teachers of students with physical and health disabilities perceived themselves in the knowledge and skills of educating students with physical and health disabilities. Special education professors in university programs with and without concentrations in this field were also surveyed to determine how well students were prepared. In addition, district special education directors and directors of state Departments of Education were also surveyed to gain more information on teachers' competencies and resources in the field of physical and health disabilities.

METHOD

Participants

Questionnaires were sent to state Special Education Directors in all 50 state Departments of Education in the United States. Each state special education director received directions to fill out the questionnaire and to send a packet containing additional questionnaires to two local school district directors (one in a large school district and one, a small school district). In the packet, each school system director received instructions to complete the School System Director questionnaire and to select two teachers who taught students with physical and health disabilities to complete the Teacher questionnaires.

Questionnaires were sent to the largest college or university in each state that identified itself to CEC as having a program in physical and health disabilities. In states that did not have a university that listed physical and health disabilities as a training area, questionnaires were sent to the university that had the largest number of special education credentials offered in that state. The Special Education Department chairperson of each university was asked to give this questionnaire to the professor who has specific expertise in the area of physical and health disabilities or to pass it to the professor best qualified in this field to answer questions.

Questionnaires

The teacher and university questionnaires were based upon CEC's International Standards for the Preparation and Certification of Special Education Teachers (CEC, 1996). These standards were developed by gathering materials primarily from literature; state, provincial, and local governments; and institutions of higher education. After constructing draft competencies, surveys were sent to a stratified random sample of the division's membership, and finalization of the standards were made from the results. The validity of this document is supported by its adoption by several colleges and universities for program planning. The questions developed in this study's questionnaire were derived from the standards in physical and health disabilities, and additional questions were included to obtain specific information regarding demographics of the population. The questionnaires sent to school system directors primarily focused on adequacy of training issues. The questionnaires sent to directors of state Departments of Education contained information specific to certification and resources for supporting and training teachers in physical and health disabilities.

Teacher Questionnaire. This questionnaire was composed of general background information and eight content areas. The background information consisted of demographic information, such as state location and size of the school district, as well as the teacher's certification qualifications, degree(s) earned, and major(s). The remainder of the questionnaire consisted of eight areas that contained questions derived from the eight categories of knowledge and skills for all beginning special education teachers of students with physical and health disabilities (CEC, 1996). Each question was posed as "I have been well trained in.... "Participants responded on a 5-point Likert scale ranging from strongly disagree to strongly agree.

The first three areas addressed in the questionnaire were knowledge of laws, characteristics, and assessment. Knowledge of laws was addressed with one question specific to laws and policies governing special health care procedures in educational settings. Knowledge of characteristics of students with physical and health disabilities was addressed with two questions. One broad question asked if the teacher was well trained in the characteristics and educational implications of students with physical and health disabilities, while a second question asked about skills in the specific area of seizure management. Three questions addressed knowledge of assessment, diagnosis, and evaluation. These questions asked about modifying assessments to determine students' knowledge base, determining the most reliable method of response modification to assess students, and developing assistive technology plans.

The fourth area of the questionnaire contained eight questions and addressed instructional content and practice. Six questions asked about (a) providing appropriate instructional modifications, (b) teaching medical self-management skills, (c) teaching augmentative communication devices, (d) teaching assistive technology devices, (e) teaching independent living skills, and (f) adapting lessons and the school day to accommodate for exertion and endurance problems.

The fifth and sixth areas included five questions on managing the learning environment and one question on managing student behavior. Questions addressing the learning environment included integrating health care plans into daily programming, physical positioning and management to ensure participation, use of adaptive equipment, and knowledge of universal precautions. One question was included on managing student behavior that addressed analyzing behavior of nonspeaking students to determine if their behavior is communicative.

The last two areas of the questionnaire addressed collaborative partnerships and professionalism. Three questions addressing collaborative partnerships pertained to collaboration skills, strategies to work with chronically ill and terminally ill students, and knowledge of resources. The one question on professionalism asked whether the teacher was well trained in transdisciplinary teaming, such as assisting a student in the transition process from home to hospital or from rehabilitation facility to school.

University Questionnaire. The first part of the university questionnaire asked whether the university program offered a degree with a specific concentration in physical and health disabilities or what degree/concentration allowed the teachers to work with students with physical disabilities. Another question asked if the university employed a professor who had specific expertise in the area of physical and health disabilities. The remainder of the questionnaire contained the same eight areas and questions as the teacher questionnaire. However, the questions on the university questionnaire began with the phrase, "Our students are well trained in...." The same 5-point Likert Scale was used to respond to these items.

School System Director Questionnaire. The school system directors' questionnaire was divided into four sections. The first section consisted of questions regarding the size of the school system, the person's specific position, and the state where they were located. The second section was composed of six questions. The first three addressed whether teachers should be trained in characteristics and educational implications of teaching students with physical and health disabilities, in instructional adaptations, and in assistive technology. The remaining three questions addressed training of the teachers in these areas. The third section addressed available resources, the need for additional training, and how well the universities are preparing teachers in this field. Also included in this section were two questions about whether the respondents thought teachers should be specifically trained in physical and health disabilities, and if there should be a separate certification in this area. The last section pertained to where students were served in the school district (e.g., general education, self-contained classes). As with the other questionnaires, responses used a 5-point Likert scale.

State Departments of Education Questionnaire. The state Departments of Education questionnaire contained questions regarding state certification in physical and health disabilities. Questions were asked about training opportunities for obtaining certification and acquiring knowledge specific to physical disabilities. Other questions asked whether a state consultant was specifically trained in such areas as physical and health disabilities, adaptive physical education, physical therapy, occupational therapy, augmentative communication, and assistive technology. Participants answered "yes" or "no" to each question.

Data Analysis

Raw data from the questionnaire were entered into Version 6 of Epi Info, which is a series of microcomputer programs designed for organizing questionnaire data that can later be analyzed using a variety of statistical programs. After double entry verification, the data file was exported to an SPSS file which provided frequency counts, percentages, valid percents, and cumulative percentages. Chi-square and post hoc analyses were performed comparing how teachers with various types of educational degrees answered the items. Using a t-test, responses of teachers residing in states with specific certification in physical and health disabilities were compared to responses of teachers residing in states without this form of certification. Universities that provided specific concentrations in physical disabilities and those that did not were compared using one way ANOVAs with a Bonferroni adjustment. Using Pearson chi-square, responses from universities with and without degrees with concentrations in physical and health disabilities were compared based on whether their states had specific certification in physical and health disabilities.

RESULTS

A total of 400 Teacher, University, School System Director, and State Department questionnaires were mailed. One hundred and fifty were returned for a 38% return rate. Fifty-nine teacher questionnaires were returned for a 30% return rate, 26 universities returned questionnaires for a 52% return rate, 36 local school system directors returned questionnaires for a 36% return rate, and 29 state departments returned questionnaires for a 58% return rate. (While the return rates from teacher and school system directors were low, their responses were consistent with responses from university and state department questionnaires indicating they were probably representative of the original sample. In addition, the consistency suggests a need for change that should not be ignored because of low return rates.)

Teacher Questionnaire Data. Special education teachers who are certified to teach students with physical and health disabilities were asked to agree or disagree (on a 5-point Likert scale) if they were well trained in specific competencies in the area of physical and health disabilities. By responding they disagreed or strongly disagreed that they were well trained, over 40% of the teachers indicated that they were not well trained on about half (11 out of 23) of the competencies. As seen in the first column of Table 2, teachers do not feel they are well trained on

* Seizure management (47.5%).

* Development of assistive technology plans (45.7%).

* Instructional modifications to teach reading to a nonverbal student with physical disabilities (54.2%).

* Teaching medical self-management skills (e.g., tube feeding, catheterization) (81.4%).

* Teaching augmentative communication devices and systems (52.5%).

* Teaching students the use of assistive technology devices (50.8%).

* Integrating health care plans into students' daily programming (42.3%).

* Using adaptive equipment such as wedges and prone standers to facilitate positioning, mobility, communication, and learning (42.4%).

* Analyzing behavior of students who are nonspeaking to determine if behavior is communicative (49.1%).

* Strategies to work with chronically ill and terminally ill students and families (72.4%).

* Participating in transdisciplinary team activities such as assisting students to transition from home to hospital or from rehabilitation facility to school (56.9%).

TABLE 2 Special Education Teachers Who Are Certified to Teach Students with Physical Disabilities by Degree

                                           Percentage of Teachers
                                           Indicating They are NOT
                                                Well Trained
                                           Specific Concentration
Questions                                   All SPET(a)   PMD(b)
                                                 %           %

Legal Foundations
  Health care                                  33.9        12.5

Characteristics
  Physical and health characteristics          17.2         0.0
  Seizures                                     47.5         0.0

Assessment/Evaluation
  Modifying assessment                         23.7         0.0
  Determining response modification            34.5         0.0
  Assistive technology plans                   45.7        12.5

Instructional Content and Practice
  Instructional modifications                  34.4         0.0
  Modifying reading for nonverbal              54.2        25.0
  Medical self-management                      81.4        50.0
  Augmentative communication                   52.5         0.0
  Assistive technology                         50.8        12.5
  Independent living skills                    38.9         0.0
  Adapt lessons to minimize exertion           30.5         0.0
  Schedule school day due to fatigue and       37.2         0.0
  endurance

Managing Learning Environment
  Integrating health care plans in             42.3         0.0
  programming
  Physical positioning/management              35.6         0.0
  Adaptive equipment                           42.4        12.5
  Universal precautions                        25.5         0.0

Managing Student Behavior
  Analyzing behavior to determine if           49.1        12.5
  communicative

Collaborative Partnership
  Collaboration skills                         20.4         0.0
  Work with chronically/terminally ill         72.4        37.5
  Knowledge of resources                       37.2        12.5

Professionalism
  Transdisciplinary team                       56.9        25.0

                                           Percentage of Teachers
                                           Indicating They are NOT
                                                Well Trained
                                           Specific Concentration
Questions                                   SPEGP(c)      General
                                                 %           %

Legal Foundations
  Health care                                  33.3        50.0

Characteristics
  Physical and health characteristics           3.1        56.3
  Seizures                                     42.4        81.3

Assessment/Evaluation
  Modifying assessment                         18.2        50.1
  Determining response modification            25.0        68.8
  Assistive technology plans                   39.4        81.3

Instructional Content and Practice
  Instructional modifications                  31.3        62.5
  Modifying reading for nonverbal              54.6        75.1
  Medical self-management                      84.8        93.8
  Augmentative communication                   48.5        87.6
  Assistive technology                         48.5        81.3
  Independent living skills                    30.3        81.3
  Adapt lessons to minimize exertion           21.2        62.5
  Schedule school day due to fatigue and       24.3        81.3
  endurance

Managing Learning Environment
  Integrating health care plans in             36.4        81.3
  programming
  Physical positioning/management              36.4        56.3
  Adaptive equipment                           39.4        68.8
  Universal precautions                        15.2        56.3

Managing Student Behavior
  Analyzing behavior to determine if           39.4        81.3
  communicative

Collaborative Partnership
  Collaboration skills                         12.1        50.1
  Work with chronically/terminally ill         71.9        93.8
  Knowledge of resources                       33.3        56.3

Professionalism
  Transdisciplinary team                       51.5        86.6

Note: (a) SPET = Special Education Teacher, (b) PMD = Physical & Multiple Disabilities, (c) SPEGP = Special Education Generic Program

The extent to which teachers reported they were well trained varied according to whether their degree was in special education with a specific concentration in physical and health disabilities, special education from a generic special education program (or in a couple instances, a different area of special education), or general education. Fourteen percent of the teachers received a special education degree with a concentration in physical and health disabilities or multiple disabilities (multiple disabilities being included since it tends to be a subset of physical and health disabilities). These teachers reported being the best trained with very few teachers indicating that they were not well trained in the competencies. All of these teachers indicated they were trained or well trained in over half (57%) of the competencies. Teachers with special education degrees in physical and health disabilities (not including those with multiple disabilities) unanimously indicated they were trained or well trained in six additional areas, resulting in being trained or well trained on a total of 83% of the items. When teachers with concentrations in physical and health disabilities or multiple disabilities indicated they were not well trained, the percentages were typically small with 12.5% indicating they were not well trained on six competencies, and 25% indicating they were not well trained on two other competencies. Exceptions to this occur in medical self-management where 50% indicated they were not well trained and in working with chronically/terminally ill where 37.5% indicated they were not well trained. However, if only those with concentrations in physical and health disabilities are examined in the last item of working with chronically/terminally ill, all of these teachers reported being trained or well trained.

The majority of teachers (56%) received a degree in special education with either a generic special education concentration or a concentration in an area other than physical and health disabilities. In states where a generic certification is required to teach students with physical and health disabilities, no further coursework or training is required to permit a teacher to instruct students with physical and health disabilities. In states with specific certification requirements in physical and health disabilities, teachers with a concentration in an area other than physical and health disabilities (e.g., learning disabilities) may have taken additional coursework or training to qualify for certification to teach students with physical and health disabilities in their state. For some states, this can be one or two courses, which is in sharp contrast to the multiple courses needed for a degree in this area. Across each of the items of the questionnaire, there is a higher percentage of these teachers who indicated that they were not well trained (by disagreeing or strongly disagreeing they were well trained) in the various competencies than special education teachers with specific degrees in physical and health disabilities.

Some of the special education teachers had degrees in general education (27%), or degrees outside of education (3%) and then took coursework or additional training to qualify them as special education teachers certified to teach students with physical disabilities. Teachers with degrees in general education had even higher percentages of disagreement that they were well trained in each competency (range 50% - 93.8%). The majority of special education teachers with degrees in general education indicated that they were not well trained in every competency on the questionnaire.

A significant difference was found between the responses of teachers who obtained special education degrees with a specific concentration in physical and health disabilities and those who did not. There are 11 out of 23 competencies for which 40% or more of the total sample of special education teachers indicated they were not well trained. Using a chi-square and post hoc analysis, a significant difference was found on six competencies between teachers with special education degrees with concentrations in physical and health disabilities (including multiple disabilities) and those without this training. These competencies are seizure management ([chi square] = 30.85, p = .002), augmentative communication ([chi square] = 33.72, p = .001), assistive technology ([chi square] = 43.86, p = .0001), integrating health plans in programming ([chi square] = 28.11, p = .005), and analyzing behavior for communicative intent ([chi square] = 22.86, p = .029). If the teachers who received special education degrees with concentrations in multiple disabilities (a subset of physical and health disabilities) are excluded, there is a significant difference between how teachers with concentrations in the broader category of physical and health disabilities and teachers without degrees with concentrations in this specific area ([chi square] = 27.7, p = .034) responded to working with students with chronic and terminal illness.

Data were also compared between teachers who teach in states that required specific certification in physical and health disabilities and those that have more generic or noncategorical certification. No significant difference was present in the way the competencies were addressed by each group except teachers working in states with specific certification in physical and health disabilities indicated that they were better trained in instructing students with chronic/terminal illnesses (t = 2.82, p = .007) and in scheduling a school day for students with fatigue and endurance issues (such as those with muscular dystrophy) (t = 2.32, p = .024).

University Questionnaire Data. In the university questionnaire, 42.3% of universities had special education degrees with specific concentrations in physical and health disabilities and 61.5% of the universities reported employing a professor with specific expertise in the area of physical and health disabilities. Eighty percent of the university programs with concentrations in physical disabilities were in states that have certification and 81% of university programs reporting no concentration in physical disabilities were in states that had no certification specific to the area of physical disabilities. These data indicate a tendency of states with a certification to have university programs with a concentration in the area of physical disabilities and those states without certification to not have university programs with a concentration in physical disabilities ([chi square] = 9.46, p = .002).

The results from the university questionnaire indicate that 40% or more of the professors in university programs that did not have specific concentrations in physical and health disabilities, but a more generic special education program, indicated that their students were not well trained in 7 of the 23 items. As seen in Table 3, items included

* Modifying reading for students who are nonverbal (45.5%).

* Medical self-management skills (72.7%).

* Adapting lessons to minimize exertion (54.6%).

* Scheduling a school day for students who experience fatigue and lack of endurance (45.5%).

* Integrating health care plans into programming (63.7%).

* Adaptive equipment (45.5%).

* Strategies to work with chronically and terminally ill students and families (63.7%).

TABLE 3
Universities

                                    % Indicating That Their
                                 Students are NOT Well Trained

                                     Universities with No
                                       Concentration in
Questions                            Physical Disabilities

Legal Foundations
  Health care                                36.4

Characteristics
  Physical/health characteristics             9.1
  Seizures                                   36.4

Assessment/Evaluation
  Modifying assessment                       27.3
  Determining response                       27.3
    modification
  Assistive technology plans                 36.4

Instructional Content and Practice
  Instructional modifications                18.2
  Modifying reading for nonverbal            45.5
  Medical self-management                    72.7
  Augmentative communication                 36.4
  Assistive technology                       20.0
  Independent living skills                  36.4
  Adapt lessons to minimize                  54.6
    exertion
  Schedule school day due to                 45.5
    fatigue and endurance

Managing Learning Environment
  Integrating health care plans              63.7
    in programming
  Physical positioning/                      36.4
    management
  Adaptive equipment                         45.5
  Universal precautions                      36.4

Managing Student Behavior
  Analyzing behavior to determine            36.4
    if communicative

Collaborative Partnership
  Collaboration skills                        0.0
  Work with chronically/terminally           63.7
    ill
  Knowledge of resources                     36.4

Professionalism
  Transdisciplinary team                      9.1

                                    % Indicating That Their
                                   Students are NOT Well Trained

                                       Universities with
                                       Concentrations in
Questions                            Physical Disabilities

Legal Foundations
  Health care                                 0.0

Characteristics
  Physical/health characteristics             0.0
  Seizures                                    0.0

Assessment/Evaluation
  Modifying assessment                        0.0
  Determining response                        9.1
    modification
  Assistive technology plans                  9.1

Instructional Content and Practice
  Instructional modifications                 0.0
  Modifying reading for nonverbal             9.1
  Medical self-management                    36.4
  Augmentative communication                  0.0
  Assistive technology                        9.1
  Independent living skills                   0.0
  Adapt lessons to minimize                   0.0
    exertion
  Schedule school day due to                  0.0
    fatigue and endurance

Managing Learning Environment
  Integrating health care plans               0.0
    in programming
  Physical positioning/                       0.0
    management
  Adaptive equipment                          0.0
  Universal precautions                       0.0

Managing Student Behavior
  Analyzing behavior to determine             0.0
    if communicative

Collaborative Partnership
  Collaboration skills                        0.0
  Work with chronically/terminally           27.3
    ill
  Knowledge of resources                      0.0

Professionalism
  Transdisciplinary team                      9.1

Most universities with concentrations in physical and health disabilities indicated that their students were well trained in most competencies, as seen by 0% disagreeing that their students were well trained in the majority of the competency. Only on two competencies did over 20% of the professors indicate that their students were not well trained: medical self-management (36.4%) and working with chronically and terminally ill children (27.3%). When comparing programs that have a concentration in physical and health disabilities and those that do not, a significant difference was found across several of the individual items in which 40% or more universities lacking concentrations in physical and health disabilities indicated that they did not train their teachers well. These included adapting lessons to minimize exertion (F = 2.902, p = .002), scheduling the school day due to fatigue and endurance (F = 6.92, p = .016), integrating health care plans in programming (F = 14.02, p = .001), using adaptive equipment (F = 8.48, p = .009), and working with the chronically and terminally ill (F = 5.63, p = .028).

School System Directors' Data. School system directors indicated that the majority of students with severe physical and health disabilities with mild to no intellectual disabilities are taught in general education classes, and that special education teachers providing support to these classrooms or directly instructing the students are poorly trained. As seen in Table 4, these students are primarily taught in general education classes (59.3%) with the majority of these receiving support from the special education teacher (31.9%). Another 37.1% of special education teachers directly teach students in resource rooms or self-contained classrooms.

TABLE 4
Primary Location of Service Delivery

Placement Options                              Percentages

General education class                           27.4
General education class with support from         31.9
  special education teacher
Mild disabilities resource rooms                  21.2
Physical disabilities resource rooms               4.4
Self-contained rooms                              11.5
Other                                              3.5

School system directors agreed or strongly agreed that teachers should be trained in characteristics and educational implications of teaching students with physical and health disabilities, instructional adaptations needed for students with severe physical and health disabilities, and assistive technology (range = 91.6% - 94.5%). However, as seen in Table 5, very few directors agreed that teachers were well trained (11.4% - 22.8%). None agreed that their teachers were well prepared to teach reading to nonverbal students (0%). Although none of the directors agreed that the universities were doing a good job of preparing teachers in physical and health disabilities (0%), the majority of the teachers certified to teach students with physical and health disabilities (86%) that the directors selected to complete the teacher questionnaires received their degree in generic special education or an area of special education other than physical and health disabilities. Eighty percent of the directors agreed that it would be helpful to have teachers specifically trained in physical and health disabilities. The majority of school system directors responded that the school system needed to provide additional training for teachers to effectively teach students with severe physical and health disabilities (91.5%) and felt that resources were available to them in the area of physical and health disabilities (44.5%). A third (33.4%) of the directors felt there should be a separate certification for physical and health disabilities.

TABLE 5
School System Directors

Questions                                        Percentages
                                           Agree & Strongly Agree
                                              Should Be Trained

Characteristics and educational
  implications of physical and health               91.6
  disabilities
Instructional adaptations                           94.5
Assistive technology                                94.4

                                           Agree & Strongly Agree

Teachers of students with physical
disabilities are well prepared to                    0.0
teach reading to nonverbal students

Universities are doing a good job
preparing teachers in physical and                   0.0
health disabilities

Helpful to have teachers specifically
trained in physical and health                      80.0
disabilities

School system needs to provide
additional training for teachers to
effectively teach students with                     91.5
physical and health disabilities

Teachers have resources available to
them in area of physical and health                 44.5
disabilities

There should be a separate
certification in physical and health                33.4
disabilities

                                                 Percentages
                                         Agree & Strongly Disagree
                                           Have Been Well Trained

Characteristics and educational
  implications of physical and health               22.8
  disabilities
Instructional adaptations                           17.6
Assistive technology                                11.4

                                            Disagree & Strongly
                                                  Disagree

Teachers of students with physical
disabilities are well prepared to                   66.7
teach reading to nonverbal students

Universities are doing a good job
preparing teachers in physical and                  68.6
health disabilities

Helpful to have teachers specifically
trained in physical and health                       5.7
disabilities

School system needs to provide
additional training for teachers to
effectively teach students with                      2.9
physical and health disabilities

Teachers have resources available to
them in area of physical and health                 11.1
disabilities

There should be a separate
certification in physical and health                45.5
disabilities

State Departments of Education Data. Thirty states reported not having certification in physical and health disabilities. Of those states having certification in physical disabilities, four state departments are considering dropping the physical disability certification or have already adopted new certification without physical disabilities.

State department personnel reported that special education teachers received training in a number of different ways. In states that provide specific certification in physical disabilities, 73% of the training is provided by courses at universities and colleges, as compared to 50% in states without specific certification in physical disabilities. Inservices and continuing education classes compose the other forms of training that are provided. However, 69% of the states that do not have specific certification in physical disabilities, but a noncategorical or mild-severe disability certification, reported that training was not required in physical disabilities for special education teachers.

Thirty-one percent of the states have a consultant specifically trained in physical and health disabilities. States that have certification were far more likely to have consultants in physical disabilities (90%), than not (10%). Most states that do not have certification specific to physical disabilities do not have a consultant specifically trained in physical and health disabilities (56%). When asking all of the state department personnel about other specialty areas, 55.2% of the states have a consultant specifically trained in assistive technology, 35.7% in augmentative communication, 20.7% in adaptive physical education, and 13.8% in physical therapy, occupational therapy services.

DISCUSSION

Results of this survey indicate that a large portion (40%) of special education teachers certified to teach students with physical disabilities report lacking knowledge and skill in about half of the competencies in physical and health disabilities included in the teacher questionnaire. Whether the special education teacher was specifically certified in physical and health disabilities or had a generic certification was not statistically significant in regard to their reported knowledge and skills of the competencies except on two items. Special education directors and university data also support many teachers' perception that they are not well trained during their teacher education programs. However, the data indicate that teachers certified to teach students with physical and health disabilities who have a degree with a concentration in physical and health disabilities (including multiple disabilities) perceive themselves as far better trained in educating students with physical and health disabilities than those with other backgrounds.

The vast majority of teachers with special education degrees with concentrations in physical and health disabilities agree that they are well trained in most of the competencies. In addition, the overwhelming majority of universities with concentrations in physical disabilities indicate that they are training students well in these competencies. The weakest area identified both by teachers with concentrations in physical and health disabilities and professors in universities with a concentration in physical and health disabilities is the area of medical self-management. Since teachers are frequently performing these procedures (Heller et al. 1997), this lack of expertise is especially alarming and could result in life-threatening situations. Teachers are often the most qualified to develop instructional strategies and adaptations for students with cognitive impairments in conjunction with a nurse's technical expertise in the procedure. University personnel in programs with concentrations in physical disabilities need to examine more closely the preparation they provide in this area and adjust their course content to meet this competency.

There are some differences between teachers receiving special education degrees with a concentration in the broader physical and health disability area and those with a concentration in the subset area of multiple disabilities. This was especially the case in areas more commonly addressed for students with high cognitive functioning, such as modifying reading for nonverbal students and using appropriate strategies with chronic and terminally ill students. Programs with multiple disabilities often focus more on combinations of severe mental retardation and physical disabilities, rather than adapting academics and critical thinking skills for high functioning students with physical disabilities. Programs specializing in physical and health disabilities tend to address the range of intellectual abilities (profound mental retardation to gifted with physical disabilities) of which multiple disabilities is a subset. University programs need to be certain to include strategies specific to high functioning students (i.e., mild mental retardation, learning disabilities, normal intelligence, and gifted) with physical disabilities, as well as those with severe or profound mental retardation and physical disabilities.

Only 31% of states have a consultant specifically trained in physical and health disabilities, with states having certification specific to physical disabilities being far more likely to have a consultant (90%) in this field. Local school district personnel who have questions or concerns in this area will have limited support or assistance when there is no one in the state department with this expertise.

This study provides important considerations for practice, even through there are two potential limitations. The first potential limitation is that the instruments were not assessed for internal consistency. However, the goal was to collect data on perceptions of preparedness based on what were already identified as necessary competencies in the field of physical and health disabilities (CEC, 1996). Therefore, the questionnaires directly asked about these competencies. Given that, in many instances, the competencies were perceived to be lacking, the need for change in special education teacher preparation seems clear. A second potential limitation is the low return rate from teachers and school system directors. However, those who responded were similar to university and state departments in their responding, suggesting the concerns are valid.

In summary, the study shows that 40% of the special education teachers certified to teach students with physical disabilities indicate they are not well trained in about half of the competencies in physical disabilities. Although teachers with special education degrees with a concentration in physical and health disabilities are well trained overall, and their university programs address most of the competencies well, few teachers have degrees with concentrations in this area. This will only become worse when fewer universities are able to provide programs in the area of physical and health disabilities if their states move to a more generic form of certification. State departments of education need to closely examine the adequacy of the certification requirements that allow their special education teachers to teach students with physical disabilities. The implications of moving away from certification in physical disabilities need to be closely examined as it affects teacher competencies, university offerings, and the likelihood of having a state consultant in physical disabilities. The competency of teachers and the education of students with physical disabilities is already suffering and is at further risk unless appropriate steps are taken to assure effective training in the area of physical and health disabilities.

IMPLICATIONS FOR PRACTICE

The findings from this research have implications across certification, university preparation programs, teacher training, and state department support. Each is discussed briefly here.

University Personnel Preparation

The data indicate that teachers often lack knowledge and skills in the competencies of physical disabilities when they do not have a degree with a concentration in that area. Over 40% of professors in universities without concentrations in physical disabilities indicated that their students are not well trained in seven competencies noted in this study, five of which were the same competencies that the teachers indicated they are not well trained. Universities with preparation programs that train special educators who will be teaching students with physical disabilities, need to include coursework that will address the unique skills and competencies in the field of physical disabilities. One method of including the unique knowledge and skills of this field in university coursework is to utilize the CEC document of international standards (CEC, 1996). These standards come with a section for universities to document which courses address each physical disabilities competency. Missing competencies can be easily identified and lead to decisions as to where the missing content can be provided.

Teacher Training

The lack of training in these basic beginning competencies for special education teachers who instruct students with physical disabilities can affect the students' educational progress, emotional stability, and physical well-being. If the teacher lacks knowledge and skill in augmentative communication and assistive technology, the student will lack appropriate access to educational material and instruction, as well as formal and social communication. If the teacher is not well trained in teaching reading to nonverbal students, the student may not learn to read. If the teacher does not know how to analyze students' behaviors to determine if they are communicative, students' efforts to communicate may be ignored and the student may either stop trying to communicate or increase undesirable behaviors. When the teacher lacks strategies to work with chronically ill and terminally ill students and their families, the result can be feelings of isolation, helplessness, and increased emotional stress. Students who need to learn how to perform (or participate) in their physical health care procedure typically require the skills of a teacher knowledgeable of instructional strategies to work in conjunction with medical personnel who possess technical skills. When teachers lack knowledge in how to perform these procedures or are unable to integrate required health maintenance activities into the students' daily schedule, the students' self-care needs may not be adequately met and their physical well-being may be jeopardized. For example, 47.5% of special education teachers who instruct students with physical disabilities reported not being well trained in how to manage a variety of seizures. This places the student at risk for serious injury or worse.

Additional training should be provided for teachers who do not have adequate competency meeting the needs of students with physical disabilities, but whose current certification allows them to teach these students. Teachers who feel they have not received adequate training to effectively teach students with physical disabilities should seek additional training. Also, due to the rapidly changing nature of assistive technology, communicative technology, and medication technology on which this field relies, teachers will need continuing education and should be provided this training. Special education directors should carefully evaluate teachers in this field to determine if additional training is necessary, since this becomes an issue of quality education, professional liability, and ethical practice. The competencies can be used as a checklist to determine adequacy of knowledge and skill. Parents should also expect that the teachers instructing their children who have physical disabilities are competent to teach their children well. Additional training may include coursework at a university, intensive inservice training, and/or mentoring by a teacher trained in this area.

State Department Support

State department directors should consider hiring personnel with expertise specific to physical disabilities. Although some state departments may have a network of personnel that can be consulted when questions arise from the school districts, this person usually cannot perform all the required functions of state department personnel (e.g., on-site consultant as representative of state department).

Certification

Certification standards for each state should assure that teachers are prepared to teach the population of students for which they are being certified. The results of this study indicate that a large portion of teachers who are certified to teach students with physical disabilities lack the specific competencies needed to address this population of students. State certification departments should design certification standards based upon the knowledge and skills needed to instruct students with the specific disabilities the teacher is expected to teach. In the area of physical disabilities, certification departments should assure that their certification standards include the multiple educational, technological, and health care needs that require the teacher to have specific knowledge and skills to provide an appropriate education. These unique competencies are reflected in CEC's Knowledge and Skills for All Beginning Special Education Teachers of Students with Physical and Health Disabilities (CEC, 1996).

States that do not have specific certification in physical disabilities are at risk of having (a) inadequate competencies in physical disabilities, (b) inadequate numbers and specialization in university preparation programs, (c) fewer national resources, and (d) lack of expertise in the state department. At present, 30 states do not have a specific certification category in physical disabilities and 4 states are considering discontinuing this certification category. Sixty-nine percent of the states that do not have specific certification in physical disabilities, but a noncategorical or mild-severe disability certification, reported that training was not required in physical disabilities for special education teachers. A critical issue under consideration at the national level is that placing the certification area of physical disabilities under a more generic form of certification will increase the risk that the knowledge and competencies of this specific disability area will not be addressed (Heller, 1997). Just as most states maintain distinct certification categories for the low incidence areas of vision and hearing, the low incidence area of physical disabilities also has a professionally validated unique body of specialized knowledge and skills. Maintaining or creating a certification area specific to physical disabilities that reflects the required unique competencies should help assure that teachers and other school-based professionals are trained in the necessary competencies.

The need for distinct certification in physical disabilities is further supported by the data showing that university programs with concentrations in physical and health disabilities are usually found in states with a certification in that area, not in states that have no specific certification in physical disabilities. When a state department elects to discontinue a certification in an area of exceptionality, the state funded university typically closes its program due to a lack of enrollment. This phenomenon occurs because teachers do not usually seek a degree in a concentration that is no longer a certification area, and universities cannot afford to offer programs without students. This outcome creates a vicious cycle of decertification, program discontinuation, and dilution of teacher skills. When universities that provide a concentration in the area of physical disabilities close their programs, there is decreased tendency for professors to be hired in the area with a subsequent lack of adequate transmission of knowledge and skills to the students studying to be teachers. Students then emerge inadequately trained to meet field-based needs.

A lack of distinct certification in physical disabilities can also result in a decrease in expertise and leadership in this area. When university programs close due to state-level credential decertification, less research and fewer publications in the literature occur. Lack of publications lends to the false impression that specific teacher expertise is either not required, or even in existence. Fewer university programs in this area also result in fewer graduating doctoral students with knowledge in this field. These events lead to fewer resources and less expertise in the area of educating students with physical and health disabilities. To further compound this problem, states without certification are less likely to have state consultants in physical and health disabilities. This provides even fewer resources for teachers and school systems as they try to meet the needs of students with physical and health disabilities. It also provides the false impression that no specific training is needed since state level leadership is lacking. These concerns warrant careful consideration in the certification departments of each state.

Serving students with physical and health disabilities in more inclusive settings and the rise in the number of students with physical disabilities are both major reasons why more, not fewer, well-trained teachers are needed. Students now come to school with more severe and complex physical and health disabilities than ever before, increasing the need to appropriately train teachers in the knowledge and skills specific to the physical and health disability area. Assuring appropriate training through rigorous and appropriate certification requirements in physical and health disabilities will allow these teachers to be effective educators, school-based consultants, and co-teachers so that an appropriate education will be available for all children.

REFERENCES

Ammer, J. J., Best, S. J., & Kulik, B. (1994). Meeting the educational needs of students with physical handicaps: A survey of administrators and teachers in California. Physical Disabilities: Education and Related Services, 13(1), 25-39.

Best, G. A., Davidson, S. N., & Kopriva, P. (1996). Creating a credential in physical and health impairments. Physical Disabilities: Education and Related Services, 15(1), 13-25.

The Council for Exceptional Children. (1996). What every special educator must know: The international standards for the preparation and certification of special education teachers. Reston, VA: The Council for Exceptional Children. (ERIC Document Reproduction Service No. 399 727)

Department of Education. (Sept. 29, 1992). Federal register. 34 CFR Parts 300-301. Assistance to states for the education of children with disabilities program and preschool grants for children with disabilities, Final Rule, 57 (189), (pp.-44801-44802) Washington, DC: Author.(*)

Department of Education. (1996). To assure the free appropriate public education of all children with disabilities, Eighteenth annual report to Congress on the implementation of the Individuals with Disabilities Education Act. Washington, DC: Author. (ERIC Document Reproduction Service No. 400 673)

Heller, K. W. (1997). Guest editorial: The critical need for physical and health disability certification. Physical Disabilities: Education and Related Service, 16(1), 1-5.

Heller, K. W., Alberto, P. A., Forney, P. E., Schwartzman, M. N. (1996). Understanding physical, sensory, and health impairments: Characteristics and educational implications. Pacific Grove, CA: Brooks/Cole.(*)

Heller, K. W., Fredrick, L. D., & Rithmire, N. M. (1997). Special health care procedures in the schools. Physical Disabilities: Education and Related Service, 15(2), 1-22.

Johnson, M. P., Lubker, B. B., & Fowler, M. G. (1988). Teacher needs assessment for the educational management of children with chronic illnesses. Journal of School Health, 58, 232-235.

Knight, D., & Wadsworth, D. E. (1994). Guidelines for educating students who are technology-dependent. Physical Disabilities: Education and Related Service, 13(1), 1-8.

Lowman, D. K. (1997). Planning for students with complex health care needs. Physical Disabilities: Education and Related Service, 16(1), 7-22.

Porter, S., Haynie, M., Bierle, T., Caldwell, T. H., & Palfrey, J. S. (1997). Children and youth assisted by medical technology in educational settings (2nd ed.). Baltimore, MD: Paul H. Brookes.(*)

Schnieders, C. A., & Ludy, R. J. (1996). Grief and death in the classroom. Physical Disabilities: Education and Related Service, 14(2), 61-74. Tyler, J. S., & Colson, S. (1994). Common pediatric disabilities: Medical aspects and educational implications. Focus on Exceptional Children, 27(4), 1-16.

(*) To order books referenced in this journal please call 24 hrs/365 days: (800) BOOKS-NOW (266-5766) or (801) 261-1187, or visit them on the Web at http://www.BooksNow.com/Exceptional Children.htm. Use Visa, M/C, or AMEX or send check or money order + $4.95 S&H ($2.50 each add'l item) to: BooksNow, 448 E. 6400 South, Suite 125, Salt Lake City, UT 84107.

KATHRYN WOLFF HELLER

LAURA D. FREDRICK Georgia State University

MARY KAY DYKES University of Florida

SHERWOOD BEST California State University, Los Angeles

ELISABETH TUCKER COHEN Georgia State University

KATHRYN WOLFF HELLER (CEC #685), Associate Professor; and LAURA D. FREDRICK, Assistant Professor, Department of Educational Psychology and Special Education, Georgia State University, Atlanta. MARY KAY DYKES (CEC #1024), Professor, Department of Special Education, University of Florida, Gainesville. SHERWOOD BEST (CEC #538), Associate Professor, Division of Special Education, California State University, Los Angeles. ELISABETH TUCKER COHEN (CEC #685), Assistant Project Director, Department of Educational Psychology and Special Education, Georgia State University, Atlanta.

Address all correspondence to Kathryn Wolff Heller, Georgia State University, Department of Educational Psychology and Special Education (EPSE), University Plaza, Atlanta, GA 30303. Phone: (404) 651-2310, E-Mail: heller@gsu.edu

Manuscript received January 1997; revision accepted June 1998.

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