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Canadian Journal of Occupational
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DOI: 10.1177/000841740006700311
2000 67: 162Canadian Journal of Occupational TherapyHelena Hemmingsson and Lena Borell
Severe Physical DisabilitiesAccommodation Needs and Student-Environment Fit in Upper Secondary Schools for Students w
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Accommodation needs and student-environment fit in uppersecondary schools for students with severe physical disabilities HELENA HEMMINGSSON LENA BORELL
ABSTRACTThe purpose of this study was to identify, from the
personal perspective of students with disability,
their needs for physical and social accommoda-
tions in upper secondary schools specially adapt-ed for students with severe physical disabilities.
The study also aimed to identify those areas of
student-environment fit which were most often
achieved.
Forty-eight students in four schools in Sweden
were assessed by occupational therapists using
the School Setting Interview. Forty-seven students
reported needs for accommodations in the school
setting.The study indicates that schools generally
were able to meet the students accommodation
needs in the physical environment. The schools
also met studentsaccommodation needs for fieldtrips,sport activities and assistance.Student-envi-
ronment fit in occupations requiring reading,
remembering and speaking was unsatisfactory.
Accommodations on a general, group and indi-
vidual level are highlighted and discussed. The
study recommends that occupational therapists
become more involved and offer society their
expertise in barrier removal to a greater extent.
RSUMLe but de cette tude tait didentifier les besoins en terme
dinstallations matrielles et damnagements sociaux
dans les coles secondaires spcialement adaptes pour
les lves ayant des dficiences physiques, du point de vuedes lves concerns. Ltude avait galement pour but de
cibler les adaptations et amnagements les plus souvent
russis dans lenvironnement tudiant.
Quarante-huit lves de quatre coles en Suisse ont t
valus par des ergothrapeutes au moyen du School
Setting Interview. Quarante-sept lves ont mentionn un
besoin dadaptations dans le milieu scolaire. Ltude
indique quen gnral les coles arrivaient rpondre aux
besoins des lves en ce qui a trait lenvironnement
physique. Les coles rpondaient galement aux besoins
des lves lors des sorties,des activits sportives et de laide
physique requise. Les lves ont indiqu que lesadaptations environnementales ncessaires pour effectuer
des occupations faisant appel la lecture, la
mmorisation et la discussion taient insatisfaisantes.
Larticle dcrit et discute des adaptations gnrales, de
groupe et individuelles. En conclusion de ltude, les
auteurs recommandent que les ergothrapeutes
simpliquent davantage et offrent leur expertise la socit
pour faire disparatre les barrires.
KEY WORDSArchitectural accessibility
Environmental modification
School-based occupational therapy
Helena Hemmingsson,OT(r),
is a Doctoral Student at the
Karolinska Institutet,
Institution of Clinical
Neuroscience,Occupational
Therapy and Elderly Care
Research, Division of
Occupational Therapy,
Retzius vg 13,
171 77 Stockholm, Sweden.
E-Mail: Helena.Hemmingsson
@neurotec.ki.se
Lena Borell, Ph.D.,OT(r), is
Associate Professor and Head,
Division of Occupational
Therapy at the Karolinska
Institutet, Institution of
Clinical Neuroscience,
Occupational Therapy and
Elderly Care Research,
Stockholm, Sweden.
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Hemmingsson & Borell
In recent decades, many developed western societies have
introduced important changes in law and social policy to
eliminate discrimination against individuals with disabili-
ties. For example, such changes have occurred in Canada,
Great Britain, Sweden and U.S.A (Ait-Hocine,1990; Kalscheur,
1992; Law & Dunn, 1993; Madill, Tirrul-Jones & Magill-Evans,
1990; SOU, 1998:66). The concept of health is also moving
from a medical model to a more socio-political perspective
that takes into account the person - environment relation-
ship (Ait-Hocine, 1990; Baum & Law, 1997; Jongbloed &
Chrichton, 1990; Kalscheur, 1992; Law & Dunn,1993; Madill et
al., 1990; SOU, 1998:66; World Health Organization (WHO),
1993; 1997). As a result of efforts to eliminate discrimination,
a growing trend of including students with physical disabili-
ties in the regular classroom is evident in the countries men-
tioned above (Ait-Hocine, 1990; Madill et al., 1990; Kellegrew
& Allen, 1996; Law & Dunn, 1993; SOU, 1998:66). Among stu-
dents with physical disabilities, the most common diagnoses
are cerebral palsy and spina bifida (Bille & Olow, 1996;Erhardt
& Cook Merill, 1998; Hall & Hill, 1997). In addition to motor
problems, students with these diagnoses could also have
other impairments, such as cognitive/perceptual problems,
speech impediments or visual impairments (Hall & Hill,1997;
Lie,1993; Stukt, 1985; Turner, Foster, & Johnson,1996).
Internationally, the percentage of occupational thera-
pists employed in school settings is increasing (Madill et al.,
1990). One important challenge for school-based occupa-
tional therapists is finding ways to adapt or modify the regu-
lar educational environment for students with physical dis-
abilities.Schools that are not fully accessible may prevent stu-
dents with physical disabilities from enjoying full access to
spaces and educational activities (Dudgeon, Massagli & Ross,
1996; Law & Dunn, 1993; SOU, 1998:66). On the other hand,
schools that are accessible may afford a student with a severe
disability the opportunity to participate in most or all educa-
tional activities.
In the International Classification of Impairments,
Disabilities, and Handicaps (ICIDH), a handicap is character-
ized to reflect the consequences for the individual cultural,
social, economic, and environmental - that stem from the
presence of impairment and disability (WHO, 1993). The
ongoing revision of the ICIDH, emphasizes the role physical
and social environments play in the handicapping process
and advances the importance of clarifying the role and inter-
relationships of environmental factors and disablement
(WHO,1997).
The significance of the environment for preventing or
reducing activity limitations is well known in occupational
therapy (Christiansen & Baum, 1997; Dunn, Brown &
McGuigan, 1994; Kielhofner, 1995; Krefting & Krefting, 1991;
Law,1991; Rogers, 1982).The term environment is defined to
include physical, social and cultural elements. Models in
occupational therapy describe a persons occupational
behaviour as an interaction between the person, the task and
the environment (Canadian Association of Occupational
Therapists (CAOT), 1997; Dunn et al., 1994; Kielhofner; 1995,
Law,1991).The person, the environment and the occupation
are seen as inseparable and interrelated to each other.A per-
son-environment fit is achieved when the skills and abilities
of the person are balanced with the demands of the environ-
ment to promote effective engagement in occupation (CAOT,
1997; Dunn et al., 1994; Kielhofner; 1995, Law, 1991).
Occupational therapy researchers have highlighted the
need for environment-centred assessments and intervention
strategies in the area of school-based practice (Broillier,
Shepherd & Markley, 1994; Clark & Miller, 1996; Griswold,
1994; Hemmingsson & Borell, 1996; Kalscheur, 1992; Orr &
Schadke, 1997; Rourk, 1996). Dudgeon, Massagli and Ross
(1996) examined the educational participation of children
with spinal cord injury. They found that accommodation in
schools supported program completion and advancement to
higher levels of education.
Niehus, Bundy, Mattingly, & Lawlor (1991) and Case-
Smith (1997) examined the nature of occupational therapy
practice in public schools and identified variables related to
successful school-based practice, as perceived by occupa-
tional therapists.These studies found that effective and suc-
cessful occupational therapy practice included reframing the
students behaviour so that it became understandable for
other members of the school team.This reframing minimised
the discrepancy between what the educational team mem-
bers thought the students should be able to do, and what the
students actually were accomplishing at school. The impor-
tance of team work and a collaborative approach for success-
ful intervention in the school setting has also been noted by
other researchers in the area of school based practice (for
example see Clark & Miller, 1996; Kellegrew & Allen, 1996;
Kemmis & Dunn, 1996).
While occupational therapy researchers have proposed
an environment-centred approach to school based therapy,
studies concerning the student environment fit and
demands in the school setting, as perceived by students with
physical disabilities, are lacking. Studies of students accom-
modation needs in the school setting and the ability of the
school environment to meet these needs are urgently need-
ed.Knowledge and understanding in this area could improve
the occupational therapy interventions and facilitate co-
operation among the teachers, the students, the parents, and
other members of the team.
The aim of this study was to identify accommodation
needs in the school setting for students with severe physical
disabilities attending a specially adapted upper secondary
school.The study sought to examine occupational behaviour
areas to determine where a good student-environment fit is
achieved or lacking.
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MethodParticipantsAll students with physical disabilities (n=51) who were
attending their first semester in one of the four specially
adapted upper secondary schools in Sweden, during the
actual year of the study, were asked to participate in the
study. Forty-eight (94 %) students, 28 boys and 20 girls, with
various diagnoses, agreed to participate. A majority of the
students had special educational needs due to their disabili-
ties. Only 15 of the 48 students were attending an ordinary
program in regular classrooms. The students characteristics
are shown in table 1.
Of the 48 students, 34 (71%) used a wheelchair for trans-
portation. Two of the students, who used a manual wheel-
chair, needed assistance to propel the wheel chair. Four stu-
dents (8%) used alternative communication devices, such as
Bliss symbolic technology or a word table.
The students level of disability was classified according
to criteria used by the nationally based government admis-
sion committee (see table 2) (SOU 1996:167).The basis for the
classification was the students application information. As
table 2 shows, one third of the participants in this study
needed assistance throughout the 24 hours.
SchoolsThis study investigated Swedish upper secondary schools
especially adapted for the needs of physically disabled stu-
dents (which will be referred to as specially adapted upper
secondary schools in this paper) (SFS 1985:1100).The special-
ly adapted upper secondary schools are physically integrated
within regular upper secondary schools in four cities
throughout Sweden. In these particular settings, a student
can choose to attend a regular class with non-disabled peers
or a special education class. These schools are accessible for
wheelchair users and the students who attend them are
guaranteed adapted schedules within the national upper
secondary programme. Assistance and therapeutic services
are available during the school day for students who need
these services (SOU 1996:167) and, if desired, the student
may live in a boarding house with special care (SFS
1985:1100).
Instrument and procedureThe School Setting Interview (SSI) (Hemmingsson, 1998) is
designed to assess the accommodation needs of students
with physical disabilities in the school setting. The SSI is
based upon concepts from the model of human occupation
(Kielhofner, 1995), specifically the models conceptualisation
of the environment (i.e., objects, spaces, forms and groups)
and Canadian concepts of client-centred practice (Law,
Baptiste & Mills, 1995). SSI uses a collaborative approach to
assessment,that enables small teams of persons with diverse
expertise (e.g.,the student and the occupational therapist) to
mutually define problems and generate creative solutions
(Hemmingsson, 1998).
The SSI is a semi-structured interview that covers 11
content areas (see table 3). For example, the therapist gets
information about the students ability to write, read, ver-
balise,remember things and do homework.The SSI also gives
information about the students classroom functioning,
exam-taking, going on field trips, doing math, need of assis-
tance and participating in sport, art and music.The content
areas are expressed in everyday language to increase the
students understanding of the interview questions.
For each content area, the assessment includes open-
ended questions that result in one of the following ratings:
a) no accommodation needs, b) accommodation needs ful-
filled, c) accommodation needs unmet. If the student needs
accommodation in the school setting (either fulfilled or
unmet needs), these needs are documented on the form in
order to record detailed information about the type of prob-
lem the student is experiencing. The presence of unmet
accommodation needs indicates a need for occupational
therapy intervention.
Table 1Participants characteristics N=48
Characteristics n (%)
Gender
Boys 28 (59)
Girls 20 (41)
Educational participation
Regular classroom 15 (31)
Special classroom 33 (69)
Diagnosis
Cerebral palsy 20 (42)
Spina bifida 8 (17)
Brain tumour 3 (6)
Congenital abnormalities 3 6)
Hemiparesis 2 (4)
Muscle diseases 4 (8)
Arthritis 4 (8)
Freidrich ataxia 3 (6)No diagnosis 1 (2)
Mode of Locomotion
Walking 14 (29)
Manual wheelchair 20 (42)
Power wheelchair 14 (29)
Use of alternative
communication devices 4 (8)
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A test of reliability and validity of SSI has been conduct-
ed (Hemmingsson & Borell, 1996). Regarding interrater relia-
bility, a kappa between .76 and 1.0 was found, indicating a
good agreement between pairs of raters. When all content
areas together were examined, the SSI demonstrated a sensi-
tivity of 0.96 and a specificity of 0.80. Thirteen occupational
therapists and a panel of experts investigated content validi-
ty. Separately they judged the content areas to be adequate
for the assessments intended purpose.
Data were collected with the SSI by 14 occupational
therapists who worked in the selected schools. All occupa-
tional therapists were very experienced having worked as
school-based occupational therapists for an average of 14
years. The occupational therapists read the SSI manual and
participated in a 1.5 hour training session in which they
learned how to administer the SSI.
Analysis of data1. The number of students with accommodation needs
(either unmet or fulfilled) was calculated for each con-
tent area.2. Proportion of students with accommodation needs ful-
filled versus the number of students with accommoda-
tion needs unmet was determined for each content
area.
3. The term student-environment fit is used to describe the
degree to which the conditions of the school met the
students accommodation needs. Therefore, for each
content area,the frequency of students with accommo-
dation needs fulfilled, in relation to all students who
Table 2The Level of Physical Disability, as Classified by theAdmission Committee
Level Definition n %
1 Relatively good ability to managedaily living tasks. 4 (8)
2 Ability to partly manage daily living
tasks independently but needs
extensive assistance and/or
assistive devices. 27 (56)
3 Requires 24-hour assistance
with all activities. 15 (32)
4 Fluctuation between level 1 and 3,
for example the students with an
arthritis diagnosis. 2 (4)
Total 48 (100)
Table 3The 11 Content Areas and Guiding Questions of the SSI
1. write, make notes, write a composition.
Have you tried any technical aids?
Are you in the habit of using com-puters? Which software have you
been using? Are you using any spe-
cial equipment?
2. read, aloud during the lesson, short texts,
a great number of,studying for an
examination.Enlarged text or taped
books. How do you carry all the
books and pick up the ones you
need?
3.say something, answer a question,join in thedebate,participate in group work,
call for assistance.
4.remember things, the timetable, different classrooms,
your homework, special appoint-
ments. Do you use an agenda?
5.do homework, what kinds of assistance do you
need and from whom? Do you have
the use of a computer or taped
books?
6. maths, physics,
chemistry, drawing a curve, formula.
Calculators,extra heavy rulers, spe-
cial equipment?
7.examinations, which different ways of taking
examinations have you tried? Oral
examination, written or by a com-
puter.The need for more time, priva-
cy or assistance.
8.sport,art,music, in which ways do you participate?
The use of any special equipment
like drawing-table, splints, software.
9.the classrooms, private chairs or desk, special work-
ing place, the blackboard. Classroom
for practical subjects.Transfer
between classrooms.
10. field trips, the use of public transport?
Different wheelchairs for different
occasions, assistance?
11.assistance, how do you usually get your assis-
tance? How satisfied are you with
the way you get the assistance?
(Hemmingsson, 1998)
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Table 4Students in Need of Accommodations, and Student-Environment Fit (Unmet and Fulfilled Needs) (N=48)
Students reporting need for Student-environment fit
Content area accommodations Fulfilled needs Unmet needs
n n %* n %*
write 37 21 (57) 16 (43)
the classroom 35 20 (57) 15 (43)
home work 35 22 (63) 13 (37)
assistance 34 26 (76) 8 (24)
field trips 34 27 (79) 7 (21)
examination 31 15 (48) 16 (52)
read 29 13 (45) 16 (55)
sport, art, music 28 24 (86) 4 (14)
count 27 14 (52) 13 (48)
remembering things 24 11 (46) 13 (54)
say something 12 5 (42) 7 (58)
* Reflects the unmet/fulfilled needs in relation to the total number of students who reported accommodation needs in the particular content area.
Hemmingsson & Borell
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indicated accommodation needs in that content area,
was tabulated and converted into a percentage. One
hundred percent can be interpreted to mean that the
school met every students accommodation needs in
this content area, indicating a perfect student-environ-
ment fit.The more students with accommodation needs
unmet in relation to all students with accommodation
needs,indicates a misfit on an increasing scale.Fifty per-
cent would indicate that half of the studentsaccommo-
dation needs were unmet and zero percent would indi-
cate that the school met none of the students accom-
modation needs.
4. When an accommodation need was identified on SSI,
the open-ended questions were coded by grouping
similar responses into matching categories (Polit &Hungler, 1995).
ResultsStudents Accommodation NeedsIn total, 47 out of 48 students (98%) reported accommoda-
tion needs in the school setting. Of the 11 content areas in
SSI, the number of content areas in which each student need-
ed accommodation ranged from 0-11, with a median of 7.
The need for accommodations (including both fulfilled and
unmet needs) was most frequent in the areas of writing,
classroom, homework and assistance (Table 4).
Seven students indicated that their accommodation
needs were met in all areas and they were therefore, satisfied
with the student-environment fit. Forty students (83%)
reported unmet accommodation needs.
Altogether, the students reported 326 different areas
where accommodation was needed. Of these, 198 needs
were fulfilled and 128 needs were unmet.The number of con-
tent areas with unmet accommodation needs per student
ranged from 1-11 with a median of 2.
Accommodation needs for writingThirty-seven students (77%) reported accommodation needsin writing. All these students were already using adaptive
writing techniques. Among the students in need of assistive
devices for writing, only ten indicated their devices made
them independent in writing tasks. Many students reported
the use of more than one strategy for being able to do writ-
ing tasks. The major strategies used for notetaking, and cre-
ative or report writing, respectively, are shown in table 5.
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Other accommodations requested by students were a
locker, work space for a computer, better information on the
part of assistants and teachers, and strategies, like visual
clues, for easier orientation within the school environment.
Accommodation needs for assistanceThirty-four students (71%) reported that they needed assis-
tance during the school day. All of them had access to a pool
of assistants. Despite this access to assistants, eight students
believed their needs were not being met.The majority of the
students wanted the occupational therapist to inform the
assistants about their activity limitations and special needs.
This information most often concerned the studentspercep-
tual/cognitive problems, such as problems in orientation,
memorising or understanding written language. Others
wanted the assistants to know more about the high technol-
ogy assistive devices that students used. Some students
wanted to discuss how to be enabled to manage better with
less assistance.
For many of the students,the system for providing assis-
tance had changed from upper level of compulsory school to
upper secondary school (table 6). In upper level of compul-
sory school, most students were accustomed to having a per-
sonal assistant employed for the particular student. In the
specially adapted upper secondary schools they had class
assistants or a pool of assistants available for the students
with disabilities. Only one student reported having access to
a personal assistant in upper secondary school,compared to
24 students (50%) in compulsory school. Nevertheless, a
majority of the students stated that they preferred the sys-
tem used in the specially adapted upper secondary school
where they freely drew from a pool of assistants. Only one
student indicated that he preferred the system that provided
students with an assigned personal assistant.
An assistant who wrote for the student was a common
accommodation, especially in notetaking. Thirty-five stu-
dents needed assistive devices in writing, most commonly a
computer. Frequently special equipment for the computer
was needed (for example an adaptive computer interface,
headgear, mouth stick, forehead stick, and special control
devices like a joystick or puff-suck switches). Other assistive
writing devices reported were special pencils, pencil holders
and mobile arm supports.
Sixteen students reported unmet accommodation needs
in writing.The majority of these students needed to add some-
thing to the accommodations they already had. Additional
required accommodations included special equipment for the
computer,software,pencil holders or information to assistants
and teachers about their assistive devices.
Six students were dissatisfied with the accommodation
they had. All of these wanted to have access to a personal
computer in regular classrooms.
Accommodation needs in the classroomThe students major concern about the classrooms was the
furniture.Eight students, six of whom were attending a regu-
lar classroom, were dissatisfied with their desks.The students
in power wheelchairs needed a desk which was higher than
the standard desk height and the students using manual
wheelchairs needed desks which were lower than standard.
Four students reported that they needed a special chair in
the classroom. The students in regular classrooms changed
classroom several times every day for different subjects. Four
students in regular classrooms reported that some of the
classrooms were outside the school building and not acces-
sible for wheelchair users because of stairs,lack of door open-
ers or steep ramps. These students indicated that they want-
ed to change classrooms.
Table 5The major writing techniques used in two writingtasks by students requiring an assistant or assistivedevices
Writing technique Notetaking Creative writing,
report writing
Self-writing with device 13 2
Computer 2 16
Computer with assistance* 2 5
Assistance 20 14
Total 37 37
*Needed help from start to finish
Table 6Type of assistance required at compulsory school andupper secondary school
Compulsory Upper
school secondary
school
Personal assistant 24 1
Class assistant 9 25
Pool of assistants 0 10
Friends, teachers 4 0
No assistance 10 12
Total 47* 48
* One missing answer
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Student-Environment FitThe specially adapted upper secondary schools, which were
physically integrated into regular schools, had important
accommodations to suit the students they served. The
accommodations available in these schools could be
described as general, group or individual (table 7). General
accommodations were those that could be used by anyone
in the setting,even if they were of special importance for the
students with physical disabilities. Group accommodations
were arranged for and available only for students with dis-
abilities. Individual accommodations were those arranged for
and used by a specific student (for example,see table 7).
The findings (see table 4) indicate that the schools were
most successful in meeting students accommodation needs
in sport,art, music, field trips and assistance.In these content
areas, the schools offered important accommodations for
disabled students as a group, meeting more than 75% of the
students accommodation needs. According to these find-
ings, group accommodations in these content areas suited
the students very well.
On the other hand, student-environment fit in reading,
remembering and speaking (i.e. saying something) was
unsatisfactory. Only 50 % of the students accommodation
needs were fulfilled in these three areas. The discrepancy
between the schools expectations and the students ability
to meet these expectations was most notable in these areas.
The results indicated that the students activity limitations in
these areas were mostly related to problems of a cogni-
tive/perceptual nature rather than motor problems. For
example, one frequent problem reported was inability to
remember the things that were expected. As many as seven
students wanted to learn how to use an agenda in order to
be more independent in time-management. Some students
needed personal assistance when reading and/or to get writ-
ten material audiotaped as they were unable to read the
expected quantity of written material. In these areas, the
schools general and group accommodations did not fully
meet these students needs. Although most of the students
were attending a special education classroom (a group
accommodation), they still reported unmet accommodation
needs. Several of these students with accommodation needs
in reading, remembering and speaking wanted the occupa-
tional therapist to inform the educational team about their
activity limitations so that the schools expectations could be
more in accord with each students ability.
Another interesting finding was that every student with
accommodation needs in reading (n=29), also had accom-
modation needs in writing. Moreover, every student with
accommodation needs in speaking (n=12), needed accom-
modation within both writing and reading. No other strong
relationships between areas of need were found. It was also
found that students with accommodation needs in reading
and speaking tended to report accommodation needs inmore content areas than other students do.For the students
with accommodation needs in reading, the number of con-
tent areas with accommodation needs per student ranged
from 3-11 with a median of 9. For the students with accom-
modation needs in speaking, the number of content areas
with accommodation needs per student ranged from 6-11
with a median of 10. Thus, students with accommodation
needs in reading and speaking were the students who need-
ed the most accommodation and had the most unmet
needs.
DiscussionThe areas the specially adapted upper secondary schoolshad adjusted with most success were a) sport, art, music,
b) field trips and c) assistance. In these areas, the schools
offered important group accommodations that suited stu-
dents with disabilities very well.These findings were interest-
ing, since several studies have found that in the regular
school system both field trips and physical education are
usually the areas in which students with disabilities do not
participate, or in which they experience most problems
(Barron, 1995; Mattsson, 1995; Stukt, 1985; Whitehouse,
Shope, Sullivan & Kulik, 1989). This finding illustrates the
interrelationship of environmental factors and disablement(CAOT, 1997; Dunn et al., 1994; Kielhofner, 1995, Law, 1991;
WHO, 1997). Contrary to findings in other studies, the school
personnel in the schools in this study were successful in cre-
ating environments that enabled the engagements of stu-
dents with severe physical disabilities in extra curricular
activities. Group environmental accommodations in these
content areas, were a notable adaptation by the school per-
sonnel.
Another successful type of group accommodation was
Table 7Examples of Accommodations Available in the Specially Adapted Schools
General Group Individual
Elevators Special educational classroom Special chairs and desks
Spacious areas Sport activities arranged for students with disabilities Assistive devices
Automatic door-openers Free access to a pool of assistants Use of alternative strategies
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the system of having class assistants or a pool of assistants
available for the students with disabilities. A majority of the
students stated that they preferred the system used in the
specially adapted upper secondary school where they freely
drew from a pool of assistants, indicating a preference for a
group solution rather than a more individual one. This find-
ing corresponds with Barron (1995), who found that a per-
sonal assistant could be experienced as an obstacle for
autonomy by the disabled youth.According to Barron (1995),
the close contact between the assistant and the disabled
youth could mean that the role of assistant and friend
became intertwined. The person who is dependent on the
assistant may be afraid of hurting the assistants feelings by
complaining. It is possible that having class assistants or a
pool of assistants, which eliminates the students depen-
dence on one single person, decreases the students feeling
of emotional dependence.
Assistance appeared to be an especially complex issue.
For the student with severe physical disability and additional
impairments, having assistance in daily living activities and
school tasks may be inevitable (Barron,1995; Dudgeon et al.,
1996; SOU 1996:167; Stukt, 1985). However, the students
need of assistance in academic tasks as well as in self-care
activities within the school environment, places heavy
demands on the pool of assistants employed by the school.
Although the assistants have a key role in the educational
process, there is no minimal education required for assis-
tants. Most have limited understanding of the students
underlying problems and how to manage them.Several stu-
dents identified this lack of understanding as a problem and
also wanted the occupational therapist to inform the school
staff about their activity limitations.
Therefore, to improve the assistants understanding of
the individual students specific problems, supervision and
guidance by the professional staff is extremely important.
The occupational therapist, who has knowledge of medical
conditions and the psychosocial problems associated with
disability, as well as expertise in assistive devices and envi-
ronmental accommodations,is well suited for serving as con-
sultants for this group of assistants. As Niehus et al. (1991)
and Case-Smith (1997) found, reframing a students behav-
iour can minimise the discrepancy between what the educa-
tional team members think the student is able to do and
what the student actually is able to accomplish.Consultation
and co-operation between the occupational therapist and
the assistant, as well as the teachers, could enhance the stu-
dents well being and accomplishments in the school envi-
ronment.
Another important point seems to be to increase the
students capability to negotiate with professionals to get
the support and accommodations they needed by promot-
ing self-advocacy. As teenagers, these students probably
need training in self-advocacy skills, for example being able
to explain how a specific accommodation will help them or
being able to describe their disability, to enhance personal
self-advocacy. It could be one important issue for the school-
based occupational therapist to help these adolescents
develop skills in self-advocacy, skills that they indeed will
need throughout their lives (Schlaff, 1993; Vessey & Miola,
1997;West et al.,1993).
Some of the most important accommodations in the
schools were probably the general accommodations of the
physical environment. In studies of disabled students in reg-
ular schools, architectural barriers have been mentioned fre-
quently as obstacles (Dudgeon et al., 1996; Korpela &
Koivikko, 1992; Mattsson, 1995; SOU 1996:167; Turner et al.,
1996).These accommodations seemed to be well integrated
into the schools included in this study,since students did not
always experience them as accommodations but just as part
of the usual environment, indicating a good student-envi-
ronment fit. Students mainly recognised the absence of
architectural accommodations but took their presence as
something natural. For example, only a few students men-
tioned wheelchair accessibility as an accommodation they
needed even though it was indispensable for about 70% of
the students. Students who mentioned that they needed
accommodations to provide wheelchair accessibility were
those who experienced barriers, e.g., stairs, steep ramps or a
lack of door openers.
On the other hand,the students would not have experi-
enced some of the unmet needs as such if the schools had
offered more general accommodations by creating a more
enabling environment. Six students reported they wanted to
have access to a computer in the classroom to be more inde-
pendent in writing tasks,and eight students reported unsuit-
able desks. We did not expect to encounter these conditions
in schools specially adapted for severely disabled students. If,
for example, all regular classrooms had been equipped with
one or two special desks and a computer free to use when
needed, some of the students with disabilities would have
used those general accommodations rather than wanting an
individual solution.
The insufficient student-environment fit in the areas of
reading,remembering and speaking,was especially disquiet-
ing as these content areas are related to skills necessary for
success in many academic tasks. It is possible that the misfit
indicates that the students with accommodation needs in
these content areas are the students more in need of individ-
ual solutions and individual support. Obviously general and
group accommodations available in these schools were not
enough for these students.
Regardless of the need for additional individual accom-
modations, general and group accommodations could be
improved. Our findings indicate that accommodation needs
in reading,and speaking, should be considered key factors in
ensuring educational success for these students. Therefore it
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is an urgent need to develop accommodations that fit these
studentsneeds both on a general, group and individual level.
Maybe this is an area to which extra attention should be paid
in the future.
Removal of architectural barriers is not enough to fulfil
the need for accommodation experienced by students with
physical disabilities in the school setting. There is a need to
develop accommodations to meet students needs in more
academic tasks like reading and remembering things. This
suggestion also corresponds with the literature in the field.
Paulsson & Grip (1976) and Stukt (1985) state that it is not
solely the physical disability that causes problems in school.
Rather, it is the combination of a physical disability with addi-
tional impairments that causes the most important problems
in the educational situation. If, for example, students with a
physical disability and limited reading skills had the right to
free taped text books,provided by the government, it would
be an effective way of meeting unmet needs in the area of
reading.
Although general accommodations and group accom-
modations seemed to be extremely important for students
with disabilities, they were not enough. This study indicates
that general and group accommodations had to be com-
bined with an assessment of each students needs to create
individual solutions when needed. A proper assessment of
each students individual accommodation needs before
attending the schools would indeed be of great value for the
student.For example, assistance is sometimes given in a rigid
way without careful attention to each students own desires
or without references to specific activity demands. Several
students who needed assistance indicated that they wanted
a more individualised solution.
This study has identified accommodation needs and
environmental solutions important for the understanding of
school performance for students with physical disabilities.The
students investigated were well represented as 94% of the
possible population participated. Types of diagnoses repre-
sented by the participants correspond with the known distri-
bution for the population of students with physical disabilities
in Sweden (Skolverket, 1996;Billie & Olow, 1996).However, the
participantsphysical disability was more severe and the need
for assistance in school tasks was more frequent,compared to
students with physical disabilities in regular school. The fact
that this study was conducted in Sweden means that replica-
tion is needed in other countries in order to establish the
potential for generalisation. One limitation of this study could
be the influence of one specific European society and its laws
and regulations, as well as the way this specific society inter-
prets physical disability. However, the need to further clarify
the role and interrelationships of environmental factors and
disablement are international (WHO, 1993).
The instrument used in this study is another factor for
attention when considering the results of this study. The
School Setting Interview (Hemmingsson, 1998) is a client-
centred assessment, built upon a semi-structured interview.
In such an assessment, the relationship between the inter-
viewer and respondent, as well as the occupational thera-
pists skills in interviewing could influence the result. In this
study, the occupational therapists conducting the interview
had an ongoing professional relationship with the respon-
dents. This situation meant that 13 different persons were
involved in collecting data for this study. The relatively large
number of people involved in data collection could be a lim-
itation as the interpretation of the manual and the training-
session, as well as the occupational therapy perspective, is
individual for each person, and could influence the result.It is
possible the result would be somewhat different if the inter-
viewer had been the same person and somewhat unknown
by the students. In our view, this limitation was balanced by
the assumption that a closer relationship probably encour-
aged the students to more truly express their needs as they
could see the direct use of speaking up about their problems.
There is a growing trend of inclusion of students with
physical disabilities in regular classrooms in many countries.
For example, currently about 90% of Swedish students with
physical disabilities are attending a regular class in their
neighbourhood compulsory school (Skolverket, 1996). Some
of these students have a severe physical disability as well as
additional impairments. Whether such students experience
barriers in regular schools and whether the schools meet such
students needs for accommodations requires further investi-
gation. These findings indicate that physically disabled stu-
dents need a combination of general, group and individual
accommodations. It would be useful to employ this categori-
sation in an investigation of the student-environment fit in
regular schools. This investigation could provide knowledge
about students accommodation needs and identify possible
improvements in the school setting on general, group and
individual levels for students with physical disabilities in regu-
lar schools. How students with disabilities experience general,
group or individual accommodations, and if and how these
accommodations contribute to participation in school activi-
ties, is another area that needs further investigation.
Occupational therapists traditionally help clients on an
individual level. The findings indicate that students with
physical disabilities need a combination of accommodations,
on different levels, to increase their participation in school
activities. Therefore it is suggested that occupational thera-
pists take more responsibility for barrier removal and envi-
ronmental modifications in a broader sense that may be ben-
eficial for the whole society. It is important that occupational
therapists offer society their expertise. Co-operation with
other professionals in the field, as well as with the students,
concerning when and how to adapt the physical and social
environment can remove obstructions or restrictions to the
full participation of people with disabilities in life activities.
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AcknowledgementsThis study was supported by grants from the Karolinska
Institute in Stockholm,Sweden.
The authors also wish to thank the occupational thera-
pists working in the upper secondary schools especially
adapted for the needs of physically disabled students, for
their active contribution to this study.
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Copyright of articles published in the Canadian Journal of Occupational
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