Leading the Way in School-Based Care for Exceptional Children

Forty years ago, the North Carolina Department of Public Instruction and the UNC School of Medicine’s Department of Allied Health Sciences partnered to deliver quality related services, specifically Occupational and Physical Therapy, to exceptional children in North Carolina’s public schools. The model is among the most effective in the nation.

Leading the Way in School-Based Care for Exceptional Children click to enlarge From left to right: Lauren Holahan and Laurie Ray
Leading the Way in School-Based Care for Exceptional Children click to enlarge From left to right: Margaret Moore, Dianne Lindsey, Marlys Mitchell

Early in her career as a school-based physical therapist (PT) in Wilson County, North Carolina, Laurie Ray needed help. She had received excellent training at UNC School of Medicine’s Department of Allied Health Sciences (DAHS) as a PT student, but the cases and situations she encountered in the school system were new to her. 

At first, Ray didn’t know where to turn for guidance. Then she connected with Dianne Lindsey, a DAHS PT who was the North Carolina Department of Public Instruction (DPI) Exceptional Children Division consultant for school-based PTs, a role Lindsey filled for nearly three decades before retiring in 2005.

View a slideshow highlighting accomplishments during the last 40 years.

“I was young, relatively new to practice, and practicing in a county by myself,” said Ray, who serves in Lindsey’s role today. “It was challenging, but through DPI, Dianne was a phone call away. She put me in touch with PTs who had resolved similar issues in the schools where they worked, and talked with me about the best equipment to purchase on a tight budget. That kind of resource is invaluable.”

Lindsey was a national leader for school-based physical therapy and a driving force behind the identifying and publishing the competencies required to provide school-based physical therapy.

Occupational therapist (OT) Lauren Holahan had a similar experience while providing school-based OT care for exceptional children in Durham County, North Carolina, early in her career. Like Ray, Holahan found a precious resource to guide her: Jane Rourk, a DAHS OT who was the DPI school-based consultant for OTs in the state, a position Rourk, like Lindsey, held for almost 30 years.

“Jane was so important to my work at the local level,” said Holahan, who succeeded Rourk in 2007. “She was a mentor to me, and is a huge figure in school-based OT, not only in North Carolina, but in the nation.”

For Holahan, the importance of having someone to call with practice questions, who could also help with real-time problem solving around particular cases and with understanding program and policy issues, cannot be overstated.

“Jane was on the frontlines of the latest in policy, research, and funding,” said Holahan, “and that information reached all school-based OTs in the state.”

At the Forefront

The relationship between DAHS and DPI became official in August 1977, when the Education for All Handicapped Children Act (EAHCA or P.L. 94-142), which had been passed by Congress two years earlier, went into effect.

Known today as the Individuals with Disabilities Education Act (IDEA), this federal law requires public schools to provide exceptional children with education, needed services and appropriate plans of care during school hours.

In North Carolina, after EAHCA became law, responsibility for providing services for exceptional children fell to DPI. Dr. Marlys Mitchell, the then-director of OT at DAHS, explained to her friend and colleague through previous special education work, Ted Draine, Director of Exceptional Children at DPI, that schools were different from medical settings where therapists worked; they would require new skills and ways to provide service. She also discussed the importance of having an OT and a PT as state consultants to assist educators and therapists in local schools to develop local program capacity and to provide effective, educationally relevant therapy services.

Lindsey, meanwhile, had worked with institutionalized children in Buffalo, New York, and she, too, saw troubles ahead if DPI didn’t consult with PT and OT experts. She understood the significant challenges public schools would face when incorporating therapy into schools. She approached the then director of PT at DAHS, Dr. Margaret Moore, about her concerns.

“School systems and state-level agencies didn’t know about PT and OT work and how to make environments accessible to children,” said Lindsey. “It had never been their job to know about it, and suddenly they were told they’d have X number of children to care for.”

Wisely, DPI tapped DAHS to help build service capabilities in PT and OT across the state.

“DPI contracted consultant positions for Dianne and Jane to ensure that the most updated services were being provided in schools,” said Director of DPI’s Exceptional Children Division Bill Hussey, who oversees more than 200,000 exceptional students in the state. “Today, we have many more consultants who cover a wide spectrum of specialties and are designated to specific regions in North Carolina, but it all began with Dianne and Jane at DAHS.”

After EAHCA went into effect and DAHS consultants began advising school-based practitioners, North Carolina’s commitment to supporting exceptional children became apparent to education and health care professionals around the nation. In the mid-1970s, PT Dr. Susan Effgen (now of the University of Kentucky College of Health Sciences) testified at the federal hearings that led to EAHCA. In the early years of DPI’s employment of Lindsey and Rourk, Effgen made school visits alongside Lindsey.

“North Carolina’s policies and dedication to supporting therapies in schools became a key model for the development of similar programs around the country,” said Effgen. “This is due, in no small part, to the strong partnership between DAHS and DPI, which helped put the expertise and knowledge into the public school systems.”

DPI, with the help of DAHS, developed one of the first state-level programs to deliver comprehensive care for exceptional children, which included the implementation of new curriculum in schools and the adoption of one of the first guidebooks, authored by Lindsey, to be used by school-based PTs.

“I taught the schools how to feed, carry, and push the children,” said Lindsey. “EAHCA significantly expanded the field of PT and OT in the United States. Schools were the perfect place for us to share our expertise on how to make environments accessible for exceptional children, and North Carolina became the state for school-based PT and OT care.”

Real-World Impact

DPI consultants offer key insights about state and federal regulations, policy decisions, and Medicaid issues for school-based practitioners. Another critical function of the consultant role is to translate research to the field for implementation.

“In other disciplines, particularly in health care, it takes a long time to translate evidence into changed practitioner behavior,” said Holahan. “As consultants, we have direct access to the end user: school-based practitioners. So, for exceptional children in schools, we implement change much faster.”

Together, Holahan and Ray have tracked the last decade of emerging evidence on the connections between physical activity and student achievement. They’ve provided professional development for teachers and therapists to install more movement into the instructional day.

“We share the evidence with them, discuss what new practices can be incorporated in the classroom without taking time away from instruction, and explore how we can use the practices to enhance the delivery of curriculum, while making it more fun and increasing student engagement,” said Holahan.

Holahan will soon showcase a collaborative project aimed at getting children who struggle to participate in meal times at school, whether due to difficulty chewing or swallowing or for social or emotional reasons, into the cafeteria. Schools are required to provide the support necessary for students, no matter their challenges, so that they can participate in lunchtime with their peers.

“Lunch is a huge part of a child’s social engagement at school, especially when the child reaches middle and high school, so we’re doing a series of trainings around the state to explain the factors that may limit the child’s ability to go to the cafeteria,” said Holahan. “It seems so basic, but it’s incredibly complicated. If done right, it can be so important for a child’s development.”

In recent years, Holahan and Ray discovered that requirements for Plans of Care for exceptional children were not being met by Individualized Education Plans (IEP). They’ve begun educating PTs and OTs statewide about requirements to comply with the licensure law and to clarify practice in schools. Meanwhile, Ray and Holahan are also collaborating with speech-language and preschool consultants on embedding interventions into the classroom, which means taking therapeutic interventions and making them a part of school routines. The idea came from DPI preschool consultant Vivian James, and Ray and Holahan took it to the PTs and OTs across North Carolina.

“Rather than pulling children out for one-on-one therapy, we want these trainings to fit into classroom instruction,” Ray said. “Although we’re consultants and not tasked with providing direct care, our roles can have direct impacts on all children in the classroom.”

The Mission Continues

When she’s not guiding school-based PTs about Medicaid policy or answering questions about best practice, Ray sometimes takes a moment to think about how proud she is to be part of DPI and the school-based PT community.

“You make less money working in schools than the average PT working anywhere else,” Ray said. “But the PTs I work with believe in the mission of public schools and want to make sure kids with disabilities get a great start on their lives.”

Ray points out that school-based PTs must be able to solve problems. They have to be persistent, flexible, collaborative, and passionate.

“They’re the finest group of PTs that I’ve encountered, and I’m always amazed at what the people in the field are able to accomplish for children with disabilities – it’s awe-inspiring,” Ray said.

And Ray would know. She’s been a school-based practitioner who’s had to tackle complicated cases with limited resources. But North Carolina’s practitioners will be the first to admit that they don’t do it alone. For 40 years, thanks to the DPI-DAHS partnership, they’ve turned to DPI consultants for help with resources, expertise, and access to research from the national perspective to public school classrooms across North Carolina. PTs and OTs working in poorer and remote counties have had the same access to information and resources as their colleagues working in better resourced, more populated counties.

“The model has been an equalizer for children, regardless of where they live,” said Stephen Hooper, PhD, and associate dean and chair of DAHS. “This is so important when you think about our rural communities, which might not have great access to these types of services. It’s a testament to the dedication and commitment of DPI to serve North Carolina in this way, and we’re proud to be a partner with them.”

For younger practitioners, the struggles before IDEA (formerly EAHCA) became law may seem like another era, but not to Lindsey, who recalls how ill-prepared schools were to care for exceptional children. Before IDEA, public schools in North Carolina and around the nation commonly refused to admit exceptional children, and children who were admitted were often dismissed because schools considered their education and care too challenging. Before IDEA, children with lesser disabilities would remain at home with their families and those with more severe disabilities were institutionalized. Thanks to interagency collaboration around shared passions and goals, great strides have been made.

“DPI and DAHS believe that everyone benefits when exceptional children attend school,” said DPI director Hussey. “Attending public school gives exceptional children the opportunity to normalize their situation as best as possible. It allows them to be around same-age peers and experience activities in school that are so critical in childhood.”

In North Carolina, because DPI accepted that DAHS could be a resource of expertise and knowledge, exceptional children are getting a better, earlier start in education and socialization and are building life skills that will help them become self-sufficient.

“For 40 years, DAHS has always been a very visible part of our scene,” Hussey continued. “They have been present for a long, long time, and our hope is that we can continue that relationship in the future.”

To maintain that presence, DAHS consultants like Ray and Holahan strive to model the example and contributions of their predecessors, Lindsey and Rourk.

“Forty years ago, DPI had a strong start with Dianne and Jane,” said Holahan. “They created an embodied value wherever they went. They knew their work and how to get people the answers and information they needed. DPI recognizes that having content-area experts saves money – consultants head off complaints in terms of compliance and ensure that best practices are applied. If we can emulate the work of our predecessors, we’ll continue to offer a level of special education that’s worthy of our state’s children.”

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