Recent U.S. Department of Education figures indicate that
approximately 147,000 students are being treated for physical
disabilities, of which 41,000 are orthopedically handicapped, 43,000 are
other health impaired and 63,000 are multiple-handicapped. Approximatly
17,000 students are technology-dependent and this number is expected to
Until recently, students with severe health problems who needed
continuous medical monitoring received their academic instruction in the
isolated settings of residential facilities, hospitals and homes. Now,
however, historic education laws have opened public school classroom
doors to "medically fragile" or physically challenged
students. These laws include Section 504 of the Vocational
Rehabilitation Act of 1973 (PL 93-112), the Education for All
Handicapped Children Act of 1975 (PL 94-142) and its 1986 Amendments (PL
99-457), and the Individuals with Disabilities Act of 1990 (PL 101-476).
The Council for Exceptional Children defines medically fragile
students as requiring "specialized technological health care
procedures for life support and/or health support during the school day.
These students may or may not require special education" (Council
for Exceptional Children, 1988, pp. 5-6). Students qualifying as
"other health impaired" have "limited strength, vitality,
or alertness, due to chronic or acute health problems, ... which
adversely affects their educational performance" (Sirvis, 1988, p.
42). Physical disabilities may include a variety of neurological or
musculo-skeletal impairments such as cerebral palsy, epilepsy, spina
bifida, muscular dystrophy, arthritis or scoliosis. Severe, chronic
illnesses include asthma, cystic fibrosis, diabetes, leukemia,
sickle-cell anemia and hemophilia.
Physically challenged students are the fastest growing population of
children receiving special education services. Advances in medical
technology ensure declining mortality rates and improve the chances of
preventing or curing many diseases and disorders. Recent U.S. Department
of Education figures indicate that approximately 147,000 students are
being treated for physical disabilities, of which 41,000 are
orthopedically handicapped, 43,000 are other health impaired and 63,000
are multiple-handicapped (Hallahan & Kauffman, 1991). Approximately
17,000 students are technology-dependent and this number is expected to
rise (Caldwell, Sirvis, Todaro & Accouloumre, 1991).
While school district central office personnel face the legal,
financial and administrative issues associated with these students,
regular classroom teachers and special education professionals must form
a team to effectively serve this growing population. The following
specific suggestions provide preschool, elementary and middle grade
teachers with some immediate assistance necessary for the day-to-day,
successful integration of students with physical and medical
difficulties. The tips focus on parent involvement, peer interaction,
environmental/training considerations and instructional adaptations.
Family members can provide key information about the student's
abilities, interests, strengths and weaknesses. Parental insights
complement information obtained from school sources and provide a
general picture of the student's needs and capabilities
(Bernheimer, Gallimore & Weisner, 1990). Teachers must acknowledge
parents' anxiety, while channeling their concern into healthy,
constructive contributions. Teachers can promote maximum parental
involvement in the following ways:
* Medical History. Obtain the student's complete medical
history, including names, addresses and telephone numbers of attending
physicians. When possible, secure parental permission to contact
physicians in a medical emergency or with questions. Make careful notes
about the student's need for medication (dosage, frequency) and
regularity of ongoing medical treatments (chemotherapy, radiation,
dialysis, suctioning). Question parents about the student's
physical limitations, stamina and endurance levels, as well as side
effects of medication/treatment (appetite loss, lethargy, hair loss,
mood swings). Educators should become familiar with danger signs, such
as a specific localized pain in a student with sickle-cell anemia,
seizure activity in a student with epilepsy or a severe cut or bruise on
a student with hemophilia.
Parents must understand that school attendance increases the risk of
exposure to diseases. Teachers should inform parents immediately about
any potential health threats. Such notification is particularly
important for students who have undergone cancer treatments or organ
transplants, as they are more susceptible to contagion.
* Emergency Care Plans. Emergencies can result from medical
equipment failure, natural disasters or physiological breakdown. Consult
parents as to what person or agency should be notified in an emergency.
As a general rule, inform local telephone and electric companies, fire
and police departments, ambulance services, as well as the nearest
hospital emergency room, about technology-dependent students. Avenues of
emergency transportation in the community and alternate routes of
transportation should be explored well in advance of any crisis. Trial
runs might be conducted to ensure smooth operation during an emergency.
* Parent Participation. Parents of technology-dependent or other
health impaired students and parents of non-health impaired students may
have differing concerns. A harmonious balance needs to be established in
attending to their concerns, beginning with the initial contact.
Continuous communication between school and parents cannot be
Anxiety levels and potential stressful situations can be alleviated
by being sensitive to parents' needs. Concentrate on the positive
aspects of issues or situations, not on "problems." Encourage
parental observation in the classroom at the time of first placement.
Discourage overprotectiveness and encourage parents to allow their child
to attempt new activities independently. Serve as a resource for
parents, helping them to realize their assets and strengths through
support groups, community involvement or as school volunteers.
The self-esteem of a physically challenged student has a critical
effect on learning. To enhance self-image, the education team must be
constantly mindful of ways to involve these students in classroom
activities. Maximum socialization must be promoted to ensure a positive
mainstreaming experience. In order to accomplish this objective,
however, teachers must first be comfortable with their own understanding
of physical disabilities and have parental support (American Cancer
Society, 1980; Chekryn, Deegan & Reid, 1987). The following
strategies may help foster positive peer interaction:
* Orientation to Equipment. When a physically disabled student
initially joins the class, any unfamiliar equipment should be introduced
to all students. Orthopedically handicapped students may use
wheelchairs, walkers or braces. Technology-dependent students may
require ventilators, suctioning machines and nebulizers. Such machines
feature sounds, alarms, lights, cords, hoses and gauges that may prove
frightening at first.
* Peer Socialization. Special care to promote
"normalization" must be exercised. Peer acceptance will be
strengthened by involving the disabled student in all daily activities
(academic classes, art, music, physical education, cafeteria,
playground, extracurricular events). Adapt situations to facilitate
active participation and increase chances of success. For example, a
student with a physical disability could hit the ball, but not run,
during a baseball game.
Educators must be careful to avoid the appearance of giving
"special privileges" to physically challenged students. If not
handled appropriately, non-health impaired students may come to resent
the frequent snacks given to a student with diabetes or the extra
attention (therapy) paid to the student with cystic fibrosis.
* Classroom Management. Parents and the education team must jointly
generate a consistent behavioral management program that will fit within
preestablished classroom rules, while not compromising special health
care needs. To further promote peer acceptance, this plan should be as
similar as possible to that for other students. The teacher must be
careful to feel "empathy" for the student, not
"sympathy." Although it may be tempting to "give in"
to the wishes of a student with a physical disability or
life-threatening illness, such treatment will be detrimental. A mentor
(another student or adult) can prevent possible behavioral problems by
assisting the student with physical tasks or being available to talk,
listen and understand.
Depending on health constraints, regular classroom placement of these
students may be on a limited basis or for an extended period of time.
Modifications in the structure and daily routine of the classroom may be
necessary to accommodate students with physical disabilities. Some
students can benefit from the use of specially constructed adaptive
positioning equipment designed to foster social interaction, learning
and independence. Other students will require continuous repositioning
to relieve pressure points or to prevent the development of deformities
(Sirvis, 1988). The following tips should be considered in regard to
classroom environment and teacher training:
* Scheduling. Specialized equipment should be integrated in a
manner that does not detract from the existing learning centers,
equipment, furniture and routine of the classroom. Some physically
disabled students may receive health care services at regularly
scheduled times throughout the day, while others will require services
as the situation demands. For technology-dependent students, such
services (ventilating, breathing treatments, tube feeding) may conflict
with the time allotted and/or required for instructional tasks. As much
as possible, however, interruptions for medical intervention should be
nondisruptive to peers and planned at times of minimal social
interaction (rest times, individual study times).
One-to-one assistance may be periodically needed for missed
instruction. For students with other health impairments experiencing a
remission in health, the school team may need to work closely with the
homebound teacher to ensure learning continuity.
* Spatial Requirements and Mobility. The school building must be
accessible in its entirety to ensure maximum normalization. Students
with orthopedic impairments need lowered shelves and hooks for easy
storage and retrieval of instructional materials and personal
belongings. Lowered water fountains and handrails in bathrooms
facilitate the acquisition of personal hygiene and self-help skills.
Lowered doorknobs and ramps allow the student to achieve independence in
Students who are technology-dependent have additional environmental
restraints. Adequacy of electrical outlets and power sources, space for
equipment and supplies, appropriate lighting and availability of water
need to be considered. Whenever possible, students with physical
disabilities should use the same types of desks as other students; this
will foster uniformity and self-esteem.
It is prudent to maintain easy access to replacement equipment,
should a breakdown/failure occur. Wheelchairs, braces and walkers may
need repair on a moment's notice. In addition, manual backup for
the power source (12 volt battery) and equipment for
technology-dependent students (supplemental oxygen, resuscitator bag,
suctioning catheter, extra trachea tubes) should be immediately
available and may be stored in the regular classroom.
* Specialized Training. Team members and parents should stress the
development of academic, language, motor and social skills; methods for
fostering these skills can be the focus of inservices/workshops. In
addition, general training sessions designed to disseminate information
regarding types and usage of equipment, warning signs for pending
crises, repositioning techniques, CPR and universal
precautions/infection control will alleviate anxiety and promote
The total development of physically disabled students depends upon
professionals from a variety of disciplines sharing their expertise
(Lowenthal, 1992; Taylor, Willits & Lieberman, 1990). The team must
adapt instructional materials, methods and assessments, while providing
direct instruction that is as close to grade level and/or age
expectation as possible. Close adherence to approved curriculum guides
and minimum standards should occur, while fostering problem-solving
skills, creativity and individuality. The following strategies can help
teachers adapt instructional materials:
* Support Service Assistance. Because of health constraints, many
physically disabled students receive supplemental services from other
educators and health care professionals. In many instances, it is both
possible and desirable for the teacher to reinforce these learned skills
in the regular classroom.
Activities promoting motor skill development (stamina and endurance,
mobility, motor planning, range of motion) should be planned in
conjunction with the physical therapist, occupational therapist and/or
adaptive physical education teacher. Augmentative communication
techniques (signing, communication boards, switches) may be necessary
for students with vocal cord paralysis, disease-affected musculature,
spinal muscular atrophy or tracheotomy installation. The services of a
speech/language therapist may be required.
* Lesson Plan and IEP (Individualized Education Plan) Development.
Regular classroom teachers should actively participate in IEP
development if a student in their classroom also receives special
education instruction. Such participation will allow teachers to develop
lesson plans that reflect the student's strengths and weaknesses
and to write specific objectives in behavioral terms, reflecting the
student's needs and achievement expectations.
The special education teacher can be a valuable resource in designing
and implementing specific behavioral and instructional interventions.
Daily contact is recommended to ensure lesson continuity, skill
reinforcement, task completion and mastery learning. Appendix A reflects
simple adaptations, which may be necessary when teaching physically
In the past, poor integration of the education system and the medical
field made it difficult for physically challenged students to
participate in regular classroom activities. Today's societal
demands call for the pooling of knowledge from a variety of
professionals to provide timely, cost-effective and time-efficient
The tips in this article are designed to raise the awareness level of
educators and, at the same time, assist them in making the inclusion of
physically challenged students a more pleasant, nonthreatening
experience. Independence, normalcy and acceptance can be the positive
American Cancer Society. (1980). When you have a student with cancer.
(80-(100m)-No. 2613-LE). New York: Author.
Bernheimer, L. P., Gallimore, R., & Weisner, T. S. (1990).
Ecocultural theory as a context for the individual family service plan.
Journal of Early Intervention, 14, 219-233.
Caldwell, T. H., Sirvis, B., Todaro, A., & Accouloumre, D. S.
(1991). Special health care in the school. Reston, VA: Council for
Chekryn, J., Deegan, M., & Reid, J. (1987). Input on teachers
when a child with cancer returns to school. Children's Health Care,
Council for Exceptional Children. (1988). Final report: CEC ad hoc
committee on medically fragile. Reston, VA: Author.
Hallahan, D. P., & Kauffman, J. M. (1991). Exceptional children:
Introduction to special education (5th ed.). Englewood Cliffs, NJ:
Lowenthal, B. (1992). Collaborative training in the education of
early childhood educators. Teaching Exceptional Children, 24, 25-29.
Sirvis, B. (1988). Students with special health care needs. Teaching
Exceptional Children, 20, 40-44.
Taylor, R. L., Willits, P., & Lieberman, N. (1990).
Identification of preschool children with mild handicaps: The importance
of cooperative efforts. Childhood Education, 67, 26-32.
Instructional Adaptations for Physically Challenged Children
1. Prevent paper and objects from slipping by using pads of paper,
tape, clipboards, metal cookie sheets and magnets, photo album pages
with sticky backings and plastic cover sheets, dycem (plastic) placed
under paper and objects, or plastic photo cubes for displaying and
2. Place a rubber strip on the back of a ruler or use a magnetic
ruler to measure or draw lines.
3. Use calculators to perform computations.
4. Use felt tip pens and soft lead pencils that require less
pressure. Improve grip on writing utensils by placing rubber bands,
corrugated rubber or plastic tubing around the shaft. A golf practice
ball or a sponge rubber ball may also be used.
5. Permit use of electronic typewriters, word processors or
computers. Typing aids can include a pointer stick attached to a head-
or mouthpiece to strike keys, a keyboard guard that prevents striking
two keys at once, line spacers that hold written materials while typing
and corrective typewriter ribbons that do not require the use of
6. Use lap desks or a table-top easel with cork that allows work to
be attached with push pins.
7. Provide an "able table" that adapts to varying positions
and angles and may be attached to a wheelchair or freely stood on a tray
(elastic straps hold books/materials in place, while knobs adjust
8. Write or type at tables/desks that adjust to wheelchair heights.
9. Provide two sets of books/workbooks--one for home and one for
10. Tape assignments, lectures and activities that require extensive
11. Allow a peer to carbon copy or photocopy class notes and provide
written copies of board work.
12. Design worksheets/tests that allow students to answer in one of
the following modes: one-word answers, lines placed through correct
answers, magnetic letters moved on metal cookie sheets to indicate
responses, wooden blocks placed on correct answers or containers with
different categories in which answers can be dropped.
13. Use color-coded objects that are easy to handle and do not slip
to indicate responses to polar questions: true/false, same/different,
14. Select materials that are available on talking books or cassette
tapes for students unable to hold books.
15. Use communication boards or charts with pictures, symbols,
numbers or words to indicate responses.
16. Extend testing/assignment time and/or allow oral responses.
Diane Knight is Assistant Professor and Donna Wadsworth is
Instructor, Special Education, Department fo Curriculum and Instruction,
University of Southwestern Louisiana, Lafayette.