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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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LA REVUE CANADIENNE

DERGOTHRAPIE JUIN 2000

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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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CAOT PUBLICATIONS ACEC A N A D I A N J O U R N A L O F

JUNE 2000 OCCUPATIONAL THERAPY

1

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.


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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

Therapy (CJOT) is held by the Canadian Association of Occupational

Therapists.Permission must be obtained in writing from CAOT to photo-

copy,reprint, reproduce (in print or electronic format) any material pub-

lished in CJOT.There is a per page,per table or figure charge for commer-

cial use.When referencing this article,please us APA style,citing both the

date retrieved from our web site and the URL.For more information,

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