Supplementary Aids and Services Webinar

by Sue Cecere PT, MHS

A young boy interacts with his sister seated in an activity chair by using a supplemental aid and service tablet deviceSupplementary aids and services are a valuable way for therapists to support students in school systems. By viewing this 30 minute webinar, you will improve your knowledge of the role of supplementary aids and services as part of the IEP process, including decision making, key factors, and service delivery. This webinar also touches on the ICF in school-based practice, and the universal design for learning, also known as UDL, as well as the use of adaptive equipment in the context of student health and participation. All this relates to current evidence-based practice. The guidance offered by this webinar may be new to many school systems. Don’t miss the concluding slides with take home points, sources, and references. A full webinar transcript is provided below.

Rifton  Supplementary Aids and Services Webinar

Webinar Transcript:

  1. 00:20 (the number of seconds of narration on this slide)
    Welcome to this webinar. Thank you for joining us. We asked Sue Cecere to present this webinar, knowing of her insights on the use of supplementary aids and services in the classroom. She will be joined by guest contributor Peggy Belmont. Both are physical therapists with years of experience in school-based practice.
  2. 00:18 Sue Cecere is an active member of the Pediatric Section of the American Physical Therapy Association. She is also a certified MOVE International Trainer, and the PT instructional specialist for Prince George’s County in Maryland. It’s an honor for Rifton to share her expertise.
  3. 00:14 Peggy Belmont currently works as a consultant on school-based physical therapy administration and intervention. She is a retired manager of the therapy division of Fairfax County Public Schools in Virginia.
  4. 00:37 This is Susan Cecere. During today’s webinar, we’ll be discussing the ICF in school-based therapy, supplementary aids and services, the purposeful use of adaptive equipment and the universal design for learning, also known as UDL, decision making, key factors, and service delivery. My colleague, Peggy Belmont, will be discussing evidence-based practice, student health and participation, and then wrapping up this webinar with take home points, sources, and references.
  5. 00:50 We hope that as a result of listening and watching this webinar, viewers will gain awareness of the ICF focus on participation and the role of the environment, improve their knowledge of the role of supplementary aids and services as part of the IEP process, understand the purposeful use of adaptive equipment in school-based practice and UDL principles, recognizing that the application of adaptive equipment can be a therapist intervention, gain perspective on supplementary aids and service decision making and service delivery, gain awareness of current research on health and participation with the use of adaptive equipment, and ultimately be able to apply these concepts to their current practice.
  6. 00:38 The ICF is the World Health Organization framework for health and disability. It stresses health in the presence of disability, and is extremely client-centered. It does not see disability as only a medical or biological dysfunction. Changing the perspective from a deficit one, to an enablement one, and it shifts the focus from cause to impact, including the impact of the environment. It’s a framework that helps us identify what the active ingredients of our intervention process may be.
  7. 01:57 The ICF describes three levels of functioning: body structures and function, the capacity to perform activities, and the ability to participate with others. This third level, participation, engagement in life activities that are meaningful to the person, is universally the most meaningful, and is the level toward each person instinctively strives. How well a child with disabilities participates in his or her daily routines is paramount to their health and wellbeing. There are some key concepts to practicing using the ICF. Number 1, the ICF requires the clinician to systematically evaluate the relationships among all health factors in order to develop a PT plan of care – goals, outcomes, and evidence-based interventions, for the IEP. Number 2, the ICF has us build on an individual’s strengths, desires, and performance in relative contexts. It focuses on positive outcomes rather than the negative consequences of the pathology. It is a strength-based approach. Number 3, a student’s diagnosis alone does not impart the necessary information to adequately address his or her educational needs with regard to service provision, level of assistance, or functional outcomes. Number 4, a direct relationship cannot be assumed between the severity of impairment, and the student’s functional independence. Every aspect of the ICF model affects the other. And Number 5, the ICF empowers the student or the client. It emphasizes their goals and activity, not ours.
  8. 00:38 The documentation of supplementary aids and services is part of the IEP process. If you notice from the quotes on the slide, you will read that they are intended to enable children with disabilities to be educated with non-disabled children to the maximum extent possible. And to support students with disabilities as active participants with non-disabled peers, as well as to enable access to the general ed curriculum. It is meant to keep children in general ed, and is very supportive of the idea of the least restrictive environment.
  9. 01:19 You will notice from the slide that the areas covered by supplementary aids and services are very diverse. As an example, in the area of collaborative. This is where a therapist can work with the classroom staff to support students in a variety of ways. Whether it be in their way of learning, how materials need to be presented, in their physical management. In the area of instructional, it could be special devices in order for them to see better, to hear better, to support the way instruction is delivered. In the area of physical, which is sort of nearest and dearest to the physical therapist’s heart, adaptations and modifications to the physical environment, including the application of adaptive equipment, can be applied, in order to support a student in a general ed setting. And lastly, social and behavioral supports, can be used to support disruptive behaviors, or any other interfering behaviors that may affect a child’s ability to learn. How decisions are made in each of these areas requires the team to come together and brainstorm for things that would improve access and participation for any student that has been identified to need special education and/or related services.
  10. 01:08 Therapists must fully understand supplementary aids and services, to assure appropriate services in the least restrictive school environment. Critical to this process is data collection, and making data driven decisions. How do we do that? We do that as a team. This approach requires the IEP team members to collaboratively gather and analyze information about a student in relationship to the regular ed classrooms that represents the first environment considered in their educational placement. So how do we do that? We compile and organize information about a student, we create a profile of the setting and expectations, we identify potential barriers to achieving goals, meeting expectations and curricular demands, we discuss existing supports, and we discuss ways to remediate barriers. We use the ICF framework, and focus on the contextual factors, the environmental factors, and the personal factors. And that is where the adaptive equipment often steps in.
  11. 00:27 Having worked with our team, we are now able to identify environmentally-referenced supplementary aids and services that will support a student to participate and learn within the general education classroom. Some identified uses of equipment are for classroom-based intervention, health and wellness, skill development, and access and participation.
  12. 00:29 As an example of classroom-based intervention, you see this student sitting in an activity chair at their desk. What this enables this student to do, is several things. Have the postural control to engage long enough in a table top activity with peers, and to be appropriately positioned. They’ll get better use of their upper extremities, they’ll have better visual engagement, as well as practicing sitting skills.
  13. 00:33 This student with limited mobility is being provided an opportunity to stand for physical health and wellbeing. It is also used as a way to enable his involvement in the classroom. It could also be used in the help of the acquisition of skills such as propelling a wheelchair for greater independence, and to give him practice in doing so. It’s also a way to support social interactions. At the end of this webinar, there are some research references that support the value of standing.
  14. 00:42 Adaptive equipment can be used for skill development. In this case, a Pacer is being used to develop more functional ambulation skills. The ability to remove prompts helps facilitate more independent function and skill acquisition, which could be part of a student’s IEP. The Pacer allows the student to work on moving around the classroom, or anywhere else in the school environment, including recess and in physical education. The idea of prompt reduction is to support greater and greater independence and the ability to make choices in life.
  15. 00:23 The use of adaptive equipment also facilitates access and participation for students. It allows them to engage socially with non-disabled peers of the same age in a multitude of situations, such as on a playground, or in a physical education class, or out in the community.
  16. 00:59 Physical therapists can support students who are not in need of special education and/or related services and only need the application of universal design for learning theory, response to intervention strategies, and/or a 504 plan. A 504 plan is for students who have a perceived or documented medical condition that affects a major life function such as reading or walking. Adaptive equipment can be used to level the playing field for some students. In terms of RtI, those students are not yet in need of special education or related services, but PTs can still support for the process of consultation. Sometimes, simple environmental changes can be enough to encourage engagement or to allow for full participation in any or all school routines and activities.
  17. 00:43 Universal Design for Learning is part of the Higher Education Act enacted in 2008 by Congress. It is a scientifically valid framework for guiding educational practice that provides flexibilities in the ways information is presented, in the ways students respond or demonstrate knowledge and skills, and in the ways students are engaged, and reduces barriers in instruction by providing appropriate accommodations, supports and challenges. It maintains high achievement expectations for all students including students with disabilities, and students who are limited English proficient.
  18. 00:24 What are the factors to consider when making decisions about supplementary aids and services and specifically adaptive equipment? Be reminded that all decisions regarding the need for supplementary aids and services is a team decision and should always be conducted with your team. A good resource is the toolkit that is listed on the slide.
  19. 00:34 What are the questions we ask ourselves in order to determine if a student needs supplementary aids and services in order to receive a free and appropriate education? One might be, does the student need modification to the physical environment for successful access and participation? If a student is in a wheelchair, they might need a barrier-free environment, which would be a modification to the physical environment of the classroom. It would need to be provided every day, and the teacher and classroom staff would need to be aware.
  20. 00:44 Another question we might ask ourselves is if the student needs supportive inclusive opportunities during transitions or other activities within the school day. If they do, then why do they? They may be developing more independence as they use an adaptive device to facilitate their ambulation skills and their ability to be more independent. How and where? All transitions during the school day – from the bus to the classroom, from the classroom to the cafeteria. They may need ample time to do so, and we might ask the para-educator to provide that supervision in order for the student to be successful in enacting this during the school day.
  21. 00:45 Another question might be, does the student need support of improved posture and positioning for access to curriculum or instruction? Postural control is an issue. Why? Because they are unable to sustain a sitting posture and visual engagement long enough to engage in one classroom activity such as a reading lesson or math lesson. So how and where? We’ll use that adaptive seating for all table top activities and make sure all the appropriate prompts are on. We’ll teach that to our classroom staff, and we’ll make sure it’s done daily in order for the student to have the best opportunity to access those materials.
  22. 00:57 Another question is around the ability to practice self-help skills. Does the student need support of inclusive opportunities in self-help skills and/or personal hygiene? A student might be working on their ability to participate in a toileting or self-help routine. If so, then how are we going to support that? We might support that with adaptive equipment, such as a Blue Wave toilet and/or Support Station. Why? Because they don’t have postural control for a regular commode, or they are working on developing standing ability for having their clothing managed. If yes, how and where? For all toileting opportunities. And who will we be training? Classroom staff, anyone working with the student during those times of the day, in order for this student to become very proficient in his ability to manage his own personal hygiene.
  23. 00:36 We might also ask ourselves - Does the student need support for physical management of classroom or other instructional materials during the day? If yes, then why? They may be using a Pacer or a posterior rolling walker where both hands are used in order to hold themselves up, and so cannot carry those instructional materials. So we might ask a buddy to carry them, we might put a basket on a walker or Pacer, or we might add a basket to a desk so they can keep materials with them during the course of the day.
  24. 00:24 Another question we might ask ourselves is, do I need to support this student’s health through positioning. Many of our students spend the majority of their time in some type of wheelchair, and they are not able to re-position themselves. So an alternative position is desirable to maintain their health and well being.
  25. 00:39 Another question we might ask, in order to support our decision-making, is Does the student need support of practice opportunities during the school day, for continued acquisition of motor skills for greater independence? If the answer is yes, then why? Our students might be working on propelling skills, they may be working on ambulation skills, and in order to become successful, they need opportunities during the typical activities and routines of the school day. This needs to be documented and shared with the remainder of the team in order for these activities to be incorporated into the student’s school day.
  26. 00:28 Many of our students spend the majority of their time sitting, so we have to ask ourself: does the student need support for increased social interactions with peers? Being able to stand and be at the same eye level as their peers is a way to increase those social interactions. Adaptive equipment is often the way that we do this. So if the answer is yes, then this also needs to be added to the IEP as a supplementary aid and service.
  27. 00:41 Lastly, when we start to make decisions about supplementary aids and services, we have to ask ourselves, Do the classroom staff or other school personnel need support in the physical management of the student with equipment, training and/or instruction? This often is a key component of service delivery, and the way a lot of physical therapists spend their time during the school day. Para-educators, classroom teachers, parents, and other school personnel need instruction on how to manage equipment, how to appropriately place students in equipment, and the appropriate use of equipment.
  28. 00:40 As school-based physical therapists, we must recognize the importance of supplementary aids and services in a student’s IEP. If our job is to support the least restrictive environment, then the addition of supplementary aids and services may be the only intervention we need to provide. If those supplementary aids and services are used to facilitate the development of a skill, it may affect our frequency and intensity decision. It will also affect our decisions on how often we need to train personnel, how often adaptive equipment needs to be used and what it needs to be used for.
  29. 00:15 I’d like to turn the Webinar over to my friend and colleague Peggy Belmont. Peggy Belmont will be addressing evidence-based practices as it relates to the use of supplementary aids and services, with a focus on student health and participation.
  30. 00:33 I’m Peggy Belmont. I am recently retired from being a school-based PT for over 35 years. Sue has done an excellent job for us in discussing the context for us to rethink the role and the methods for PTs working in school systems. Using the framework for the International Classification of Function, and the Universal Design for Learning 2008, school-based PTs are uniquely positioned to improve the supports to students using evidence-based practice, and that’s what I would like to talk to you about.
  31. 00:43 PTs in all areas of practice have been challenged over the last 15 or 20 years to use evidence-based practices. Most of our orthopedic therapists, our acute care therapists, our geriatric therapists, all moved forward quickly. Pediatric, and in particular school-based therapists, had very little research or practice standards to use in their decision making for students. I too found it very difficult, and I am now happy to report to you and excited for our future that school-based physical therapists now can easily find evidence to base the decision making for your students and your practices as a school-based therapist.
  32. 01:45 In the 1970’s, Special Education Law mandated two major pillars of support for students with special needs. One, Special Education, and the other – Related Services. Physical therapists, as related service providers, went into the school to help those students who required physical therapy services, to participate in their instructional program. In 2004, No Child Left Behind legislation changed pupil services of the elementary and secondary education act to “specialized instruction support personnel.” Physical therapists can fit within that definition, and their roles in the school setting will be expanded not only to special education but to general ed students also. In 2004 also, IDEA authorized with new regulations and identified a third pillar of support. Not just special education and related services but now the third pillar is called supplementary aids and services. The new mandate states that “special education, related services, and supplementary aids and services must be available to students of need and must be based on peer-reviewed research to the extent practicable.” No longer should we be considering evidence-based practice as an option. This definitely mandates that we use evidence-based practice in school-based settings.  IDEA 2004 tells us to do so.
  33. 01:01 Good news. There is now research that supports what we do as school-based therapists. At the end of the slides for this presentation, we compiled a listing of resources and references for your use. In particular, I searched for the meta-analysis for studies that could help us. There is evidence for pediatric PTs on student participation, movement, and assessments. Special education research is reporting on access, engagement to instruction, as well as access to school environments. Both PT research and physical education research informs us on motor skill acquisition, motor skill assessments, and school-based services. A recent resource came forward on norm values for musculoskeletal conditions and functional motor abilities, for the pediatric population with disabilities.
  34. 01:01 The supplemental aids and services mandate states that, quote, “Supplementary Aids and Services means aids, services, and other supports that are provided in regular education classes, other education-related settings, and in extra-curricular and non-academic settings, to enable children with disabilities to be educated with non-disabled children to the maximum extent appropriate.” End quotes. Using the ICF model and the UDL framework for decision-making, PTs will be an important part of that school team, in providing information and services that will allow the students social interaction and participation throughout the school environment. Services could include identification, resolution of environmental barriers, access to adaptive equipment, or supports and training to staff.
  35. 00:35 As school teams provide expanded opportunities for our students, the physical therapists must also bring their expertise on student health issues. This is another area of significant amounts of research. For instance, we now know that children with CP can benefit from endurance movement programs. We also know that there are many studies of the benefits of positioning programs. The data on obesity is even more relevant for our students who are challenged in movement options.
  36. 00:59 I included this slide to make sure all school PTs are aware of the new standards of practice that are being used for lifting clients. The National Institute of Occupational Safety and Health recommends a maximum of only 35 pounds for patient lifting and handling. The Occupational Safety and Health Association also recommends workplace lifting should be minimized or eliminated when possible. As the transfer and lifting specialists in school systems, PTs need to be our staff, our parents, and ourselves pain and injury free. You can be assured of back up support from these two powerful agencies as you help the parents and the school acquire the needed equipment and training. And yes, this is a part of being a school PT. Connie Johnson has an excellent article on lifting on the Rifton.com website.
  37. 01:09 So we have mandates from the school law and from safety agencies on best practices in school systems. Most of us remember how American Physical Therapy Association established a futuristic vision for PTs to be accomplished by the year 2020. It’s called Vision 20-20. One strong component was that PTs were to be giving evidence-based services and would be fully accessing basic and clinical research in our practice decisions. Be assured that the Pediatric Section and the APTA are focused on getting more and more clinical and basic research for our use so that we can accomplish that vision. The Pediatric Section has several school-based handouts, they have developed school-based competencies, they are working with the Foundation for funding for research, to fund more pediatric research. The APTA website now has a new information system called PT Now. Take time to look at the PT Now information about children with cerebral palsy.
  38. 01:12 So today’s standards of practice for school-based PTs must be based on data-driven decision making. Coming soon is research from a multi-center study on dosage and working with students. We really might have guidelines soon on what amount of time and frequency should be sufficient for making changes in student outcomes. That is a large formal study that will certainly guide us in the future. But you too can guide your practice. Why not take data on your supports and services to students. To start with, you might consider just one or two small things. See what your success rate is on successfully embedding exercise routines into daily activities. After you gather that data, decide what you will do the following year to improve your success in this area. These small self-studies will change how you do things and that is important to your practice and to outcomes for students. Not all data driven decision practice has to be formalized research studies. Take a chance, just do it.
  39. 01:08 You are the expert to the school staff and families on PT services. You may be the expert to them on the medical conditions of the child. You can be the expert that brings to them the research data, both formal and informal, that guides decisions or backs up your proposal. Of course, the opposite is also true. Parents can bring in studies that show your intervention could be done differently. But working collaboratively, the well-informed IEP team is usually the most successful IEP team. You are expected to train and follow up on your training many different people on ways to support positions, ways to practice exercises, and ways to handle our students. You may be the only one who knows the exercise principles and how they apply to student function. You are responsible to the students, the staff, and the parents to train well with a focus on student health and participation. It takes many teams working together to accomplish great outcomes for students with special needs.
  40. 00:11 Thank you to both Sue and Peggy for your insights. Following are the summary comments from both presenters. Use the small arrow at the bottom of your screen to advance through the next slides.
  41. 00:47 After viewing this webinar, we hope that you as the participant will recognize the importance of the use of the International Classification of Function as a foundation for your assessment and decision-making in school practice. With its focus on participation, and the use of activities, activity limitation, impairments, personal and environmental factors, a school-based therapist can make grounded decisions in terms of intervention strategies that will work for their students. It is critical to the student’s participation, and access to curriculum and other school activities and routines, to embed the environment and focus on environmental factors in order to make those things happen.
  42. 00:20 Another point we would like the participant to take home with them, is that the role of the school therapist may change over the student’s lifetime in school. Intervention strategies change depending upon the environment, the expectations of the environment, the critical needs of the student, as it relates to those factors.
  43. 00:33 School-based PTs can no longer declare that there is no school-based PT research. With our services now expanded into more areas than just how is the student moving or what position we should put him in, we have to prepare ourselves with data that can help make the best decisions about what equipment is needed, the environmental changes that are required, times and frequencies of activities, locations of interventions, location of practice and many more decisions that are within our expertise. You might even consider working with a university program for an opportunity to provide the clinician part of a dynamic researcher-clinician collaboration for more school-based evidence that can be used by all of us.
  44. 00:35 Take Home Point #4. Supporting supplementary aids and services is considered a therapist intervention. Clinical reasoning is absolutely necessary in order to choose appropriate adaptive equipment, integrate it into the learning program of a student, train the appropriate personnel on its use, and to focus on the data collection. Is it doing what we thought it would do? Is it supporting engagement, positioning, health? This requires the physical therapist.
  45. 01:02 Supplementary aids and services offer therapists a new way to support students in school systems. We shared with you new principles to use as you make decisions about the supports, services, and interventions you choose for each of your students. You might use the ICF model to determine where you will put your focus for the coming school year. You could use the Universal Design system as a way to identify equipment that can be placed in a classroom that would help not only the student you are assigned to, but other students as well. You certainly will use evidence-based practice, it’s expected of us. The guidance we are offering is still new to many school systems and may require great finesse as you work with your school teams. What is certain is, using these models and principles as we’ve discussed, you will be pleased with the outcomes for your students. You will certainly feel a sense of professional renewal and you will most assuredly get better outcomes for your students.
  46. 00:17 As we have seen, having a fuller understanding of the role of supplementary aids and services can greatly enhance the practice of school-based therapy. At this point, you may advance to the final slides showing resources and references for your further review. Thank you for joining us.
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