II\. STUDENT CHARACTERISTICS

Infants and Toddlers Served Under IDEA

######## Preschoolers Served Under IDEA

######### Students Ages 6 Through 21 Served Under IDEA

######### Meeting the Needs of Students with Co-occurring Disabilities

######### Students with Orthopedic Impairments

Infants and Toddlers Served Under IDEA[^1]

In 1986, the Infants and Toddlers Program was added as Part H of the
Individuals with Disabilities Education Act (IDEA), with the goal of
encouraging development or expansion of statewide early intervention
services for children ages birth through 2 with disabilities and their
families. By September 30, 1994, all States had ensured full
implementation of Part H. Under the reauthorization of IDEA, the IDEA
Amendments of 1997, Part H was renamed Part C.

# The Number of Children Served Under IDEA, Part C

It is most useful to evaluate the number of children served under Part C
of IDEA beginning with the data reported in December 1994 because it was
in this fiscal year that all States reported that they had fully
implemented Part C (see figure II-1). In 1994, 165,351 children were
reported served under Part C. By 1997, 197,625 infants and toddlers were
reported as receiving services. Anecdotal reports from the States
attributed this steady increase to better child-find efforts and more
efficient tracking and reporting methods. Surprisingly, however, the
number of children served under Part C has declined since 1997: In 1998,
the number of children reported as receiving services under Part C
decreased by 4.4 percent, to 188,926. Two States, Ohio and Illinois,
accounted for 82.4 percent of the decline. These two States reported
changes in administrative data collection procedures that may provide
some explanation for the change.

In 1997, Ohio reported 22,917 infants and toddlers served under Part C,
compared with 5,161 in 1998 (see table AH1). The State reported that
this decrease resulted from the use of a new data collection system,
Early Track, that was first implemented in 1998. Ohio's data managers
believe that this system is more reliable and will eliminate potential
duplication of child count that may have contributed to the higher
counts reported in the past. The State expects data collection to
improve as personnel become more familiar with the new tracking system.

Illinois reported a less striking but still significantly lower number
of children served in 1998: The 1997 figure of 7,758 dropped to 4,849 in
1998. Illinois noted that this decrease was likely the result of a
change in the Part C lead agency; responsibility for Part C passed from
the Department of Education to the Department of Human

Figure II-1

Number of Infants and Toddlers Served Under IDEA, Part C,\
1994 Through 1998

![](media/image1.wmf)Source: U.S. Department of Education, Office of
Special Education Programs, Data Analysis System (DANS).

Services in January 1998. A change in lead agency can affect child count
data, as different agencies often have different counting systems and
different priorities. Together, Ohio and Illinois reported serving
20,665 fewer children under Part C in 1998 than in 1997. Finally, Puerto
Rico reported serving 4,773 children in 1997 and 2,592 in 1998 a decline
of 2,181. Puerto Rico did not provide an explanation for the decline.

In contrast, 20 States and Outlying Areas reported minimal or no
declines in their 1998 Part C child counts, and 36 States and Outlying
Areas reported increases. The most significant increases were reported
by California (16,696 in 1997 to 19,421 in 1998) and New York (17,950 in
1997 to 20,592 in 1998). Texas also reported a significant increase,
serving 12,877 children in 1998 and 11,861 in 1997. Reasons for
increases in the number of infants and toddlers served under Part C
varied. For instance, Kentucky attributed its increase in the number of
children served in 1998 to a more accurate count as a result of its new
electronic counting system and general growth in the system. South
Dakota noted that its increase was the result of increased child find
efforts, an explanation given by a number of States.

The IDEA Amendments of 1997 encouraged all States to develop methods of
identifying, evaluating, and serving at-risk children. This was also the
first year that States which report that they serve at-risk children
were required to separately report the number of at-risk children
served. Currently, eight States and one Outlying Area serve at-risk
populations under Part C (California, Guam, Hawaii, Indiana,
Massachusetts, New Hampshire, New Mexico, North Carolina, and West
Virginia).[^2] Although the criteria for defining an at-risk child vary
by State, in general, an at-risk child is one who would be at risk of
experiencing a substantial developmental delay if early intervention
services are not provided. According to the *Part C Data Dictionary*,
States may consider prominent biological and environmental factors that
can have a derogatory effect on development, including low birth weight,
respiratory difficulties in newborns, infection, malnutrition, and a
history of abuse and neglect (Westat, 2000).

Of the States that serve at-risk children, two reported more than half
of their Part C population in that category. California reported 13,737
children at risk, or 70.7 percent of its Part C population, and Hawaii
reported 1,976 children at risk, or 63.4 percent of its Part C
population. The other States that serve these children reported much
smaller proportions of their Part C children as being at risk (see table
AH2).

# Race/Ethnicity of Infants and Toddlers Served

A new component of the 1998 child count for all programs under IDEA was
the collection of race/ethnicity data. This collection is intended to
provide more information on the issue of potential minority
overrepresentation among children receiving special education services.
Since race/ethnicity was a new component of the 1998 data collection,
the race/ethnicity data should be interpreted cautiously. Comparisons of
the children served under Part C with the general population of infants
and toddlers by race/ethnicity are shown in figure II-2.[^3] The
racial/ethnic distribution was generally comparable for the two groups.
It was reported that 62.2 percent of the children served under Part C
were white (non-Hispanic), compared with 62.8 percent of the
birth-through-2 population nationally. Eighteen percent of the children
served under Part C were black (non-Hispanic), compared with the
national figure of 13.7 percent. The Hispanic population accounted for
14.9 percent of the children served under Part C vs. 18.2 percent of
birth through 2-year-olds

Figure II-2

Race/Ethnicity: National Versus Part C Percentages

![](media/image2.wmf)Source: U.S. Department of Education, Office of
Special Education Programs, Data Analysis System (DANS).

nationally.[^4] Asian children comprised 3.6 percent of the children
served under\
Part C vs. 4.4 percent nationwide. Finally, 1.2 percent of the children
served under Part C were American Indian, which was comparable to the
national average of 0.9 percent for birth through 2-year-olds (see
tables AH3 and AF6).

Also reported on the basis of race/ethnicity were data describing the
at-risk populations of the States and Outlying Areas that serve them. Of
the eight States that serve at-risk children under Part C, six reported
race/ethnicity data for those children. The racial/ethnic population of
California's at-risk population was comparable to all infants and
toddlers served under Part C in that State. In both cases, the
percentage of Hispanics served under Part C, whether as at risk (13.2
percent) or under the general Part C criteria (12.0), was double the
percentage of Hispanics in California's resident population (5.6
percent). In Indiana, the percentage of at-risk children served in each
race/ethnicity category was comparable to both the general Part C and
resident populations. The racial/ethnic composition of the at-risk
children in North Carolina was almost identical to the general Part C
service population. In both these populations, the percentage of black
infants and toddlers served (40.0 percent) was greater than in the
general population (23.9 percent), while the percentage of white
children (52.0 percent in the Part C population) was less than the
general population (68.2 percent). Hawaii reported a slightly higher
percentage of its Asian population served to be at risk (89.7 percent)
than that which was represented in its total Part C population (83.9
percent) or the general population (64.6 percent). Hawaii reported only
half the percentage of white, non-Hispanic children as at risk (5.8
percent vs. 10.7 percent of the total Part C population). New Hampshire
reported higher numbers of American Indian and Hispanic children as
being at risk than occurred in the population: American Indians
comprised 0.8 percent of New Hampshire's Part C population, but 5.3
percent of the State's at-risk population, and Hispanics comprised 1.9
percent of New Hampshire's Part C population, but 10.5 percent of the
at-risk population. Finally, West Virginia reported a higher percentage
of black (non-Hispanic) children at risk (6.5 percent) than that of the
total Part C population (1.8 percent) (see table AH3).

# Early Intervention Service Settings for Infants and Toddlers with Disabilities

Since 1990, birth through 2-year-olds with disabilities have been served
in one of the following eight reported setting categories: early
intervention classroom, family child care, home, hospital (inpatient),
outpatient service facility,[^5] regular nursery school/child care,
residential facility, and other.[^6] The IDEA Amendments of 1997 placed
greater emphasis on encouraging States to provide services in natural
environments; for infants and toddlers, this is the home. In 1997, all
but 10 States and Outlying Areas reported serving children in all eight
categories. Alaska, Iowa, Maine, and American Samoa used seven settings
categories; Minnesota and Vermont used five; the District of Columbia
and Massachusetts used four; Connecticut used three; Puerto Rico used
only the outpatient service facility category, and

Figure II-3

Part C Settings

![](media/image3.wmf)

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

Massachusetts used only the home category. California[^7] and
Kentucky[^8] did not report any settings data.

The variation in the use of service setting categories makes it
difficult to analyze the data and discern trends. However, since 1994,
the most commonly reported settings have consistently been home, early
intervention classroom, and outpatient service facility (see figure
II-3). In 1997, this trend continued: 58.3 percent of infants and
toddlers were reported served in the home, 20.4 percent were served in
early intervention classrooms, and 13.1 percent were served in an
outpatient service facility (see table AH7).

The structure of the Part C program varies by State. The service
delivery models operating in the State affect the emphasis in services,
personnel, and settings. For example, Connecticut noted that its
decrease in the number of infants and toddlers served in outpatient
service facilities was a result of its attempt to provide services in
more natural environments. Delaware, while reporting increases in other
settings, reported a decrease in outpatient service facilities, which
was also related to an attempt to serve children in more natural
environments. Colorado noted that its increases in the home and early
intervention classroom settings and decrease in other settings were
largely due to more accurate reporting and categorization methods.
Colorado also pointed out that it has made a concerted effort to provide
more services in the home. In 1997, Colorado almost doubled the
percentage of children who received the majority of early intervention
services in the home (50.3 percent, vs. 28.7 percent in 1996). Other
reasons given by States for year-to-year changes in the use of different
service environments include a focus on serving children in natural
environments; increased use of managed care, which requires that
services be provided in a clinical setting; and improved reporting and
categorization methods.

# Summary

In 1998, for the first time since the full implementation of Part C of
IDEA in 1994, the States and Outlying Areas reported a slight decline in
the number of infants and toddlers served. This decline was largely the
result of changes in data collection procedures in a few States. In
addition, 1998 saw the first race/ethnicity data reported on birth
through 2-year-olds. Most State-reported data showed no significant
minority overrepresentation among the infants and toddlers served under
Part C, with the exception of some States that serve the at-risk
population. States continued to emphasize the home setting as a natural
environment in providing services to infants and toddlers with
disabilities and their families.

# References

Westat. (2000, July). *OSEP IDEA, Part C data dictionary*. Rockville,
MD: Author.

Preschoolers Served Under IDEA[^9]^,^[^10]

The 1986 Amendments to the Education for All Handicapped Children Act
(EHA)[^11] changed the Preschool Grants Program for Children with
Disabilities from an incentive program to a mandated program. In order
to be eligible for funding under this program, funds attributable to
this age under the Grants to States Program, or IDEA discretionary
grants targeted to 3- through 5-year-olds, States were required to serve
all eligible 3- through 5-year-olds by fiscal year 1991. States are
required to have in effect policies and procedures that assure the
provision of a free appropriate public education (FAPE) for all 3-
through 5-year-olds with disabilities, and, at the State's discretion,
to 2-year-old children with disabilities who will turn 3 during the
school year.

The Individuals with Disabilities Education Act (IDEA) Amendments of
1997 revised the formula for allocating funds under the Preschool Grants
for Children with Disabilities Program. Under the revised formula, each
State is first allocated an amount equal to the amount it received in
fiscal year 1997. For any year in which the appropriation is greater
than the prior year level, 85 percent of the funds above the 1997 level
are distributed based on the State's relative percentage of the total
number of children ages 3 through 5 in the general population. The other
15 percent is distributed based on the relative percentage of children
ages 3 through 5 in each State who are living in poverty. In addition,
the IDEA Amendments of 1997 provided for situations in which the program
appropriation decreases, as well as several minimums and maximums
regarding the amount a State can receive during any year. These formula
changes went into effect in Federal fiscal year 1998.

IDEA mandates that States report data that could be a measure of the
States' progress in providing special education and related services to
preschoolers with disabilities. The data analyzed in this module
summarize information about the number of children ages 3 through 5 who
received special education services, the racial/ethnic makeup of
preschoolers in special education, and the environments in which these
children received services.

# The Number of Preschool Children Served Under Part B of IDEA

During the 1998-99 school year, 573,637 preschool-aged children with
disabilities were served under Part B (see table AA1). This represented
approximately 4.8 percent of all preschool-aged children who lived in
the United States and its Outlying Areas. However, the percentage of
preschoolers served varied considerably by State. Kentucky reported the
highest percentage, with 9.4 percent of its preschoolers receiving
special education services. Arkansas, Maine, Wyoming, and West Virginia
each reported that more than 8.0 percent of their resident preschoolers
received special education and related services. California, Hawaii,
Texas, and the District of Columbia reported that fewer than 4 percent
of their preschool-aged children received special education services.
The United States territories reported the lowest special education
enrollment rates, with Palau reporting less than 1.0 percent, American
Samoa 1.0 percent, and Guam 1.3 percent (see table AA12).

Special education service provision to preschoolers increased with age.
Of the preschoolers who received services in 1998-99, 20.5 percent
(117,698) were 3 years old, 34.9 percent (199,924) were 4 years old, and
44.6 percent (256,015) were 5 years old (see table AA9). A goal of the
*U.S. Department of Education FY 2000 Annual Plan* was to identify and
provide services to children with disabilities at an earlier age (U.S.
Department of Education, 1999). Between 1992-93 and 1998-99, the
percentage of 3-year-olds receiving services grew 33.2 percent, and the
percentage of 4-year-olds receiving services increased 31.8 percent (see
figure II-4). The percentage of 5-year-olds receiving services increased
at a slower rate of 18.8 percent. The 1998-99 State-reported data
suggest that greater numbers of younger children were being identified
and provided services.

Between 1989-90 and 1998-99, the total number of preschoolers served
under IDEA increased 48.8 percent (see table AA18). The past 10 years
began with a slow growth of 2.4 percent between 1989-90 and 1990-91.
However, the next 4 years saw the most significant growth in providing
services to preschoolers with disabilities during the 1990s. Between
1991-92 and 1994-95, the number of preschool children receiving services
increased by an average of 7.3 percent in each year. Growth slowed to
5.0 percent between 1994-95 and 1995-96. Over the last 3 years of the
decade, the number of preschool children served under IDEA continued to
grow slowly, averaging 1.5 percent per year. In fact, between 1997-98
and 1998-99, the number of preschool children receiving services
increased by just 0.6 percent. This trend parallels the slower growth in
the general 3- through 5-year-old population during the same period.

Figure II-4

Number of Preschool Children with Disabilities Served by Age and Year,
1992-93 Through 1998-99

![](media/image4.wmf)Source: U.S. Department of Education, Office of
Special Education Programs, Data Analysis System (DANS).

# Race/Ethnicity of Preschoolers Served Under IDEA

In the IDEA Amendments of 1997, Congress mandated that States submit
data regarding the race/ethnicity of children receiving special
education and related services. This section of the module compares the
racial distribution of preschoolers in special education with that of
the general preschool population (see figure II-5). Since this was the
first year that race/ethnicity were collected, the data should be
interpreted cautiously.

U.S. Census population estimates for 1998 indicate that white children
represented 63.3 percent of the general 3- through 5-year-old
population, while 1998-99 State-reported data indicate that 68.9 percent
of the preschoolers receiving special

Figure II-5

Race/Ethnicity of Preschoolers Receiving Special Education and of the
General Preschool Population, 1998-99

![](media/image5.wmf)Source: U.S. Department of Education, Office of
Special Education Programs, Data Analysis System (DANS).

education and related services were white (non-Hispanic). Hispanic
children comprised 17.2 percent of the general preschool population but
just 12.0 percent of the preschoolers receiving special education.
Representation of black (non-Hispanic) children receiving Part B
services appeared to be nearly comparable to the general population:
15.7 percent vs. 15.8 percent, respectively. Asian children represented
4.2 percent of the 3- through 5-year-old population, and 2.0 percent of
the preschool Part B population. And 1.3 percent of preschoolers in
special education were American Indian, compared with 0.9 percent of the
general preschool population (see tables AA7 and AF7).

The data reported by the States for 1998-99 indicated that the
racial/ethnic distribution of the general preschool population versus
the special education preschool population was, on average, generally
comparable.[^12] Hispanic and Asian preschool children were slightly
underrepresented in the special education preschool population.
Conversely, the data indicated that white, non-Hispanic children were
somewhat overrepresented among preschoolers receiving special education
and related services.

# Educational Environments for Preschoolers with Disabilities

During 1997-98, preschool settings were defined using the same
terminology as settings for school-aged children (see table II-1).
However, the terms were changed in 1998-99 to reflect settings more
appropriate to preschoolers.[^13]

In 1997-98, Hawaii, the District of Columbia, the Northern Marianas, and
the Virgin Islands did not report on educational environments for
preschool-aged children with disabilities. Among the States that did
report settings data, 92.2 percent of preschool-aged children with
disabilities received special education and related services in a
regular public school setting. Of these children, the majority (52.5
percent, or 276,839) were served in classrooms with nondisabled children
for at least 80 percent of the day. Another 31.2 percent (164,512)
received services in separate classes from their nondisabled peers for
more than 60 percent of the school day. The remaining 8.5 percent of
preschool children who received services in a regular public school were
served in a resource room environment (see table AB3).

Among the preschoolers who did not receive services in a regular public
school setting, a public separate facility was the most common setting
for the provision of special education and related services. These
students represented 3.8 percent (20,257) of the preschool children
receiving IDEA services during 1997-98. Small percentages of
preschoolers received special education and related services in a
private separate facility (1.4 percent), public or private residential
facility (0.2 percent), or a home/hospital environment (2.3 percent).
For each of these settings, several States reported no children served
in non-public school environments. No children were reported as
receiving services in a public separate facility in 4 States, a private
separate facility in 10 States, a public residential facility in 14
States, a private residential facility in 29 States, and a home/hospital
environment in 8 States (see table AB3).

Table II-1

Educational Settings for Children Ages 3 Through 5 with Disabilities

+-----------------------------------------------------------------------+
| *[Regular Class]{.underline}*: includes children who receive services |
| in programs designed primarily for nondisabled children, provided the |
| children with disabilities are in a separate room for less than 21    |
| percent of the time receiving services. This may include, but is not  |
| limited to, Head Start centers, public or private preschool and child |
| care facilities, preschool classes offered to an age-eligible         |
| population by the public school system, kindergarten classes, and     |
| classes using co-teaching models (special education and general       |
| education staff coordinating activities in a general education        |
| setting).                                                             |
|                                                                       |
| *[Resource Room]{.underline}*: includes children who receive services |
| in programs designed primarily for nondisabled children, provided the |
| children with disabilities are in a separate program for 21 to 60     |
| percent of the time receiving services. This includes, but is not     |
| limited to, Head Start centers, public and private preschools or      |
| child care facilities, preschool classes offered to an age-eligible   |
| population by the public school system, and kindergarten classes.     |
|                                                                       |
| *[Separate Class]{.underline}*: includes children who receive         |
| services in programs designed primarily for nondisabled children,     |
| provided the children with disabilities are in a separate program     |
| more than 60 percent of the time receiving services. This includes,   |
| but is not limited to, Head Start programs, public or private         |
| preschools or child care facilities, preschool classes offered to an  |
| age-eligible population in the public school system, and kindergarten |
| classes.                                                              |
|                                                                       |
| *[Separate School (public and private)]{.underline}*: includes        |
| children who receive services in a separate program for 61 to 100     |
| percent of the time receiving services. It does not include children  |
| who received education programs in public or private separate day or  |
| residential facilities.                                               |
|                                                                       |
| *[Residential Facility (public and private)]{.underline}*: includes   |
| children who are served in publicly or privately operated programs in |
| which children receive care 24 hours a day. This could include        |
| placement in public nursing care facilities or public or private      |
| residential schools.                                                  |
|                                                                       |
| *[Homebound/hospital]{.underline}*: includes children who are served  |
| in either a home or hospital setting, including those receiving       |
| special education and related services in the home and provided by a  |
| professional or paraprofessional who visits the home on a regular     |
| basis (e.g., a child development worker or speech services provider   |
| in the child's home). It also includes children 3 through 5 years old |
| receiving special education and related services in a hospital        |
| setting on an inpatient or outpatient basis. However, children        |
| receiving services in a group program that is housed at a hospital    |
| should be reported in the separate school category. For children      |
| served in both a home/hospital setting and in a school/community      |
| setting, report the child in the placement that comprises the larger  |
| percentage of the time receiving services.                            |
+-----------------------------------------------------------------------+

Source: U.S. Department of Education, Office of Special Education
Programs, 1997.

Over the past 10 years, the regular classroom has been the most common
service setting for preschool children with disabilities (see figure
II-6). The U.S. Department of Education (1999) indicated in its FY 2000
Annual Plan that increasing inclusion of children with disabilities in
regular classroom settings was an important objective in the improvement
of special education. The use of the regular classroom has gradually
increased from 42.2 percent in 1988-89 to 52.5 percent in 1997-98 (see
table AB7). Thus, the State-reported data indicated progress toward the
Department's goal of greater inclusion for preschool-aged children with
disabilities.

Figure II-6

Percentage of Preschool Children Served in Different Educational
Environments in 1988-89 and 1997-98

![](media/image6.wmf)Note: Percentage may not sum to 100 due to
rounding.

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

Although residential programs remained the least common service
environment for preschoolers, both public and private residential
programs experienced growth from the 1996-97 school year to the 1997-98
school year. The number of preschoolers served in public residential
facilities rose from 700 in 1996-97 to 833 in 1997-98, an increase of
19.0 percent. After 3 years of decline, the number of preschoolers in
private residential facilities rose 92.5 percent, from 173 in 1996-97 to
333 in 1997-98. In addition, the use of home/hospital programs decreased
3.3 percent between 1995-96 and 1997-98 (see table AB7). The reasons for
these changes in service settings were unclear.

# Summary

In the 1990s, the number of preschool children receiving special
education and related services grew each year. State-reported data
indicated that over the past 7 years, the number of 3- and 4-year-old
children being identified and provided services grew at a much faster
rate than did the number of 5-year-old children, indicating that
children with disabilities were being identified and provided services
at an earlier age.

Race/ethnicity data, reported for the first time in 1998-99, suggest
that minority enrollment in special education was similar to the
resident population of 3- through 5-year-olds. Asian and Hispanic
children were slightly underrepresented among preschoolers in special
education, while white (non-Hispanic) children were somewhat
overrepresented.

The data reported regarding educational environments for preschool
children with disabilities indicated that the majority of 3- through
5-year-olds served under IDEA received services in regular education
classrooms with their nondisabled peers for 80 percent of the school
day. The number of preschoolers served in regular classrooms continued
to grow during the decade.

# References

U.S. Department of Education, Office of Special Education Programs
(OSEP). (1997). Instructions for *OSEP Part B Data, Part II Table 2*.
Rockville, MD: Westat.

U.S. Department of Education. (1999). *U.S. Department of Education FY
2000 annual plan, volume 2: Program performance plans*. Washington, DC:
Author.

Students Ages 6 Through 21 Served Under IDEA[^14]

The number of children with disabilities receiving special education and
related services has steadily grown since passage of the Education for
All Handicapped Children Act (EHA) in 1975. The number of students ages
6 through 21 served under Part B of the Individuals with Disabilities
Education Act (IDEA) reached 5,541,166 in 1998-99, a 2.7 percent
increase over the previous year (see table AA14). In the past decade,
the number of students served grew 30.3 percent, from 4,253,018 in
1989-90 to 5,541,166 in 1998-99. Table II-2 shows the number of children
served in 1989-90 and 1998-99 and the percentage change by disability
category.

The growth in the number of children with disabilities exceeded the
growth in both the resident population and school enrollment. For this
same period, growth in the United States resident population of children
ages 6 through 21 was 9.7 percent (from 56,688,000 to 62,204,713).
School enrollment grew 14.1 percent, from 40,608,342 to 46,349,803.[^15]

# Students Served Under IDEA by Disability Category

States and Outlying Areas report data on children served in 13
disability categories: specific learning disabilities, speech or
language impairments, mental retardation, emotional disturbance,
multiple disabilities, hearing impairments, orthopedic impairments,
other health impairments, visual impairments, autism, deaf-blindness,
traumatic brain injury, and developmental delay. The latter was the most
recently added disability category and is applicable only to children
ages 3 through 9. Prior to implementation of the IDEA Amendments of
1997, developmental delay applied only to children ages 3 through 5. The
use of the developmental delay category is at the discretion of the
State and local education agencies. Autism and traumatic brain injury
were optional reporting categories in the 1991-92 school year and were
required categories beginning in 1992-93.

Table II-2

Number of Students Ages 6 Through 21 Served Under IDEA^[a]{.underline}/^
in the 1989-90 and 1998-99 School Years

  ------------------------------- ------------- ------------- ------------------
                                  1989-90       1998-99       Percent Change

  Specific Learning Disabilities  2,062,076     2,817,148     36.6%

  Speech and Language Impairments 974,256       1,074,548     10.3

  Mental Retardation              563,902       611,076       8.4

  Emotional Disturbance           381,639       463,262       21.4

  Multiple Disabilities           87,957        107,763       22.5

  Hearing Impairments             57,906        70,883        22.4

  Orthopedic Impairments          48,050        69,495        44.6

  Other Health Impairments        52,733        220,831       318.7

  Visual Impairments              22,866        26,132        14.3

  Autism                          NA            53,576        [b]{.underline}/

  Deaf-Blindness                  1,633         1,609         -1.5

  Traumatic Brain Injury          NA            12,933        

  Developmental Delay             NA            11,910        [c]{.underline}/

  All Disabilities                4,253,018     5,541,166     30.3
  ------------------------------- ------------- ------------- ------------------

[a]{.underline}/ Data from 1989-90 through 1993-94 include children with
disabilities served under\
Chapter 1 of ESEA (SOP). Beginning in 1994-95, all services to students
with disabilities were provided under IDEA only.

[b]{.underline}/ Autism and traumatic brain injury were first required
to be reported in 1992-93. The percentage increase for these disability
categories between 1992-93 and 1998-99 was 243.9 percent and 226.6
percent, respectively (see table AA18).

[c]{.underline}/ Developmental delay was first reported in 1997-98. The
percentage increase between the two years was 214.1 percent (see table
AA18).

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

In 1998-99, specific learning disabilities continued to be the most
prevalent disability among students 6 through 21. The IDEA regulations
define this category as comprising children with ". . . a disorder in
one or more of the basic psychological processes involved in
understanding or in using language, spoken or written, that may manifest
itself in an imperfect ability to listen, think, speak, read, write,
spell, or to do mathematical calculations, including conditions such as
perceptual disabilities, brain injury, minimal brain dysfunction,
dyslexia, and developmental aphasia" (34 CFR §300.7(c)(10)(i)). Over
half of the students with disabilities served under IDEA were
categorized as having specific learning disabilities (2,817,148, or 50.8
percent). Speech and language impairments (1,074,548, or 19.4 percent),
mental retardation (611,076, or 11.0 percent), and emotional disturbance
(463,262, or 8.4 percent) were

Table II-3

Percentage of Students Ages 6 Through 21 Served Under IDEA by Disability
Category, 1989-90 and 1998-99

  ------------------------------- ------------------- -------------------
                                  1989-90             1998-99

  Specific Learning Disabilities  48.5%               50.8%

  Speech and Language Impairments 22.9                19.4

  Mental Retardation              13.3                11.0

  Emotional Disturbance           9.0                 8.4

  Multiple Disabilities           2.1                 1.9

  Hearing Impairments             1.4                 1.3

  Orthopedic Impairments          1.1                 1.3

  Other Health Impairments        1.2                 4.0

  Visual Impairments              0.5                 0.5

  Autism                          NA                  1.0

  Deaf-Blindness                  \>0.1               \>0.1

  Traumatic Brain Injury          NA                  0.2

  Developmental Delay             NA                  0.2
  ------------------------------- ------------------- -------------------

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

the next most common disabilities. As illustrated in table II-3, there
have been only slight variations in disability prevalence since 1989-90.
The largest increase, a jump of 318.8 percent, occurred in the other
health impairments category, which accounted for only 1.2 percent
(n=52,733) of the children served in 1989-90 and now accounts for 4.0
percent (n=220,808). States have reported that the increase in the
number of children with other health impairments is largely a function
of increased identification and service provision to children with
attention deficit disorder and attention deficit hyperactivity disorder.
It should also be noted that the use of the developmental delay category
for 3- through 9-year-olds affects the number of students reported in
other disability categories.

The significant growth in the higher incidence disabilities may mask
some of the changes that have occurred among the low-incidence
disabilities.[^16] As an example, consider these five disability
categories: hearing impairments, orthopedic

Figure II-7

Growth Reported in Low-Incidence Disabilities From 1989-90 to 1998-99

![](media/image7.wmf)

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

impairments, visual impairments, autism, and traumatic brain
injury.[^17] Figure II-7 shows the changes that have occurred in these
disability categories over the past decade. The percentage of students
with hearing impairments grew by 22.4 percent during the 10-year period,
and the percentage of students with visual impairments increased by 14.3
percent. Both of these rates of increase were lower than the growth rate
for all disabilities during the same period.

Table II-4

Child Counts in States Reporting Students with Other Health Impairments
in the Orthopedic Impairments Category

  ----------------- ----------------- ----------------- -----------------
  States            1989-90           1998-99           Percent Change

  Colorado          777               4,536             483.8%

  Delaware          258               746               189.1

  Michigan          3,767             10,860            188.3

  Mississippi       807               1,433             77.6
  ----------------- ----------------- ----------------- -----------------

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

Reporting in the category of orthopedic impairments showed significant
growth from 1989-90 to 1998-99, increasing by 44.6 percent. In part,
this increase is a function of the reporting by four States: Colorado,
Delaware, Michigan, and Mississippi include students with other health
impairments in this category. The growth in the number of students
reported in the orthopedic impairments category for these four States is
shown in table II-4 above.

If these four States are removed from the analysis, the growth rate in
orthopedic impairments is 22.3 percent, which is slightly below the
overall growth rate for all disabilities.

Traumatic brain injury (TBI) and autism were first reported as separate
disability categories in 1991-92. Most States require 2 to 3 years to
fully capture new data categories, as the addition of new data
requirements necessitates making adjustments to existing data systems
and training staff at the school, LEA, and State levels. In addition,
because States have a 3-year evaluation cycle, the full complement of
students with a newly specified disability may not emerge until the
cycle is complete. As shown in figure II-7, the number of students with
TBI has increased steadily since it was first reported, but growth in
this category has diminished over the past 3 years. Between 1992-93 and
1995-96, the number of students served with TBI rose by 141.9 percent;
the increase since 1995-96 was just 35.0 percent (see table AA18 for
service numbers by individual years).

The most striking increase among low-incidence disabilities has been
reporting in the autism category. Between 1992 and 1998, the number of
children with autism served under IDEA grew by 243.9 percent. Figure
II-8 examines the growth in reporting of autism by age cohort as a
percentage of the resident population. As the figure illustrates,

Figure II-8

Children Reported with Autism Served Under IDEA by Age Cohort Expressed
as a Percentage of the Resident Population^[a]{.underline}/^

![](media/image8.wmf)

[a]{.underline}/ Census figures, which are included in DANS, are from
July 1998 estimates by the U.S. Bureau of the Census.

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

the rate of growth in reporting in this category was dramatic from
1992-93 to 1995-96, the period associated with establishing a new data
collection category and subsequent re-evaluation. The rate of increase
slowed significantly after 1995-96. Since that year, States reported
increases resulting from better diagnosis and identification, continued
reclassification, and improved training in the assessment of autism.
Florida described in more detail the State's efforts to identify and
work with children with autism and their families, including:

-   Establishment of regional centers that provide better diagnosis of
    children with autism;

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-   Broadening of the definition of the disability;

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-   Better understanding of the disability; and

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-   Increase in the number of families that have children with autism
    who have moved into the State because of the availability of
    services.

# Race/Ethnicity of Students with Disabilities

The IDEA Amendments of 1997 required that States report by
race/ethnicity the number of children with disabilities served. Five
race/ethnicity categories were used in the collection of these data:
American Indian, Asian/Pacific Islander, black (non-Hispanic), Hispanic,
and white (non-Hispanic). Nine States and Outlying Areas reported
discrepancies in counts of children by disability and counts of children
by race/ethnicity (see table AA3). The Virgin Islands could not provide
the data by race/ethnicity categories. Five of the nine States reported
discrepancies of less than 30 children. The remaining States\--New York,
North Carolina, and Rhode Island\--had discrepancies of 4.3 percent, 0.9
percent, and 6.2 percent, respectively. Percentages for race/ethnicity
tables are based on the total number of students reported under
race/ethnicity. Although the requirement of race/ethnicity data was new
for this collection, 32 States were collecting such data as of fall
1993. However, many of these States used race/ethnicity categories that
differ from those used for the Federal collection. Consequently, several
States had difficulty providing race/ethnicity data. Table II-5 shows
the racial/ethnic distribution found in each disability category.

The race/ethnicity distribution of the population of students served
under IDEA and the general population of students ages 6 through 21
showed some disparities:[^18]

-   Asian/Pacific Islander students represent 3.8 percent of the general
    population. Among students receiving special education services in
    all disability categories, Asian/Pacific Islander students represent
    only 1.7 percent of the population. This percentage varies by
    individual disabilities; in the areas of hearing impairments (4.6
    percent), autism (4.7 percent), and deaf-blindness (11.3 percent),
    the representation of Asian/Pacific Islander students is greater
    than their representation in the resident population.

Table II-5

Percentage of Students Ages 6 Through 21 Served by Disability and
Race/Ethnicity in the 1998-99 School Year

  ---------------------- ---------- ---------- ---------------- ---------- ----------------
  Disability             American   Asian/     Black            Hispanic   White
                         Indian     Pacific    (non-Hispanic)              (non-Hispanic)
                                    Islander                               

  Specific Learning      1.4        1.4        18.3             15.8       63.0
  Disabilities                                                             

  Speech and Language\   1.2        2.4        16.5             11.6       68.3
  Impairments                                                              

  Mental Retardation     1.1        1.7        34.3             8.9        54.1

  Emotional Disturbance  1.1        1.0        26.4             9.8        61.6

  Multiple Disabilities  1.4        2.3        19.3             10.9       66.1

  Hearing Impairments    1.4        4.6        16.8             16.3       66.0

  Orthopedic Impairments .8         3.0        14.6             14.4       67.2

  Other Health           1.0        1.3        14.1             7.8        75.8
  Impairments                                                              

  Visual Impairments     1.3        3.0        14.8             11.4       69.5

  Autism                 .7         4.7        20.9             9.4        64.4

  Deaf-Blindness         1.8        11.3       11.5             12.1       63.3

  Traumatic Brain Injury 1.6        2.3        15.9             10.0       70.2

  Developmental Delay    .5         1.1        33.7             4.0        60.8

  All Disabilities       1.3        1.7        20.2             13.2       63.6

  Resident Population    1.0        3.8        14.8             14.2       66.2
  ---------------------- ---------- ---------- ---------------- ---------- ----------------

Source: U.S. Department of Education, Office of Special Education
Programs, Data Analysis System (DANS).

-   Black (non-Hispanic) students account for 14.8 percent of the
    general population for the 6 through 21 age group, compared with
    20.2 percent of the special education population in all
    disabilities. In fact, in 10 of the 13 disability categories, the
    percentage of the special education population composed of black
    students equaled or exceeded the resident population percentage.
    Black students' representation in the mental retardation and
    developmental delay categories was more than twice their national
    population estimates.

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-   Representation of Hispanic students in special education (13.2
    percent) was generally similar to the percentages in the general
    population\
    (14.2 percent). However, Hispanic students exceeded the resident
    population percentages in three categories: specific learning
    disabilities (15.8 percent), hearing impairments (16.3 percent), and
    orthopedic impairments (14.4 percent).

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-   American Indian students represent 1.0 percent of the general
    population and 1.3 percent of special education students. American
    Indian students slightly exceeded the national average in nine
    disability categories, reaching the largest percentages in the
    categories of deaf-blindness (1.8 percent) and TBI (1.6 percent).

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-   Overall, white (non-Hispanic) students made up a smaller percentage
    (63.6 percent) of the special education students than the general
    population (66.2 percent). However, their representation was higher
    than the national population estimates in five disability
    categories: speech and language impairments (68.3 percent),
    orthopedic impairments (67.2 percent), other health impairments
    (75.8 percent), visual impairments (69.5 percent), and TBI (70.2
    percent).

# Summary

The number of students with disabilities served under IDEA continues to
grow at a greater rate than both the resident population and school
enrollment. However, the increase in students served varies by
disability category, with the largest increase occurring among students
with other health impairments. Orthopedic impairments, traumatic brain
injury, and autism have shown the greatest increase among the
low-incidence disabilities. Reasons for the continued increase in
students served include better diagnosis and identification.
Reclassification of students in the newer disability categories accounts
for large increases in those categories.

The 1998-99 school year was the first time that States were required to
report the race and ethnicity of children served under IDEA. Comparisons
of the racial/ethnic distribution of students in special education with
the general student population reveal that Asian students and white
students were underrepresented in the special education population,
while black students were overrepresented. American Indian students were
also overrepresented. Hispanic students ages 6 through 21 were generally
represented among the special education population at a rate comparable
to the resident population. These relationships varied by category.

Meeting the Needs of Students with Co-occurring Disabilities

This module addresses issues related to students with two or more
co-occurring disabilities, defined as "the co-occurrence of at least two
different disorders in the same individual" (Light & DeFries, 1995). For
over 20 years, educators have debated the benefits of disability
categories delineated in the Individuals with Disabilities Education Act
(IDEA). Reynolds and Birch (1977, p. 75) noted that "the traditional
categories for exceptional children do not 'carve nature at its joints.'
They are not usually real, necessary, meaningful, or useful." Goldstein
and colleagues (1975) delineated advantages and disadvantages of
categorical classification. Among the advantages, the authors reported
that the categories improve communications among professionals, apply
labels that are educationally relevant, and provide a rallying point for
public support. Among the disadvantages, they noted that the categories
encourage overgeneralizations about children, assume that the cause of
learning problems resides exclusively with the child, may bias teachers'
expectations, and do not provide information necessary to design
effective instruction.

IDEA defines a child with a disability as a child:

> \(i\) with mental retardation, hearing impairments (including
> deafness), speech or language impairments, visual impairments
> (including blindness), serious emotional disturbance (hereinafter
> referred to as emotional disturbance), orthopedic impairments, autism,
> traumatic brain injury, other health impairments, or specific learning
> disabilities; and
>
> \(ii\) who, by reason thereof, needs special education and related
> services.

. . . The term 'child with a disability' for a child aged 3 through 9
may, at the discretion of the State and the local education agency,
include a child\--

> \(i\) experiencing developmental delays, as defined by the State and
> as measured by appropriate diagnostic instruments and procedures, in
> one or more of the following areas: physical development, cognitive
> development, communication development, social or emotional
> development, or adaptive development; and
>
> \(ii\) who, by reason thereof, needs special education and related
> services (§602(3)).

In part because of the definitions used in IDEA, many parents,
educators, administrators, policymakers, and other stakeholders think of
disability as a categorical construct, with categories reflecting the 13
disabilities identified in the law. Traditionally, personnel preparation
programs and certification and licensure have been categorical; in
consequence, many special education programs have also been
categorically based. The data-reporting requirements specified under
IDEA require States to report counts of children by disability, further
reinforcing the categorical model.

At one level, IDEA recognizes that some students have more than one
disability: students with deaf-blindness and multiple disabilities are
specifically mentioned. Children with developmental delay, by
definition, may have delays in one or more areas. Multiple disabilities
are defined in Federal regulations as "concomitant impairments. . .the
combination of which causes such severe educational needs that they
cannot be accommodated in special education programs solely for one of
the impairments" (CFR 34 §300.7(c)(7)). While this definition does not
require any particular level of severity of disability, it is accepted
practice for State education agencies to report their child count by
primary disability unless the co-occurring disabilities are severe.
However, the use of primary disability classifications can obscure the
fact that many special education students have more than one disability.

This module focuses on a broader scope of students than those who have
multiple disabilities, as defined by IDEA.[^19] The report reviews
available literature and uses data from the National Health Interview
Survey-Disability Supplement (NHIS-D) to explore issues related to
students with two or more co-occurring disabilities. It addresses the
prevalence of co-occurring disabilities, the demographic characteristics
of students with co-occurring disabilities, special education and
related services for this population, and parental satisfaction with
those services.

# Review of the Literature

As a group, students with co-occurring disabilities may have more
complex needs than those with a single disability (Abikoff & Klein,
1992; Downing & Eichinger, 1996; Orelove, 1996). For example, students
with co-occurring learning and emotional disabilities may have more
difficulty learning than students with only one of these disabilities.
This literature review summarizes information on the prevalence of
co-occurring disabilities, identification and assessment, special
education and related services, and educational outcomes for this
population.

## *Prevalence of Co-occurring Disabilities*

Previous research suggests that co-occurring disabilities are quite
common among children with disabilities. However, estimates vary from
study to study, in part because of differences in the populations
covered and definitions of disability used. Some researchers estimate
that 19 percent of special education students have co-occurring
disabilities; others report figures as high as 48 percent (Hogan, Msall,
Rogers, & Avery, 1997; Wagner et al., 1991).

According to the National Longitudinal Transition Study of Special
Education Students (NLTS), 19 percent of secondary-aged students in
special education had additional disabilities beyond their primary
disability; the most common were speech impairments (10 percent) (Wagner
et al., 1991). Hogan and colleagues (1997) found that approximately 48
percent of the 4 million children ages 5 through 17 who had at least one
serious functional limitation in mobility, self-care, communication, or
learning also had one or more additional mild limitations in other areas
of functioning. However, it is not clear if these mild limitations would
meet the IDEA standard for eligibility.

Based on analyses of the National Household Education Survey (NHES),
Westat (1998) found that 11 percent of children ages 3 through 5 with
disabilities had two disabilities, and 51 percent had three or more
disabilities. Among children ages 6 through 11, 26 percent had two
disabilities, and 22 percent had three or more disabilities. It should
be noted that the NHES relies on parent reports of disability, which are
generally different from administrative reports.

Many smaller studies have documented the prevalence of co-occurring
disabilities among specific populations. Learning disabilities and
emotional disturbance frequently co-occur. Fessler, Rosenberg, and
Rosenberg (1991) found that 38 percent of children treated at an
in-patient psychiatric hospital had learning disabilities. Javorsky
(1995) reported a similar percentage: 33 percent. Forness, Kavale, and
Lopez (1993) found that 27 percent of children with conduct disorder
also had learning disabilities. However, because of differences in
medical and educational definitions of emotional disorders, these
children did not necessarily meet the IDEA definition of emotional
disturbance. Hinshaw (1992) argued that the percentage of externalizing
children with learning disabilities (i.e., those exhibiting impulsivity,
defiance, or inattention) is lower than commonly believed (6 to 20
percent) and that, among children with learning disabilities, the most
common emotional disturbances are internalizing (such as sadness,
withdrawal, and anxiety).

Learning disabilities and speech and language impairments also
frequently co-occur. Schoenbrodt, Kumin, and Sloan (1997) asserted that
the boundaries between communication disorders and learning disabilities
often overlap, making it difficult to separate the effects of each from
their combined effects. Many of the defining characteristics of learning
disabilities are language related: difficulty with listening, speaking,
reading, and writing. Gibbs and Cooper (1989) found that 96.2 percent of
242 students with learning disabilities had one or more communication
disorders, including speech, language, and hearing disorders. The most
common were language disorders (90.5 percent).

Because some visual impairments have a neurological basis and because
low birth weight may increase the risk of both visual impairments and
learning disabilities, these two disabilities may co-occur at a higher
rate than would be expected (Erin & Koenig, 1997). Corn and Ryser (as
cited in Erin & Koenig, 1997) estimated that 14 percent of students with
visual impairments had co-occurring learning disabilities.

The Florida Department of Education collects duplicated and unduplicated
counts of children's disabilities. The unduplicated count captures each
child's primary disability, while the duplicated count captures all
disabilities for each child. During the 1997-98 school year, speech
impairments, language impairments, and visual impairments were the
disabilities with the highest percentage differences between duplicated
and unduplicated counts, suggesting that these disabilities occurred
more commonly among those with more than one disability. The duplicated
count of children with speech impairments was 37 percent greater than
the unduplicated count; the duplicated count of children with language
impairments was 57 percent greater, and the duplicated count of children
with visual impairments was 51 percent greater (B. Harrison, personal
communication, January 14, 1999).

## *Identification and Assessment*

Identification and assessment of students with co-occurring disabilities
can be challenging (Fessler et al., 1991; Forness et al., 1993; Light &
DeFries, 1995). Severe behavioral problems, for example, may prevent the
child's specific learning needs from being accurately identified
(Fessler et al., 1991). Learning disabilities and language disorders may
be particularly difficult to distinguish. Children who have difficulty
reading, writing, and spelling may have language disorders rather than
learning disabilities because these two disabilities often present in
similar ways, through "difficulty with language form; disruption of
content; impairment to use; distortions in interactions among form,
content, and use; and separation of form, content, and use" (Schoenbrodt
et al., 1997, p. 266). Schoenbrodt and colleagues (1997) believe that
children with learning disabilities may exhibit difficulties only in
academic settings, while those with both language and learning
disabilities may have difficulties in social situations as well.

Regulatory definitions of learning disabilities (34 CFR §300.7(c)(10))
and emotional disturbance (34 CFR §300.7(c)(4)) may force school
personnel to rule out other disabilities before including a child in
either category. For example, the IDEA regulations' definition of
learning disabilities excludes children whose learning problems are
primarily the result of mental retardation or emotional disturbance.
Therefore, the guidelines presume a distinct and measurable difference
between children with learning disabilities, emotional impairments, and
mental retardation (Bricklin & Gallico, 1984). The National Joint
Committee on Learning Disabilities' (NJCLD) definition of a learning
disability explicitly states that learning disabilities may occur
concomitantly with other disabilities, including mental retardation (as
cited in Polloway, Patton, Smith, & Buck, 1997). Some researchers
suggest that it can be difficult to distinguish among these
disabilities, which often manifest themselves through poor academic
achievement, social maladjustment, and below average IQ (Hallahan &
Kauffman, as cited in Hallahan & Kauffman, 1977). Others disagree,
noting empirical differences (Affleck, Edgar, Levine, & Kortering, 1990;
Polloway, Epstein, Polloway, Patton, & Ball, 1986). Polloway and
colleagues (1997) asserted that learning disabilities must be viewed as
a disability secondary to mental retardation and not the reverse. For
students initially identified with mental retardation, the addition of a
learning disability label encourages a view that individuals with mental
retardation have both strengths and weaknesses and that they exhibit
intrapersonal discrepancies in performance. The addition of a mental
retardation label for an individual with learning disabilities, they
suggested, may be less valuable for program planning.

In reference to students with co-occurring learning and emotional
disabilities, Fessler and colleagues (1991, p. 104) asked, "When these
\[students\] were identified as having special needs, did the mandate to
ascertain a primary \[disability\] limit the focus of the school's
evaluation? Were the subjects' behavioral problems so severe that their
individual learning needs could not be identified?" Javorsky (1995)
supported these concerns when he reported that 23 percent of the
children in psychiatric placements who were identified with learning
disabilities received special education services to address their
learning disabilities, 14 percent received services for emotional
disturbance, and only 6 percent received services for both learning and
emotional disabilities. Children with disruptive disorders were more
likely than children with affective disorders to be identified with
learning disabilities.

Because many sensory impairments are identified before children reach
school age, academic difficulties associated with a learning disability
may be attributed to the sensory impairment. For example, many signs of
learning disabilities, such as frustration with reading, difficulty
identifying letters and words, and poor handwriting, may all be
attributed to poor vision. Harley, Truan, and Sanford (as cited in Erin
& Koenig, 1997) listed the characteristics of students with visual
impairments who might have co-occurring learning disabilities. These
characteristics included academic achievement below expectations based
on intellectual capacity; distraction and inattention; use of avoidance
behaviors; and difficulties with perception, organization, memory,
concrete thinking, perseveration and fixation, language, or
generalization.

## *Special Education and Related Services*

In addition to complicating identification and assessment, co-occurring
disabilities may also impede provision of appropriate services (de
Mesquita & Gilliam, 1994; Fessler et al., 1991). For example, students
with both learning and behavior problems may be especially difficult to
serve, and special education delivery systems may be inadequate for
meeting the concomitant needs of many students in special education.

Several studies suggest that services for students with co-occurring
disabilities are inadequate (Fessler et al., 1991; Giangreco, Dennis,
Edelman, & Cloninger, 1994; Gibbs & Cooper, 1989). For example, Gibbs
and Cooper (1989) reported that only 6 percent of students with learning
disabilities received speech/language services despite the fact that
over 90 percent of them had communication disorders; many of these
disorders were in the mild-to-moderate range. Giangreco and colleagues
(1994) analyzed the IEPs of students with severe multiple disabilities.
They found that many of the IEPs included goals that were overly broad
and were unconnected to the general education curriculum; listed goals
for staff rather than students; and were discipline-referenced, meaning
that they lacked coordination among goals written by various service
providers. Because students with co-occurring disabilities are more
likely than students with a single disability to receive special
education and related services from a variety of providers, there may be
a need for greater collaboration in planning and providing these
services.

Teachers who work with students with co-occurring disabilities may
require specialized preservice and inservice training and materials
(Shaughnessy, 1996). Results from three studies suggest that personnel
who serve students with co-occurring disabilities feel inadequately
prepared to address all their students' educational needs (Ford &
Fredericks, 1995; Izen & Brown, 1991; Sobsey & Wolf-Schein, 1996). In
one of these studies, roughly half the teachers serving children with
visual impairments and severe, multiple disabilities felt they were
inadequately prepared (Erin, Daugherty, Dignan, & Pearson, 1990).
Another study found that teachers of students with profound multiple
disabilities were less satisfied with their preservice training as the
number of students with multiple disabilities in their classrooms
increased, suggesting a mismatch between preservice preparation and job
responsibilities (Izen & Brown, 1991). Ford and Fredericks (1995)
observed that the majority of children with deaf-blindness were served
by teachers trained to teach children with other severe disabilities.
These teachers' knowledge was generally inadequate to meet the needs of
children with deaf-blindness. Similarly, directors of special education
cooperatives in rural areas reported that the limited quality of
educational services provided to students with severe to profound mental
impairments and multiple disabilities was, in part, due to the lack of
qualified teachers (Cates & Kinnison, 1991).

# Study Methods

The National Health Interview Survey (NHIS) is an annual survey on the
health of the nation's civilian, noninstitutionalized population. The
NHIS includes a standard set of questions, known as the core
questionnaire, as well as supplemental questions on additional topics of
interest. The NHIS is administered through in-person, computer-assisted
interviews. An adult member of the household is asked questions about
him or herself as well as about other household members, including
children.

In 1994 and 1995, NHIS included a disability survey (NHIS-D) along with
the core questionnaire; it was used to identify children and adults with
disabilities eligible to participate in a follow-back interview on
disability. The disability follow-back for children included items on
use of and need for services, functional assessment, the impact of the
child's disability on the family, and educational services. The
respondent was the parent or adult in the household who knew the most
about the child's health.[^20] Because the data were collected from
parent interviews, underreporting or overreporting of some disabilities
is possible.

Previous research suggests that estimates of the number and percentage
of children receiving special education and related services differ
depending on whether the source of the estimate is administrative
records or parent reports. In general, prevalence estimates based on
parent reports are lower than those based on administrative records.
OSEP's *Annual Report to Congress* and the NHIS-D, for example, report
different totals for children ages 6 through 17 who received special
education and related services during the 1994-95 school year. The
Annual Report, which is based on State administration records, reports
the total number of children at 4,668,933 (U.S. Department of Education,
1996). The NHIS-D, which is a survey of a sample of parents, indicates
that the total number of children was 2,655,912. It may be that some
parents are not aware that their children receive special education and
related services, or that some parents are unfamiliar with the
terminology used in health or educational surveys. This may be
especially true for families from ethnic minority groups because the
concept of disability varies across cultures.

Prevalence estimates based on parent reports and administrative records
may also differ within disability category. Parents tend to overreport
the prevalence of visual impairments because they are unfamiliar with
the criteria States use for determining special education eligibility.
In administrative records, State and local education agencies typically
report on the primary disabilities of students receiving special
education and related services. In cases of co-occurring disabilities,
decisions about which disability is primary may also affect prevalence
estimates.

The NHIS-D follow-back survey included a sample of 2,687 children. Of
those, 801 were children age 3 or older who received special education
services during the 12 months prior to the survey. Of those 801
children, 600 had adequate disability information and were included in
the analyses. This report compares three groups of children included in
the NHIS-D: children who were reported as having one disability,
children who were reported as having two disabilities, and children who
were reported as having three or more disabilities.[^21] In some cases,
sample sizes were too small to support analyses of children with three
or more disabilities. When that occurred, children with two and three or
more disabilities were combined into a single group. Because the NHIS-D
was not designed for describing students with co-occurring disabilities,
sample sizes were too small to result in statistically significant
differences between or among groups at alpha = .05. This was exacerbated
by the complex sample design used in the NHIS-D, which had large design
effects, reducing the effective sample sizes even further. Data were
analyzed using WesVar, a statistical package designed for use with
complex samples.

# NHIS-D Findings

This section of the report describes the results of the NHIS-D analyses
on children with co-occurring disabilities. It includes information on
the prevalence of co-occurring disabilities, demographic characteristics
of children with co-occurring disabilities, the special education and
related services these students received, the educational environments
in which students were served, and parents' satisfaction with those
services.

## *Prevalence of Co-occurring Disabilities*

Based on data from the NHIS-D, 68 percent of special education students
had a single disability, 23 percent had two disabilities, and 9 percent
had three or more disabilities. This suggests that the prevalence of
co-occurring disabilities is 32 percent. However, this percentage is
somewhat lower than percentages reported in previous research.

Among children with one disability, the largest percentage had learning
disabilities (58 percent), followed by speech/language impairments (25
percent). Of children with two disabilities, the most commonly reported
co-occurring disabilities were learning disabilities and speech/language
impairments (49 percent) and learning disabilities and emotional
disturbance (24 percent).[^22]

## *Demographic Characteristics of Children with Co-occurring Disabilities*

Previous research indicates that students in special education have
different demographic characteristics from school-aged children overall.
Students with disabilities are more likely than other students to be
black, from low-income families, and from families whose parents have
less formal education (Wagner et al., 1991). This section describes the
demographic characteristics of students with co-occurring disabilities
and compares them with the characteristics of students with a single
disability. The demographic characteristics included in NHIS were
gender, race, ethnicity, family structure, parents' education, and
poverty.

The gender distributions of children with one disability and two or more
co-occurring disabilities were quite similar. Of children with one
disability, 67 percent were male, and 33 percent were female. This is
compatible with previous research that showed that males comprise
slightly over two-thirds of special education students (Wagner et al.,
1991). Of children with co-occurring disabilities, 68 percent were male,
and 32 percent were female.

Children from racial minority groups were more likely than white
children to have two or more co-occurring disabilities (37 percent
compared to 31 percent; although this difference was not statistically
significant). It is not clear from this analysis whether the
disproportion is a function of bias in the special education eligibility
process, poverty among racial minority groups, or other factors.[^23]

Data from the NHIS-D suggest that Hispanic students were slightly less
likely than non-Hispanic students to have co-occurring disabilities, 29
percent compared to 32 percent; this difference was not statistically
significant. The underrepresentation of Hispanics in special education
and, in particular, in certain disability categories, has been
documented in earlier studies (Harry, 1994; Westat, 1998). For example,
Hispanic students appear to be underrepresented in programs for students
with speech/language impairments. Because speech/language impairments is
one of the most common co-occurring disabilities, it follows that
Hispanic students may be underrepresented in this population as well.

NHIS-D also included information on family structure. Students with two
or three or more co-occurring disabilities were more likely to live with
a single parent (36 percent) or no parent (50 percent) than students
with a single disability (32 percent) (see table II-6).

The relationship between co-occurring disabilities and poverty level was
not significant. This may be because of the poverty measure used; it
distinguished only among those above and below the poverty line. A
poverty measure with more income categories might have shown a stronger
relationship with the prevalence of co-occurring disabilities. Point
estimates suggested that students with two or more co-occurring
disabilities were more likely than students with one disability to live
below the poverty level (see table II-7). It seems logical to associate
poverty with co-occurring disabilities because of the economic costs of
caring for children with co-occurring disabilities or because
co-occurring disabilities may be more common among individuals living in
poverty. The more complex needs of students with co-occurring
disabilities may impede parents' ability to work full-time outside the
home or may be associated with higher medical expenses. Families living
in poverty may have limited access to high-quality preschool experiences
or medical care, which may

Table II-6

Number and Percentage of Students Receiving Special Education and
Related Services, by Family Structure and Number of Disabilities

  -------------------- --------------------------- -------------------------- ----------------
  Number of            Both\                       Single                     Total
  Disabilities         Parents^[a]{.underline}/^   Parent^[a]{.underline}/^   
                                                   or No                      
                                                   Parent^[b]{.underline}/^   

  One                  1,057,435                   491,025                    1,548,460

  Percent              68.3                        31.7                       100.0

  Two                  319,492                     180,149                    499,641

  Percent              63.9                        36.1                       100.0

  Three or more        107,429                     106,680                    214,109

  Percent              50.2                        49.8                       100.0

  Total                1,484,356                   777,854                    2,262,210

  Percent              65.6                        34.4                       100.0
  -------------------- --------------------------- -------------------------- ----------------

> [a]{.underline}/ With or without another adult relative.
>
> [b]{.underline}/ One adult relative.
>
> Notes: The following responses were set to missing: *other* and *no
> parent, but two or more adult relatives*.
>
> Source: 1995 National Health Interview Survey.

Table II-7

Number and Percentage of Students Receiving Special Education and
Related Services, by Poverty Threshold^[a]{.underline}/^ and Number of
Disabilities

  ------------------ ------------------ ------------------ --------------
  Number of          At or Above the    Below the Poverty  Total
  Disabilities       Poverty Threshold  Threshold          

  One                1,067,390          411,208            1,478,598

  Percent            72.2               27.8               100.0

  Two                341,825            155,760            497,585

  Percent            68.7               31.3               100.0

  Three or more      119,246            71,448             190,694

  Percent            62.5               37.5               100.0

  Total              1,528,461          638,416            2,166,877

  Percent            70.5               29.5               100.0
  ------------------ ------------------ ------------------ --------------

> [a]{.underline}/ Poverty threshold is based on family size, number of
> children under 18 years of age, and family income using the 1994
> poverty levels derived form the August 1995 Current Population Survey.
>
> Source: 1995 National Health Interview Survey.

Table II-8

Number and Percentage of Students Receiving Special Education and
Related Services, by Highest Educational Level of Responsible Adult
Family Member and Number of Disabilities

  ------------------- ------------------- ------------------- ------------
  Number of           Less Than High      High School Diploma Total
  Disabilities        School Diploma      or More             

  One                 270,045             1,308,912           1,578,957

  Percent             17.1                82.9                100.0

  Two or more         141,947             596,115             738,062

  Percent             19.2                80.8                100.0

  Total               411,992             1,905,027           2,317,019

  Percent             17.8                82.2                100.0
  ------------------- ------------------- ------------------- ------------

> Notes: p \< .05.
>
> Source: 1995 National Health Interview Survey.

lead to secondary disabilities that are prevented in higher income
households. In addition, students with co-occurring disabilities were
less likely to live in two-parent households, affecting household
income.

The findings regarding poverty and family structure are interesting in
light of a recent article by Fujiura and Yamaki (2000). These authors
used NHIS data from 1983 through 1996 to examine trends in childhood
disability prevalence and their interaction with socioeconomic status.
Disability risk was higher among children living in poverty and in
single-parent households, although the direction of these relationships
was unclear. For example, the authors noted that they could not
determine "the extent to which single parenthood is a cause or
consequence of poverty, or what underlying dynamics attenuate or
exaggerate risk" (Fujiura & Yamaki, 2000, p. 196). Although these
findings could not be considered conclusive, the authors concluded that
they were "highly suggestive and should be a source of concern" (Fujiura
& Yamaki, 2000, p. 194).

The relationship between the highest education level of responsible
adults and the prevalence of co-occurring disabilities completes the
demographic profile of students with co-occurring disabilities. Parents
or guardians of children with co-occurring disabilities were less likely
than those of children with only one disability to have a high school
diploma although these differences were not significant (see table
II-8). Having a parent with a high school diploma is associated with a
range of positive outcomes for children. Education level is also highly
correlated with poverty status (Wagner et al., 1991; Westat, 1997).

Table II-9

Number and Percentage of Students Receiving Selected Special Education
and Related Services, by Type of Services Received^[a]{.underline}/^ and
Number of Disabilities

  -------------- ---------------- ----------- ----------- ------------ ---------------
  Number of      Transportation   Speech/\    Audiology   Mental       Developmental
  Disabilities                    Language                Health or    Testing
                                  Therapy                 Counseling   

  One            81,215           496,301     79,145      175,083      292,607

  Percent        5.3              32.6        5.2         11.5         19.2

  Two or more    138,437          414,615     99,482      171,336      245,243

  Percent        19.3             57.8        13.9        23.9         34.2

  Total          219,652          910,916     178,627     346,419      537,850
  -------------- ---------------- ----------- ----------- ------------ ---------------

[a]{.underline}/ Respondents could indicate more than one type of
service received. Percentages are based on total number of respondents
by type of service received and number of disabilities.

Source: 1995 National Health Interview Survey.

## *Special Education and Related Services*

Data from the NHIS-D suggest that students with co-occurring
disabilities received a greater variety of special education and related
services than students with one disability. On average, children with
one disability received only one type of service (an average of 1.4
services per child); those with two disabilities received two types of
services (1.9 services per child); and children with three or more
disabilities received three types of services (3.1 services per child).

A larger percentage of children with co-occurring disabilities than of
children with only one disability received each selected special
education and related service, such as transportation, speech/language
therapy, audiology, counseling, and developmental testing (see table
II-9). The most common service for children with one disability and two
or more co-occurring disabilities was speech/language therapy, which was
received by 32.6 percent and 57.8 percent of students, respectively (see
table II-9).[^24] The differences in the percentage of students
receiving specific services may reflect the complex needs of students
with co-occurring disabilities, although these differences were not
statistically significant.

Table II-10

Number and Percentage of Students Receiving Special Education and
Related Services in Various Educational Environments, by Number of
Disabilities

  --------------- ----------- ----------- ----------- ----------- -----------
  Number of       Regular     Resource    Separate\   More Than   Total
  Disabilities    Classroom   Room        Class       One of      
                  Setting                             These       
                                                      Locations   

  One             393,705     510,734     289,744     212,235     1,406,418

  Percent         28.0        36.3        20.6        15.1        100.0

  Two or more     147,774     118,030     188,118     207,602     661,524

  Percent         22.3        17.8        28.4        31.4        99.9

  Total           541,479     628,764     477,862     419,837     2,067,942

  Percent         26.2        30.4        23.1        20.3        100.0
  --------------- ----------- ----------- ----------- ----------- -----------

Notes: Special day schools, special residential schools, homes,
hospitals or institutions, provider's offices, and other environments
were excluded due to small sample sizes.

Source: 1995 National Health Interview Survey.

## *Educational Environments*

The majority of children with disabilities received educational services
in regular classes, resource rooms, or separate classes in regular
schools for either all or part of the day. A greater percentage of
children with two or more co-occurring disabilities than of children
with one disability received special education and related services in
separate classes (28 percent vs. 21 percent), although this was not
statistically significant. Overall, the percentage of children receiving
services at a special day or residential school, at home, in a hospital
or institution, or at a provider's office was small.

A larger percentage of children with co-occurring disabilities than of
children with one disability received their educational services in a
separate classroom located in a regular school (for either all or part
of the day). Students with only one disability received their
educational services primarily in a resource room located in a regular
school (see table II-10). Furthermore, compared to children with only
one disability, a greater proportion of children with two or more
co-occurring disabilities received services in more than one of the
specified locations (31 percent compared to 15 percent).

Table II-11

Number and Percentage of Students Whose Parents Expressed Overall
Satisfaction with Educational Services, by Number of Disabilities

  -------------------- ---------------- ---------------- ----------------
  Number of            Satisfied        Dissatisfied     Total
  Disabilities                                           

  One                  1,322,062        207,296          1,529,358

  Percent              86.5             13.6             100.1

  Two or more          579,935          140,886          720,821

  Percent              80.5             19.6             100.1

  Total                1,901,997        348,182          2,250,179

  Percent              84.5             15.5             100.0
  -------------------- ---------------- ---------------- ----------------

> Notes: Percentages may not sum to 100 due to rounding.
>
> Parents who were *very satisfied* or *somewhat satisfied* were coded
> as *satisfied,* and parents who were *very dissatisfied* or *somewhat
> dissatisfied* were coded as *dissatisfied*.
>
> Source: 1995 National Health Interview Survey.

## *Parental Satisfaction with Services*

Parents of students with co-occurring disabilities (81 percent) were
slightly less likely than parents of students with one disability (87
percent) to report that they were satisfied with the educational
services provided to their children (see table II-11). In addition, 19
percent of parents whose children had co-occurring disabilities reported
that they tried to get additional special education and related services
for their child. This compared with 10 percent of parents whose children
had one disability.

# Summary and Implications Drawn From the Literature

In comparing the demographic characteristics of students with a single
disability to students with two or more co-occurring disabilities, data
from the NHIS-D suggested that racial minorities were more likely to
have co-occurring disabilities. Hispanic students were slightly less
likely to have co-occurring disabilities. The gender distributions of
children with one disability and children with co-occurring disabilities
were compatible with previous research that suggests that males comprise
slightly over two-thirds of special education students. In addition, the
NHIS-D revealed that students with co-occurring disabilities were more
likely to live with a single parent or no parent and to have parents who
did not have high school diplomas.

One-third of students who received special education and related
services had co-occurring disabilities. The most common combinations of
disabilities were learning disabilities with speech/language impairments
and learning disabilities with emotional disturbance. Overall, children
with co-occurring disabilities received a greater number of special
education and related services than children with only one disability. A
greater percentage of children with co-occurring disabilities received
special education and related services in separate classes than children
with one disability. Also, a greater percentage of them received a
broader scope of services in more varied educational settings than
children with one disability. Caregivers of children with co-occurring
disabilities requested additional services more often than caregivers
whose children had only one disability and were less likely to report
that they were satisfied with the services provided to their children.

Co-occurring disabilities may be difficult to identify and may make the
provision of appropriate services particularly challenging. For example,
behavioral disorders may overshadow learning disabilities, leading
educators to ignore important disability-related needs. In addition,
service providers must recognize that language-based services may be
less effective for children with co-occurring speech/language
impairments. For example, individual and family counseling may be less
effective with children who have both psychiatric and language disorders
(Forness & Kavale, 1991; Forness et al., 1993; Light & Defries, 1995).
Poor communication skills may inhibit children's ability to describe
themselves and their feelings or recall or interpret what was said by
others. Direct instruction in language and social skills may be needed
(Javorsky, 1993).

Awareness of co-occurring disabilities may improve the identification
and assessment process by encouraging teachers, administrators, school
psychologists, and other service providers to look beyond students'
primary disabilities to identify and address all of their disabilities.
This may lead to improved educational services for students with
co-occurring disabilities and a more complete view of students'
characteristics and needs. Researchers must also be aware of
co-occurring disabilities in evaluating special education services and
programs. Failure to consider co-occurring disabilities may confound
studies. For example, a study of students with one disability (e.g.,
learning disabilities) may produce findings that are largely a
consequence of a second, ignored disability (e.g., ADD) (Light &
DeFries, 1995).

The prevalence of co-occurring disabilities and research on teacher
preparedness suggest a need for changes in preservice and inservice
training. Most individuals in training to serve students with learning
disabilities will face students with co-occurring learning disabilities
and speech and language impairments, emotional disturbances, and
attention deficits. Teachers of students with visual impairments are
likely to serve students with severe multiple disabilities. Many
teachers reported feeling inadequately prepared to address co-occurring
disabilities. To address these concerns, administrators of preservice
and inservice programs might consider ways to enhance their focus on the
characteristics and needs of students with common co-occurring
disabilities and on appropriate interventions to address those needs.

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Students with Orthopedic Impairments

The educational abilities and disabilities of students with orthopedic
impairments vary widely. Caldwell and her colleagues (1997) list the
following factors that may interfere with the learning process for
students with orthopedic impairments or other physical disabilities:
lack of experience; frequent school absences; poor concentration,
anxiety, pain, and fatigue due to illness, medical treatment or
medication; interference with classes and studying due to time allocated
for health care or therapies; limited acceptance and understanding by
peers; poor self-image; unrealistic expectations by service providers;
and co-occurring disabilities such as learning disabilities.

This module summarizes recent research on students with orthopedic
impairments. It describes their characteristics and prevalence, the
special education and related services they receive, their educational
results, personnel issues in meeting students' needs, and Office of
Special Education Programs (OSEP) efforts to enhance services for these
students.

# Characteristics and Prevalence

In 1998-99, the States reported that 69,492[^25] students ages 6 through
21 with orthopedic impairments received special education and related
services (see table AA2). Students with orthopedic impairments represent
a small but growing population. The number of students served increased
by 3 percent from 1997-98 to 1998-99, and by 48 percent from 1987-88 to
1998-99. The regulations implementing IDEA define an orthopedic
impairment as:

> a severe orthopedic impairment which adversely affects a child's
> educational performance. The term includes impairments caused by
> congenital anomaly (e.g., club-foot, absence of some member, etc.),
> impairments caused by disease (e.g., poliomyelitis, bone tuberculosis,
> etc.), and impairments from other causes (e.g., cerebral palsy,
> amputations, and fractures or burns which cause contractures) (34 CFR
> §300.7(c)(8)).

As this definition suggests, students with orthopedic impairments may
vary considerably in the nature and severity of their disabilities. Many
orthopedic impairments do not limit students' academic performance
(Sherrill, 1993). However, the age at which the disabilities occurred,
the underlying cause of the disability, and the presence of secondary
disabilities may affect the students' need for special education and
related services. For example, the age at onset of the disability and
the suddenness with which it occurred may affect the student's
adjustment. Students whose disabilities occur when they are young
children may miss valuable opportunities for social development through
play with same-age peers. Students with orthopedic impairments resulting
from disease may have ongoing health concerns that affect their
educational performance (Dunn, 1997). Table II-12 describes a number of
conditions that may lead to orthopedic impairments.

In general, disabilities are more common among students who are black,
male, and living in low-income households. This is less true for
secondary-aged students with orthopedic impairments than it is for
secondary-aged students with other disabilities. Table II-13 allows a
comparison of the demographic characteristics of secondary-aged students
with all disabilities and with orthopedic impairments. The percentage of
black students with orthopedic impairments is slightly smaller than the
percentage of black students with all disabilities, while the percentage
of Hispanic students with orthopedic impairments is slightly larger than
the percentage of Hispanic students with all disabilities. Students with
orthopedic impairments are almost evenly divided between males and
females, unlike secondary-aged students with disabilities overall, who
are 68 percent male. Household incomes for secondary-aged students with
orthopedic impairments are similar to those of all students with
disabilities, with slightly more families at the extremes, that is,
earning less than \$12,000 or more than \$50,000 per year (Valdes,
Williamson, & Wagner, 1990).[^26]

# Special Education and Related Services for Students with Orthopedic Impairments

An individualized education program (IEP) describes the special
education and related services to which students are entitled. Anderson
(as cited in Porter, Haynie, Bierle, Caldwell, & Palfrey, 1997)
developed a checklist of items to consider in developing an IEP for
students with physical disabilities, including students with orthopedic
impairments. They include transportation; building accessibility;
physical, occupational, and speech therapy; self-help skills; curricular
modifications; classroom

Table II-12

Selected Conditions Causing Orthopedic Impairments in Children

+---------------------+------------------------------------------------+
| Condition           | Description                                    |
+---------------------+------------------------------------------------+
| Cerebral Palsy      | Condition that results in brain lesions and    |
|                     | different types of neuromuscular disabilities  |
|                     | that limit voluntary muscle control.           |
+---------------------+------------------------------------------------+
| Traumatic Spinal    | Injury to the spinal cord affects innervation  |
| Cord Injury         | of muscles, causing weakness or paralysis. The |
|                     | higher up the spinal cord the injury occurs,   |
|                     | the great the limitations in movement.         |
+---------------------+------------------------------------------------+
| Spina Bifida        | A congenital anomaly that results when the     |
| Manifesta or Neural | dorsal arch in one or more vertebrae does not  |
| Tube Defect         | fuse.                                          |
+---------------------+------------------------------------------------+
| Congenital Hip      | Partially or completely displaced femoral head |
| Dislocation         | that is present from birth.                    |
+---------------------+------------------------------------------------+
| Talipes or Clubfoot | Usually a congenital condition in which the    |
|                     | foot is twisted out of shape or position.      |
+---------------------+------------------------------------------------+
| Osteochondrosis     | A disorder in the growth center of the bone.   |
|                     |                                                |
| (growth plate       |                                                |
| disorder)           |                                                |
+---------------------+------------------------------------------------+
| Epiphysiolysis      | Condition in which the growth center of the    |
|                     | bone separates from the bone itself.           |
+---------------------+------------------------------------------------+
| Amputation          | Extremities may be removed due to congenital   |
|                     | conditions, tumor, trauma, or disease.         |
+---------------------+------------------------------------------------+
| Burns               | May cause loss of extremity and severe         |
|                     | contractures.                                  |
+---------------------+------------------------------------------------+
| Juvenile Rheumatoid | Condition causing inflammation of the joints.  |
| Arthritis           |                                                |
+---------------------+------------------------------------------------+
| Muscular Dystrophy  | Group of muscle diseases that progressively    |
|                     | weaken muscles.                                |
+---------------------+------------------------------------------------+

Note: Table compiled by Westat (2000) based on various data sources.

assistance; physical education; enrichment; equipment needs; medication;
mobility assistance; positioning assistance; stamina issues; fire
safety; and home/hospital services. Accommodations and services such as
rest periods, extra sets of books at home, and extended school year or
extended school-day services may help students with orthopedic
impairments overcome their educational difficulties (Caldwell et al.,
1997). Environmental accommodations for students with orthopedic
impairments might include extended time, a writer for class assignments,
adequate space in the classroom for equipment, or preferential seating.
Adaptive equipment, such as adapted keyboards, track balls, keyguards,
or speech recognition systems, may also be required (St. Louis Community
College Access Office, 2000). In addition, students with orthopedic
impairments may require test accommodations, such as extended time, a
writer, oral tests, a tape recorder for recording responses, a word
processor, or adaptive equipment.

Table II-13

Demographic Characteristics of Secondary-aged Students with All
Disabilities and Students with Orthopedic Impairments

  -------------------------------------- ---------------- ----------------
  Characteristic                         Students with    Students with
                                         All              Orthopedic
                                         Disabilities\    Impairments\
                                         %\               %\
                                         (S.E.)           (S.E.)

  Race                                                    

  American Indian/Alaska Native          1.2\             0.5\
                                         (0.3)            (0.5)

  Asian/Pacific Islander                 0.7\             1.8\
                                         (0.2)            (0.9)

  Black, non-Hispanic                    24.2\            19.0\
                                         (1.2)            (2.6)

  Hispanic                               8.1\             15.1\
                                         (0.8)            (2.4)

  White, non-Hispanic                    65.0\            63.1\
                                         (1.4)            (3.2)

  Gender                                                  

  Male                                   68.5\            54.2\
                                         (1.2)            (3.1)

  Household Income (in 1986 dollars)                      

  \<\$12,000                             34.8\            36.7\
                                         (1.5)            (3.5)

  \$12,000 to \$24,900                   33.5\            30.5\
                                         (1.5)            (3.4)

  \$25,000 to \$37,999                   16.2\            12.8\
                                         (1.2)            (2.5)

  \$38,000 to \$50,000                   9.3\             8.9\
                                         (0.9)            (2.1)

  \>\$50,000                             6.1\             11.0\
                                         (0.7)            (2.3)
  -------------------------------------- ---------------- ----------------

Note: The standard error of the mean (S.E.) shows the amount of sampling
error in the estimate.

Source: Valdes, K.A., et al., 1990.

Students with orthopedic impairments may need instructional
accommodations as well. Examples include the use of multimodal teaching
materials; mental rehearsal strategies for students with limited
expressive language; use of teacher wait time to accommodate slow
student verbal response; and use of adapted curricula, such as
self-care, self-determination, and life management skills (Sherwood
Best, personal communication, March 16, 2000).

In 1997-98, the vast majority of students with orthopedic
impairments\--94 percent\--attended schools with their nondisabled
peers. This 94 percent breaks down as follows: 47 percent received
special education and related services outside the regular classroom for
less than 21 percent of the school day; 21 percent received services
outside the regular classroom 21 to 60 percent of the school day; and 26
percent received services outside the regular classroom for more than 60
percent of the day (see table AB2). The percentage of students with
orthopedic impairments receiving services in regular schools and
classrooms has grown over the past 5 years: in 1992-93, 89 percent of
students attended schools with their nondisabled peers. Comprising this
89 percent were 35 percent who received services outside the regular
classroom for less than 21 percent of the school day; 20 percent who
received services outside the regular classroom 21 to 60 percent of the
day; and 34 percent who received services outside the regular classroom
more than 60 percent of the school day (U.S. Department of Education,
1995).

Students with orthopedic impairments may be more likely to be
hospitalized than students with other disabilities. In 1997-98, 2.01
percent of students with orthopedic impairments were served in the
home/hospital category, compared with .55 percent of all students with
disabilities (see table AB2). The psychosocial needs of hospitalized
students are particularly acute. Curricular, instructional, and
equipment adaptations may be required to meet the needs of hospitalized
students.

## *Special Education Services*

Much of the research specific to students with orthopedic impairments
focuses on issues such as social adjustment, and the resources targeted
toward educators appear to deal with services such as transportation,
physical therapy, and occupational therapy. In general, the literature
contains little information on special education services for students
with orthopedic impairments; the exception to this generality is
physical education. This section of the module will therefore emphasize
physical education for students with orthopedic impairments.

*Physical Education*

Many students with orthopedic impairments may require accommodations to
participate in physical education classes or may require specialized
physical education services. Physical education may be particularly
important for students with orthopedic impairments, as it facilitates
the development of motor skills, physical health, and self-worth that
are important for broader achievement (Kasser, Collier, & Solava, 1997).
Stein (1998) describes the goals of physical education as the
"development of physical and motor fitness, development of fundamental
motor skills and patterns, and development of skills in aquatics, dance,
individual and group games and sports" (p. 80). The regulations
implementing IDEA specifically include "instruction in physical
education" as part of special education (34 CFR §300.26(a)(ii)). Stein
(1998) reports that some students with disabilities do not receive
physical education because districts replace it with physical therapy or
occupational therapy, which generally are related services, not special
education services. Stein (1998) notes that since physical education is
a primary service, physical and occupational therapy should be secondary
to it, not substitutes for it. IDEA's implementing regulations also
require the provision of special physical education if prescribed in a
child's IEP (34 §300.307(c))

One of the reasons students with orthopedic impairments may not receive
adequate special physical education is a shortage of adequately prepared
personnel. While IDEA leaves to States' discretion the qualifications
for teaching physical education, in 1998, only 15 States offered
certification or endorsements in adapted physical education. Other
States offered undergraduate courses in adapted physical education for
individuals seeking certification in physical education. Currently, most
individuals with a master's degree in adapted physical education work as
district consultants. These personnel work with school-based physical
education teachers to develop programs for students with disabilities,
and school-based personnel carry out the program in the consultant's
absence (Nolan, Ellery, & Maguire, 1998).

## *Related Services*

Many students with orthopedic impairments require related services in
order to benefit from their special education programs. Related services
may include transportation, speech pathology and audiology,
psychological services and counseling, medical services (for evaluation
purposes), physical therapy, occupational therapy, recreation, school
health services, social work services, and early identification and
assessment of disabilities. Valdes, Williamson, and Wagner (1990) found
that a large percentage of secondary-school students with orthopedic
impairments received related services, including help with
transportation (53 percent), physical therapy/mobility training (42
percent), occupational therapy (40 percent), speech-language services
(23 percent), and personal counseling (16 percent). This section of the
module summarizes recent research related to the provision of related
services to students with orthopedic impairments, with a specific focus
on physical therapy, occupational therapy, transportation, and
counseling.

### *Physical Therapy*

Physical therapy is designed to improve students' posture and balance,
prevent physical complications stemming from orthopedic impairments, and
enhance gross motor function (Cusick, 1991). Such therapy may include
"alignment of spine, legs, and feet, fitting and monitoring positioning
equipment, braces, prostheses, or casts, post-operative rehabilitation"
(Cusick, 1991, p. 16). Many students with orthopedic impairments need
physical therapy services.

Throughout the 1980s and early 1990s, the nation experienced a shortage
of physical therapists, which made it difficult for local education
agencies (LEAs) to secure adequate numbers of therapists. A study
conducted for the American Physical Therapy Association (APTA) concluded
that, by 1998, the United States would reach a balance between the
supply of and demand for physical therapists and that a sizable surplus
of 20 to 30 percent would exist by 2005-2007 (Vector Research, 1997)
and, in fact, this has proven true (APTA, 1999). A number of factors
were cited to account for this shift. The first factor cited is the
growth of managed care, which has limited the number of reimbursable
visits to physical therapists, thus reducing the demand for services. In
addition, physical therapy assistants, chiropractors, athletic trainers,
and occupational therapists absorb a portion of the market for physical
therapy services. The third factor is that the number of newly trained
physical therapists will continue to outpace changes in demand brought
about by population growth and increases in per capita income. The
results of the APTA study bode well for students with orthopedic
impairments and for the LEAs trying to meet those students' needs. After
years of difficulty in securing adequate physical therapy services,
districts may find it easier to recruit and retain qualified physical
therapists.

### *Occupational Therapy*

Many students with orthopedic impairments may also require occupational
therapy. Occupational therapy includes services provided by a qualified
occupational therapist in order to improve, develop, or restore
functions; improve students' ability to perform tasks for independent
functioning; and prevent initial or further impairment (34 CFR
§300.24(b)(5)). It may foster coordination of eye-hand skill; optimize
the use of the arms and hands for self-feeding, writing, typing, and
self-care; prevent deformity in the arms and hands; assess and remediate
perceptual skills; evaluate sensory integration; and promote
independence in activities of daily living (e.g., toileting, dressing,
and food preparation) (Cusick, 1991, p. 17).

The NLTS indicated that almost half of secondary-aged students with
orthopedic impairments received occupational therapy or life skills
training at some point. The 22 percent of students who had received such
services in the past year averaged 34.7 hours of occupational therapy
during the year. Students from higher income households were more likely
than peers from lower income households to receive occupational therapy
(Valdes et al., 1990).

### *Transportation*

Under the regulations implementing the IDEA Amendments of 1997,
transportation services are defined as including ". . . travel to and
from school, and between schools; travel in and around school buildings,
and specialized equipment (such as special or adapted buses, lifts, and
ramps). . . ." (34 CFR §300.24(b)(15)). Some students with orthopedic
impairments require specialized transportation services in order to
benefit from special education. Transportation options vary according to
or depending on the student's height and weight, the extent of needed
support and/or positioning, and the need for personal assistance.
Options include conventional car seats, specialized car seats, regular
bus seats, or wheelchair transportation. Specialized training may be
needed for drivers or other adults accompanying students with orthopedic
impairments in transit (Daley & Larson, 1997). Valdes et al. (1990)
reported that, of the various types of transportation assistance that
youths with orthopedic impairments received, rides on a special vehicle
were most common. Less common were rides to go places they could not
otherwise go, an aide to push their wheelchair, and help in getting into
vehicles. Many students with orthopedic impairments benefit from
assistive technology to facilitate mobility. Additional NLTS data
indicate that 45 percent of secondary-aged students with disabilities
use a wheelchair; 25 percent use crutches, a cane, or a walker; 20
percent use prosthetics or orthotics; and 14 percent use computers to
aid in their mobility (Valdes et al., 1990).

### *Counseling*

Some students with orthopedic impairments may also require counseling to
benefit from special education. The visibility of many orthopedic
impairments requires that they be acknowledged in social situations;
such disabilities may alter social relations between students with
orthopedic impairments and their peers or between students and their
service providers (Best, 1999). A study of high school students with
physical disabilities found that the students were rated highly by their
nondisabled peers on measures of independence and assertion but lower on
measures of social acceptance. The author speculated that nondisabled
students may be comfortable expressing positive attitudes toward their
peers with orthopedic impairments but are reluctant to include them in
group activities (Isaacson-Kailes, as cited in Best, 1999). Findings
such as these suggest a possible need for further training to help
students with orthopedic impairments better manage social situations
(Sherwood Best, personal communication, March 16, 2000). Field and
Hoffman (as cited in Best, 1999) emphasized that students with
orthopedic impairments may be at risk for setting inappropriate goals
because service providers, family members, and peers may be
overprotective or may reinforce passivity. An emphasis on
self-determination, which includes recognition of individual strengths
and weaknesses, is likely to be important for many students with
disabilities, including those with orthopedic impairments.

Counseling services are rarely provided to secondary-aged students with
orthopedic impairments. The NLTS found that 86 percent of these students
did not receive counseling services from their school in the past year,
and, of those who did receive counseling, the average number of hours
provided was just 8 per year. These figures were fairly consistent
across rural, suburban, and urban schools and between males and females.
Students with orthopedic impairments from higher income households were
slightly more likely to receive counseling services than were their
peers from lower income households (Valdes et al., 1990).

## Personnel Serving Students with Orthopedic Impairments

In 1996, few States offered teacher certification in physical and health
disabilities, and several of those that did offer such certification
were considering eliminating it as they moved toward more generic
special education certification and licensure. States with certification
in physical and health impairments were more likely to employ State
agency personnel or consultants with expertise in that area, and
universities in those States were more likely to employ faculty with
such expertise (Heller, Fredrick, Dykes, Best, & Cohen, 1999).

As for all students with disabilities, the availability of a qualified
workforce is critical in meeting the needs of students with orthopedic
impairments. A survey of teachers serving students with physical and
health impairments, including orthopedic impairments, found that over 40
percent of respondents felt they were not well-trained on 11 of 23
competencies selected from the Council for Exceptional Children's list
of essential knowledge and skills for special education teachers serving
students with physical and health impairments. Large percentages of
teachers responding to the survey did not feel well trained in teaching
students to use assistive technology (50.8 percent); using adaptive
equipment, such as wedges and prone standers to facilitate positioning,
mobility, communication, and learning (42.4 percent); and strategies to
work with chronically or terminally ill students and their families
(72.4 percent). Smaller percentages of teachers reported feeling
inadequately trained in physical and health characteristics (17.2
percent), collaboration skills (20.4 percent), and modifying assessments
(23.7 percent). Teachers who held degrees in special education with an
emphasis in physical or health impairments, a subset of respondents,
reported higher levels of preparedness; however, only 14 percent of
responding teachers held such degrees. This research suggests that many
teachers serving students with orthopedic impairments do not feel
adequately prepared for their teaching assignments (Heller et al.,
1999). Table II-14 at the end of this module lists recommended knowledge
and skills necessary for beginning special education teachers serving
students with physical and health impairments, including orthopedic
impairments.

## Educational Results for Students with Orthopedic Impairments

Data on educational results for students with orthopedic impairments can
help gauge the extent to which these students receive appropriate
services. This section explores several measures of educational results:
functional and self-care skills, high school performance and completion,
self-determination, and postsecondary enrollment.

Valdes and colleagues (1990) reported on the self-care and functional
skills of secondary-aged students with orthopedic impairments. The
measure of self-care combined the ability to dress oneself completely,
feed oneself, and get to places outside the home. Based on these
measures, 42 percent of secondary-aged students with orthopedic
impairments had high self-care skills, 31 percent had medium skills, and
27 percent had low self-care skills. The functional skill rating
combined data on youths' abilities to count change, tell time on an
analog clock, read and understand common signs, and look up telephone
numbers and use a phone. As with the self-care skills, youths with
orthopedic impairments were diverse in their level of functional skills.
On a 16-point scale, 40 percent of respondents with orthopedic
impairments scored 16, meaning they could complete all the
aforementioned tasks very well. However, 30 percent scored 13 to 15; 22
percent scored 9 to 12; and 8 percent of respondents with orthopedic
impairments scored 4 to 8 on the 16-point scale (Valdes et al., 1990).

Valdes and colleagues (1990) also reported on the high school
performance of students with orthopedic impairments. Many of these
students receive good grades in secondary school. Fifteen percent of
youths with orthopedic impairments had a grade point average (GPA) of
3.25 or higher. Twenty-four percent had GPAs from 2.75 to 2.74, 28
percent from 2.25 to 2.74, 19 percent from 1.75 to 2.24, and 15 percent
had GPAs below 1.74. Of those students with orthopedic impairments
required to take a minimum competency test in high school, 60 percent
passed the test in full, and 31 percent passed portions of the test
(Valdes et al., 1990).

High school completion is an important educational milestone, in part
because it is strongly associated with earning power and other adult
outcomes. In 1997-98, 72.4 percent of students with orthopedic
impairments ages 17 and older who left the educational system graduated
with a diploma, 12.8 percent received a certificate of completion, 4.4
percent reached the maximum age for services, and 10.3 percent dropped
out of school[^27]. The percentage of students with orthopedic
impairments graduating with a diploma was higher than that for students
with disabilities overall, 72.4 percent compared to 61.6 percent.

Despite their relatively strong academic performance, Hostler (as cited
in Johnson & Dorval, 1999) found that 57 percent of adolescents with
physical disabilities ages 11 to 14 were unable to explain their
disability, 50 percent could not name medications they take or the
reasons they take them, and 90 percent could not describe their
long-term therapeutic goals. Capelli, MacDonald, & McGrath (as cited in
Johnson & Dorval, 1999) found that self-care skills, such as managing
catheters, bowel care, taking medication, making doctor's appointments,
and performing daily health care procedures, were better predictors than
"book knowledge" of successful transitions from secondary school to
adult life.

Postsecondary education and training are also important educational
achievements supported by IDEA, through its transition requirements.
Fowler, Brewer, and Abresch (1997) conducted a survey of college
students with neuromuscular diseases and disorders, which are considered
orthopedic impairments. They found that the students with neuromuscular
disabilities were similar to nondisabled students in terms of gender,
marital status, degrees expected, living arrangements, and grade point
averages. Students with neuromuscular disabilities were older than their
nondisabled peers, were more likely to be enrolled part-time, and,
generally, took longer to complete school. About half of the respondents
with neuromuscular conditions received financial support from Social
Security Insurance or vocational rehabilitation programs. More than 60
percent reported that their disability had a negative effect on their
career goals. Respondents with neuromuscular impairments cited a
supportive family, personal attitude, and influence of faculty as
factors in their academic success. Eighty-nine percent of these students
indicated that special education programs in high school were beneficial
for them.

The Postsecondary Education Descriptive Analysis Reports (PEDAR)
published by the National Center for Education Statistics (NCES)
provides a more detailed picture of high school graduation rates and the
postsecondary results experienced by students with orthopedic
impairments (Horn & Berktold, 1999). The National Education Longitudinal
Study of 1988, Third Follow-up (NELS:88/94) examined the high school
completion status of students who were in the eighth grade in 1988. By
1994, 75 percent of students with an orthopedic impairment had received
a high school diploma, compared with 72 percent of all students with
disabilities and 84 percent of students without disabilities. However,
17 percent of the students with orthopedic impairments had dropped out
of school, compared with 10.3 percent of

Table II-15

Percentage of Students Exiting High School, by Disability Status

  ------------------------- ----------- ------------ ----------- -----------
                            High School GED or       Enrolled in Dropped Out
                            Diploma     Equivalent   High        
                                                     School/\    
                                                     Working     
                                                     Toward GED  

  Students with an          75.0        1.7          5.9         17.4
  orthopedic impairment                                          

  All students with         72.4        6.7          10.6        10.3
  disabilities                                                   

  Students with no          83.8        5.9          4.3         6.0
  disability                                                     
  ------------------------- ----------- ------------ ----------- -----------

Source: National Education Longitudinal Study of 1988, Third Follow-up
(NELS:88/94).

all students with disabilities and 6.0 percent of students without
disabilities (Horn & Berktold, 1999; see table II-15)[^28].

The NELS:88/94 data also suggest that students with orthopedic
impairments have high rates of postsecondary enrollment. Seventy-four
percent of the students with orthopedic impairments were reported
enrolled in postsecondary education in 1994, compared with 63 percent of
all students with disabilities and 72 percent of students without
disabilities (see table II-16). The samples for some of the individual
disability types were small, but when students with specific
disabilities were compared to all students with disabilities, those with
orthopedic impairments were much more likely to be enrolled in a 4-year
institution (71 percent vs. 42 percent of all students with
disabilities). These data differ somewhat from those of the 1995-96
National Postsecondary Student Aid Study (NPSAS:96), which were also
reported in PEDAR. In that study, 34 percent of students with orthopedic
impairments were enrolled in a 4-year institution, compared with 40
percent of all students with disabilities and 47 percent of students
with no disability. Enrollment rates for other institutions[^29] were 66
percent for students with orthopedic impairments, 60 percent for all
students with disabilities, and 53 percent for students without
disabilities (Horn & Berktold, 1999).

Table II-16

Percentage of Students Enrolled in Postsecondary Education,\
by Disability Status

  ---------------------------------- ------------ -------------- --------------------------------
                                     Total        Four-Year      Other
                                     Enrolled     Institutions   Institutions^[a]{.underline}/^

  Students with an orthopedic        74           71             29
  impairment                                                     

  All students with disabilities     63           42             58

  Students with no disability        72           62             39
  ---------------------------------- ------------ -------------- --------------------------------

> [a]{.underline}/ Includes private for-profit institutions; public
> less-than-2-year institutions; and private, non-profit
> less-than-4-year institutions.

Source: National Education Longitudinal Study of 1988, Third Follow-up
(NELS:88/94).

In addition, PEDAR provides information about the extent to which
students with orthopedic impairments persist in postsecondary education.
The Beginning Postsecondary Students Longitudinal Study (BPS:90/94)
looked at students with and without disabilities who began postsecondary
training during the 1989-90 school year. In 1994, 45 percent of the
students with orthopedic impairments had attained a degree or
certificate, and 10 percent were still enrolled in postsecondary
education; 45 percent had dropped out. Among all students with
disabilities, 41 percent had earned a degree or certificate and 12
percent were still enrolled. Just over half of the students with no
disability had completed a degree or certificate, and 13 percent were
still enrolled (Horn & Berktold, 1999; see table II-17).

Finally, PEDAR includes data from the 1993 Baccalaureate and Beyond
Longitudinal Study, First Follow-up (B&B:93/94), which provide
information about how students with orthopedic impairments fare after
completing a bachelor's degree. Of students with an orthopedic
impairment who earned a bachelor's degree in 1992-93, 64 percent were
employed full-time, compared with 67 percent of all students with
disabilities and 73 percent of those without disabilities. Unemployment
rates were 10 percent for the students with orthopedic impairments, 11
percent for all students with disabilities, and 4 percent for students
with no disability. There were small differences in the percentages of
students in each group who were out of the labor force altogether (see
table II-18). The students with orthopedic impairments had an average
starting salary of \$23,345 in 1994, compared with \$26,988 for students
with all disabilities and \$25,219 for students without disabilities
(Horn & Berktold, 1999).

Table II-17

Percentage of Students Persisting in Postsecondary Education,\
by Disability Status

  ------------------------- ------------- ----------- ----------- -------------
                            Persisted                             

                            Attained      Enrolled in Total       Not
                            Degree or     1994                    Enrolled/No
                            Certificate                           Degree or
                                                                  Certificate

  Students with an          45            10          55          45
  orthopedic impairment                                           

  All students with         41            12          53          47
  disabilities                                                    

  Students with no          51            13          64          36
  disability                                                      
  ------------------------- ------------- ----------- ----------- -------------

Source: Beginning Postsecondary Students Longitudinal Study (BPS:90/94).

Table II-18

1994 Employment Status of 1992-93 Bachelor's Degree Recipients,\
by Disability

  ------------------------- ----------- ----------- ------------ -----------
                            Employed    Employed    Unemployed   Out of
                            Full-Time   Part-Time                Labor Force

  Students with an          64          16          10           10
  orthopedic impairment                                          

  All students with         67          13          11           10
  disabilities                                                   

  Students with no          73          14          4            8
  disability                                                     
  ------------------------- ----------- ----------- ------------ -----------

Source: 1993 Baccalaureate and Beyond Longitudinal Study, First
Follow-up (B&B:93/94).

## OSEP Efforts To Improve Results for Students with Orthopedic Impairments

Under its discretionary grant program, OSEP funds a number of projects
to improve results for students with orthopedic impairments. For
example, the Oregon Research Institute (ORI) is investigating the
efficacy of realistic, three-dimensional computer-generated
representations of real-world settings for conducting science
experiments that students with orthopedic impairments could not
otherwise complete. Staff at the ORI Virtual Reality Lab are working
with secondary science teachers to identify units in the curriculum from
which students with orthopedic impairments are excluded. Technical staff
will develop the virtual reality experiments, implement them in selected
classrooms, evaluate the results, and disseminate findings. At the
Education Development Center, Inc. in Newton, Massachusetts, an OSEP
grant is being used to make *Re:Search Organizer* more accessible to
middle-school students with orthopedic and other disabilities.
*Re:Search Organizer* is a software program that helps students pose
research questions, develop research plans, collect and analyze data,
and present their findings. The improved software package will be tested
in middle schools and disseminated throughout the nation.

OSEP has also contracted for design and completion of two major new
studies that will provide detailed information on students with
orthopedic impairments as well as other disabilities. The Special
Education Elementary Longitudinal Study (SEELS) will describe
elementary-aged students with disabilities, including orthopedic
impairments; their academic and social skills; and the services they
receive. Preliminary SEELS results will be available in 2001. The NLTS-2
will provide similar information on secondary-aged students with
orthopedic impairments. Preliminary results from the NLTS-2 will be
available in 2002. These OSEP-funded studies will provide valuable
information on the experiences of students with orthopedic impairments
as they progress through elementary and secondary school and make the
transition to adult life.

# References

American Physical Therapy Association. (1999). *Job losses and reduced
hours most prevalent in skilled nursing facilities, home health, and
private practices*. Alexandria, VA: Author. Retrieved April 3, 2000,
from the World Wide Web:
http://www.apta.org/research/survey_stat/employment/surveyfinds

Best, S. (1999). Psychosocial correlates of physical and health
disabilities. In V.L. Schwean & D.H. Saklofske (Eds.), *Handbook of
psychosocial characteristics of exceptional children*. NY: Kluwer
Academic/Plenum Publishers.

Caldwell, T.H., Sirvis, B.P., Still, J., Still, M., Schwab, N., Jones,
J., et al. (1997). Students who require medical technology in school. In
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settings* (pp. 3-18). Baltimore: Paul H. Brookes.

Council for Exceptional Children (CEC). (1998). *What every special
educator should know*. Reston, VA: Author.

Cusick, B. (1991). Therapeutic management of sensorimotor and physical
disabilities. In J.L. Bigge, *Teaching individuals with physical and
multiple disabilities*, (3^rd^ ed.), (pp. 16-49). Upper Saddle River,
NJ: Prentice-Hall.

Daley, J.E., & Larson, S.M. (1997). Transportation of students with
special health care needs. In S. Porter, M. Haynie, T. Bierle, T.
Heintz, & J. Palfrey (Eds*.*), *Children and youth assisted by medical
technology in educational settings*\
(pp. 63-73). Baltimore: Paul H. Brookes.

Dunn, J.M. (1997). *Special physical education: Adapted, individualized,
developmental.* (7^th^ ed.). Madison, WI: Brown and Benchmark.

Fowler, W.M., Brewer, M.L., & Abresch, R.T. (1997). *Postsecondary
education profiles in neuromuscular and other diseases*. Washington, DC:
National Institute on Disability and Rehabilitation Research.

Heller, K.W., Fredrick, L.D., Dykes, M.K., Best, S., & Cohen, E.T.
(1999). A national perspective of competencies for teachers of
individuals with physical and health disabilities. *Exceptional
Children, 65*, 219-234.

Horn, L., & Berktold, J. (1999). *Students with disabilities in
postsecondary education: A profile of preparation, participation, and
outcomes.* NCES 1999-187. Washington, DC: National Center for Education
Statistics.

Johnson, C.P., & Dorval, J. (1999). *Spotlight: Transition in
adolescence*. Retrieved\
March 14, 2000, from the World Wide Web:
http://www.sbaa.org/html/sbaa_docs.html

Kasser, S.L., Collier, D., & Solava, D.G. (1997). Sport skills for
students with disabilities: A collaborative effort. *Journal of Physical
Education, Recreation, and Dance, 68*, 50-53.

Nolan, J., Ellery, P., & Maguire, P. (1998). *Perspectives on adapted
physical education services to rural populations. Coming together:
Preparing for rural special education in the 21^st^ century*. Conference
proceedings of the American Council on Rural Special Education, March
25-28, 1998, Charleston, SC.

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

Sherrill, C. (1993). *Adapted physical activity, recreation, and sport*.
Boston: MCB/McGraw-Hill.

St. Louis Community College Access Office. *Orthopedic disabilities*.
Retrieved\
March 14, 2000, from the World Wide Web:
www.stlcc.cc.mo.us/fv/access/ortho.htm

Stein, J.U. (1998). Physical education and special education\--Likely
partners? *Journal of Education, 180*, 77-93.

U.S. Department of Education. (1995). *Seventeenth annual report to
Congress on the implementation of the Individuals with Disabilities
Education Act (IDEA)*. Washington, DC: U.S. Government Printing Office.

Valdes, K.A., Williamson, C.L., & Wagner, M.M. (1990). *The National
Longitudinal Transition Study of special education students: Statistical
almanac, Volume 1*.\
Menlo Park, CA: SRI International.

Vector Research, Inc. (1997). APTA executive summary conclusions*.
Workforce study prepared for the American Physical Therapy Association*.
Retrieved January 12, 2000, from the World Wide Web:
http://www.apta.org/research/WorkforceStudy.html

Table II-14

Knowledge and Skills for All Beginning Special Education Teachers of
Students with Physical\
and Health Disabilities

+-----------------------------------------------------------------------+
| **Philosophical, Historical, and Legal Foundations of Special         |
| Education**                                                           |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Current educational definitions of individuals with physical and      |
| health disabilities including identification criteria, labeling       |
| issues, and current incidence and prevalence figures.                 |
|                                                                       |
| Historical foundations and classic studies, including the major       |
| contributors, that undergird the growth and improvement of knowledge  |
| and practices in the field of special education and related services  |
| for individuals with physical and health disabilities and their       |
| families.                                                             |
|                                                                       |
| Contemporary issues in special education and related services for     |
| individuals with physical and health disabilities and their families. |
|                                                                       |
| Laws, regulations, and policies related to the provision of           |
| specialized health care in the educational setting.                   |
+-----------------------------------------------------------------------+
| [Skills]{.underline}                                                  |
|                                                                       |
| Articulate the service delivery for individuals with physical and     |
| health disabilities and its relation to contemporary educational      |
| placement and instructional content.                                  |
+-----------------------------------------------------------------------+
| **Characteristics of Learners**                                       |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Implications of physical and health disabilities on psychosocial,     |
| educational, vocational, and leisure outcomes for individuals,        |
| families, and society.                                                |
|                                                                       |
| Generic medical terminology used to describe the impact of physical   |
| and health disabilities.                                              |
|                                                                       |
| Etiology and characteristics of physical and health disabilities      |
| across the life span.                                                 |
|                                                                       |
| Secondary health care issues that accompany specific physical and     |
| health disabilities.                                                  |
+-----------------------------------------------------------------------+
| **Assessment, Diagnosis, and Evaluation**                             |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Specialized terminology used in the assessment of individuals with    |
| physical and health disabilities.                                     |
|                                                                       |
| Legal provisions, regulations, and guidelines regarding unbiased      |
| assessment and use of instructional assessment measures of            |
| individuals with physical and health disabilities.                    |
|                                                                       |
| Specialized policies regarding referral and placement procedures for  |
| students with physical and health disabilities.                       |
+-----------------------------------------------------------------------+

Table II-14 (cont'd)

+-----------------------------------------------------------------------+
| **Assessment, Diagnosis, and Evaluation (continued)**                 |
+-----------------------------------------------------------------------+
| [Skills]{.underline}                                                  |
|                                                                       |
| Modify and adapt assessment procedures for use with individuals with  |
| physical and health disabilities.                                     |
|                                                                       |
| Develop and use a technology plan based on assistive technology       |
| assessment.                                                           |
|                                                                       |
| Assess reliable method(s) of response of individuals who lack typical |
| communication and performance abilities.                              |
|                                                                       |
| Use results of specialized evaluations, such as oral, motor, reflex,  |
| and movement, to make instructional decisions for individuals with    |
| physical and health disabilities.                                     |
+-----------------------------------------------------------------------+
| **Instructional Content and Practices**                               |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Research-supported instructional practices, strategies, and           |
| adaptations necessary to accommodate the physical and communication   |
| characteristics of students with physical and health disabilities.    |
|                                                                       |
| Sources of specialized materials, equipment, and assistive technology |
| for students with physical and health disabilities.                   |
+-----------------------------------------------------------------------+
| [Skills]{.underline}                                                  |
|                                                                       |
| Interpret sensory, mobility, reflex, and perceptional information to  |
| create appropriate learning plans for individuals with physical and   |
| health disabilities.                                                  |
|                                                                       |
| Use appropriate adaptations and assistive technology such as          |
| switches, adapted keyboards, and alternative positioning to allow     |
| students with physical and health disabilities full participation and |
| access to the core curriculum.                                        |
|                                                                       |
| Adapt lessons that minimize the physical exertion of individuals with |
| specialized health care needs.                                        |
|                                                                       |
| Design and implement an instructional program that addresses          |
| instruction in independent living skills, vocational skills, and      |
| career education for students with physical and health disabilities,  |
| emphasizing positive self-concepts and realistic goals.               |
|                                                                       |
| Design and implement curriculum and instructional strategies for      |
| medical self-management procedures by students with specialized       |
| health care needs.                                                    |
|                                                                       |
| Participate in the selection and implementation of augmentative or    |
| alternative communication devices and systems, including sign         |
| language, electronic devices, picture and symbol systems, and         |
| language boards, for use with students with physical and health       |
| disabilities.                                                         |
+-----------------------------------------------------------------------+

Table II-14 (cont'd)

+-----------------------------------------------------------------------+
| **Planning and Managing the Teaching and Learning Environment**       |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| School setting adaptations necessary to accommodate the needs and     |
| abilities of individuals with physical and health disabilities.       |
|                                                                       |
| Appropriate use of assistive devices to meet the needs of individuals |
| with physical and health disabilities.                                |
|                                                                       |
| Specialized health care practices, first aid techniques, and other    |
| medically relevant interventions necessary to maintain the health and |
| safety of students in a variety of educational settings.              |
|                                                                       |
| Common environmental and personal barriers that hinder accessibility  |
| and acceptance of individuals with physical and health disabilities.  |
+-----------------------------------------------------------------------+
| [Skills]{.underline}                                                  |
|                                                                       |
| Use local, community, and state resources available to assist in      |
| programming for individuals with physical and health disabilities.    |
|                                                                       |
| Coordinate activities of related services personnel to maximize       |
| direct instruction time for individuals with physical and health      |
| disabilities.                                                         |
|                                                                       |
| Use techniques of physical positioning and management of individuals  |
| with physical and health disabilities to ensure participation in      |
| academic and social environments.                                     |
|                                                                       |
| Use local, community, and state resources available to assist in      |
| programming for individuals with physical and health disabilities.    |
|                                                                       |
| Coordinate activities of related services personnel to maximize       |
| direct instruction time for individuals with physical and health      |
| disabilities.                                                         |
|                                                                       |
| Use techniques of physical positioning and management of individuals  |
| with physical and health disabilities to ensure participation in      |
| academic and social environments.                                     |
|                                                                       |
| Demonstrate appropriate body mechanics to ensure student and teacher  |
| safety in transfer, lifting, positioning, and seating.                |
|                                                                       |
| Use appropriate adaptive equipment such as wedges, seat inserts, and  |
| standers to facilitate positioning, mobility, communication, and      |
| learning for individuals with physical and health disabilities.       |
|                                                                       |
| Use positioning techniques that decrease inappropriate tone and       |
| facilitate appropriate postural reactions to enhance participation.   |
|                                                                       |
| Practice recommended universal precautions to maintain healthy        |
| environments.                                                         |
|                                                                       |
| Assist individuals to develop a sensitivity toward those who have     |
| communicable diseases.                                                |
|                                                                       |
| Monitor the effects of medication on individual performance.          |
|                                                                       |
| Integrate an individual's health care plan into daily programming.    |
+-----------------------------------------------------------------------+

Table II-14 (cont'd)

+-----------------------------------------------------------------------+
| **Managing Student Behavior and Social Interaction Skills**           |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Communication and social interaction alternatives for individuals who |
| are nonspeaking.                                                      |
+-----------------------------------------------------------------------+
| **Communication and Collaborative Partnerships**                      |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Sources of unique services, networks, and organizations for           |
| individuals with physical and health disabilities.                    |
|                                                                       |
| Roles and responsibilities of school-based medical and related        |
| services personnel.                                                   |
|                                                                       |
| Roles and responsibilities of community-based medical and related     |
| services personnel.                                                   |
+-----------------------------------------------------------------------+
| [Skills]{.underline}                                                  |
|                                                                       |
| Collaborate with service providers regarding acquisition,             |
| development, modification, and evaluation of assistive technology,    |
| procedures, and curricula to assist in meeting functional, social,    |
| educational, and technological needs of students with physical and    |
| health disabilities.                                                  |
|                                                                       |
| Use strategies to work with chronically ill and terminally ill        |
| individuals and their families.                                       |
+-----------------------------------------------------------------------+
| **Professionalism and Ethical Practices**                             |
+-----------------------------------------------------------------------+
| [Knowledge]{.underline}                                               |
|                                                                       |
| Rights to privacy, confidentiality, and respect for differences among |
| all persons interacting with individuals with physical and health     |
| disabilities.                                                         |
|                                                                       |
| Consumer and professional organizations, agencies, publications, and  |
| journals relevant to the field of physical and health disabilities.   |
|                                                                       |
| Types and transmission routes of infectious disease.                  |
+-----------------------------------------------------------------------+
| [Skills]{.underline}                                                  |
|                                                                       |
| Participate in transdisciplinary team activities in providing         |
| integrated care for individuals with physical and health              |
| disabilities, particularly when students are transitioning from home, |
| hospital, or rehabilitation facility to school.                       |
|                                                                       |
| Maintain confidentiality of medical records and respect for privacy   |
| of individuals with physical and health disabilities.                 |
|                                                                       |
| Practice appropriate universal precautions when interacting with      |
| individuals with physical and health disabilities.                    |
|                                                                       |
| Seek information regarding protocols, procedural guidelines, and      |
| policies designed to assist individuals with physical and health      |
| disabilities as they participate in school and community-based        |
| activities.                                                           |
|                                                                       |
| Participate in the activities of professional organizations relevant  |
| to the field of physical and health disabilities.                     |
+-----------------------------------------------------------------------+

Source: Council for Exceptional Children, 1998.

[^1]: This annual report includes child count data for 1998-99 and
    non-child count data for 1997-98.

[^2]: Two States\--Massachusetts and New Mexico\--did not separately
    report the number of at-risk infants and toddlers served on the data
    form.

[^3]: Census figures, which are included in DANS, are from July 1998
    estimates by the U.S. Bureau of the Census.

[^4]: For this analysis, we excluded the infants and toddlers served in
    Puerto Rico and the Outlying Areas. Puerto Rico classified its
    children as nearly 100 percent Hispanic. Including those children
    increases the percentage of Hispanic children served under Part C of
    IDEA to 16.2 percent.

[^5]: Outpatient service facility refers to an office, clinic, or
    hospital where an infant or toddler receives services for a short
    period of time; services may be offered individually or in small
    groups.

[^6]: States report on only the primary setting, or the setting in which
    the child receives the most hours of early intervention services.

[^7]: California noted that it did not have reliable data to report.

[^8]: Kentucky said that it could not provide the information in the
    format requested because its data collection system could only
    collect data in two categories: home or community-based and office-
    or center-based settings.

[^9]: This annual report includes child count data for 1998-99 and
    non-child count data for 1997-98.

[^10]: Although preschoolers are generally ages 3 through 5, some States
    also serve 2-year-olds who will turn 3 during the school year under
    Part B.

[^11]: In 1990, the Act was renamed the Individuals with Disabilities
    Education Act (IDEA).

[^12]: Comparisons were based on July 1998 U.S. Bureau of the Census
    estimates and were included in DANS.

[^13]: Data using the new settings categories will be reported for the
    first time in the *23^rd^ Annual Report to Congress*.

[^14]: This annual report includes child count data from 1998-99 and
    non-child count data from 1997-98.

[^15]: Resident population counts are based on July 1998 estimates from
    the U.S. Bureau of the Census. Enrollment is based on National
    Center for Education Statistics (NCES) counts of enrollment for
    individuals with and without disabilities in pre-kindergarten
    through 12^th^ grade. Population and enrollment figures reflect data
    from the 50 States and the District of Columbia.

[^16]: Low-incidence disabilities are defined as those that occur in
    fewer than 100,000 persons.

[^17]: While developmental delay meets this definition, it is an
    optional category and applies only to children ages 3 through 9. The
    1997-98 school year was the first time these data were collected. It
    has been excluded from this discussion.

[^18]: The racial and ethnic composition of Puerto Rico and the Outlying
    Areas may be expected to differ from that of the 50 States and the
    District of Columbia; for example, Puerto Rico classified as
    Hispanic 99.89 percent of its 6- through 21-year-olds served under
    IDEA. Puerto Rico and the Outlying Areas have therefore been
    excluded from this analysis. See tables AA3 and AF8 for the
    racial/ethnic distribution of students served under IDEA and the
    resident populations of Puerto Rico and the Outlying Areas.

[^19]: Students who have been described in some literature as having
    multiple disabilities will be referred to in this module as having
    co-occurring disabilities, where applicable.

[^20]: Once respondents indicated that their children received special
    education and related services, they were asked about the types of
    disabilities their children had. Interviewers read a list of
    disabilities to the respondent and asked whether the child had each
    disability. The order in which the disabilities were listed could
    have affected responses. For example, the multiple disability
    category is one of the last disabilities listed. All of the
    respondents who indicated that their children had multiple
    disabilities also indicated that they had other specified
    disabilities. This suggests that there may have been some double
    counting of disabilities. Three disabilities were always selected in
    combination with other disabilities: traumatic brain injury, autism,
    and mental retardation. As in the case of multiple disabilities, it
    is not clear whether respondents were referring to different aspects
    of a single disability or to separate disabilities.

[^21]: A series of complex decision rules were used to code students as
    having one, two, or three or more disabilities. Children with
    deaf-blindness were coded as having two disabilities. Children with
    multiple disabilities were coded as having two or more disabilities
    depending on the specific disabilities reported by parents**.** For
    example, if parents indicated that their child had a learning
    disability, emotional disturbance, and multiple disabilities, the
    child was coded as having two disabilities. If parents indicated
    that their child had a learning disability, speech or language
    impairments, visual problems, and multiple disabilities, the child
    was coded as having three or more disabilities. It was difficult to
    determine whether children with developmental delays had
    co-occurring disabilities because one or more delays may be included
    under the definition; these children were excluded from the
    analyses. A total of 152 children were reported as having
    developmental delays.

[^22]: Caution should be used in interpreting this percentage due to
    small sample sizes.

[^23]: Sample sizes were inadequate to conduct a multivariate analysis
    predicting the prevalence of co-occurring disabilities based on
    demographic characteristics.

[^24]: Physical therapy and occupational therapy were not included in
    the analysis because of the small numbers of students in the sample
    who received those services.

[^25]: Colorado, Delaware, Michigan, and Mississippi include students
    with other health impairments in their count of students with
    orthopedic impairments.

[^26]: Although it is now a decade old, the National Longitudinal
    Transition Study (NLTS) remains the best source of information on
    students with orthopedic impairments. An update of the study, the
    NLTS-2, is scheduled to be completed in the next few years. The
    Special Education Elementary Longitudinal Study (SEELS), which
    begins data collection in 2000, will provide comparable data on
    elementary-aged students with orthopedic impairments, which have
    been unavailable to this point.

[^27]: Because students may drop out prior to age 17 but rarely graduate
    before age 17, OSEP recommends calculating graduation percentages
    based on school leavers ages 17-21+ and dropout percentages based on
    school leavers 14-21+. In 1997-98, 14.0 percent of students with
    orthopedic impairments ages 14-21+ who left the educational system
    dropped out of school.

[^28]: The sample of eighth graders in NELS:88/94 excluded about 5
    percent of the potential sample. The sample excluded "1) students
    with severe mental disabilities; 2) those whose knowledge of English
    was not sufficient to complete the tests; and 3) students with
    severe physical or emotional problems that would have made it
    difficult for them to participate in the survey" (Horn & Berktold,
    1999, p. 4). The NELS sample was therefore more representative of
    students with less severe disabilities than of all students served
    under IDEA.

[^29]: This category included private for-profit institutions; public
    less-than-2-year institutions; and private, non-profit, less-than-4
    year institutions.