Canadian Journal of Occupational Therapy

http://cjo.sagepub.com/ Accommodation Needs and Student-Environment Fit in Upper Secondary Schools for Students with Severe Physical Disabilities
Helena Hemmingsson and Lena Borell Canadian Journal of Occupational Therapy 2000 67: 162 DOI: 10.1177/000841740006700311 The online version of this article can be found at: http://cjo.sagepub.com/content/67/3/162

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Accommodation needs and student-environment fit in upper secondary schools for students with severe physical disabilities
HELENA HEMMINGSSON LENA BORELL KEY WORDS
Architectural accessibility Environmental modification School-based occupational therapy
Helena Hemmingsson, OT(r), is a Doctoral Student at the Karolinska Institutet, Institution of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Division of Occupational Therapy, Retzius vg 13, 171 77 Stockholm, Sweden. E-Mail: Helena.Hemmingsson @neurotec.ki.se Lena Borell, Ph.D., OT(r), is Associate Professor and Head, Division of Occupational Therapy at the Karolinska Institutet, Institution of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Stockholm, Sweden.

ABSTRACT
The purpose of this study was to identify, from the personal perspective of students with disability, their needs for physical and social accommodations in upper secondary schools specially adapted for students with severe physical disabilities. The study also aimed to identify those areas of student-environment fit which were most often achieved. Forty-eight students in four schools in Sweden were assessed by occupational therapists using the School Setting Interview. Forty-seven students reported needs for accommodations in the school setting. The study indicates that schools generally were able to meet the students accommodation needs in the physical environment. The schools also met students accommodation needs for field trips, sport activities and assistance. Student-environment fit in occupations requiring reading, remembering and speaking was unsatisfactory. Accommodations on a general, group and individual level are highlighted and discussed. The study recommends that occupational therapists become more involved and offer society their expertise in barrier removal to a greater extent.

RSUM
Le but de cette tude tait didentifier les besoins en terme dinstallations matrielles et damnagements sociaux dans les coles secondaires spcialement adaptes pour les lves ayant des dficiences physiques, du point de vue des lves concerns. Ltude avait galement pour but de cibler les adaptations et amnagements les plus souvent russis dans lenvironnement tudiant. Quarante-huit lves de quatre coles en Suisse ont t valus par des ergothrapeutes au moyen du School Setting Interview. Quarante-sept lves ont mentionn un besoin dadaptations dans le milieu scolaire. Ltude indique quen gnral les coles arrivaient rpondre aux besoins des lves en ce qui a trait lenvironnement physique. Les coles rpondaient galement aux besoins des lves lors des sorties, des activits sportives et de laide physique requise. Les lves ont indiqu que les adaptations environnementales ncessaires pour effectuer des occupations faisant appel la lecture, la mmorisation et la discussion taient insatisfaisantes. Larticle dcrit et discute des adaptations gnrales, de groupe et individuelles. En conclusion de ltude, les auteurs recommandent que les ergothrapeutes simpliquent davantage et offrent leur expertise la socit pour faire disparatre les barrires.

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n recent decades, many developed western societies have introduced important changes in law and social policy to eliminate discrimination against individuals with disabilities. For example, such changes have occurred in Canada, Great Britain, Sweden and U.S.A (Ait-Hocine, 1990; Kalscheur, 1992; Law & Dunn, 1993; Madill, Tirrul-Jones & Magill-Evans, 1990; SOU, 1998:66). The concept of health is also moving from a medical model to a more socio-political perspective that takes into account the person - environment relationship (Ait-Hocine, 1990; Baum & Law, 1997; Jongbloed & Chrichton, 1990; Kalscheur, 1992; Law & Dunn, 1993; Madill et al., 1990; SOU, 1998:66; World Health Organization (WHO), 1993; 1997). As a result of efforts to eliminate discrimination, a growing trend of including students with physical disabilities in the regular classroom is evident in the countries mentioned above (Ait-Hocine, 1990; Madill et al., 1990; Kellegrew & Allen, 1996; Law & Dunn, 1993; SOU, 1998:66). Among students with physical disabilities, the most common diagnoses are cerebral palsy and spina bifida (Bille & Olow, 1996; Erhardt & Cook Merill, 1998; Hall & Hill, 1997). In addition to motor problems, students with these diagnoses could also have other impairments, such as cognitive/perceptual problems, speech impediments or visual impairments (Hall & Hill, 1997; Lie, 1993; Stukt, 1985; Turner, Foster, & Johnson, 1996). Internationally, the percentage of occupational therapists employed in school settings is increasing (Madill et al., 1990). One important challenge for school-based occupational therapists is finding ways to adapt or modify the regular educational environment for students with physical disabilities. Schools that are not fully accessible may prevent students with physical disabilities from enjoying full access to spaces and educational activities (Dudgeon, Massagli & Ross, 1996; Law & Dunn, 1993; SOU, 1998:66). On the other hand, schools that are accessible may afford a student with a severe disability the opportunity to participate in most or all educational activities. In the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), a handicap is characterized to reflect the consequences for the individual cultural, social, economic, and environmental - that stem from the presence of impairment and disability (WHO, 1993). The ongoing revision of the ICIDH, emphasizes the role physical and social environments play in the handicapping process and advances the importance of clarifying the role and interrelationships of environmental factors and disablement (WHO, 1997). The significance of the environment for preventing or reducing activity limitations is well known in occupational therapy (Christiansen & Baum, 1997; Dunn, Brown & McGuigan, 1994; Kielhofner, 1995; Krefting & Krefting, 1991; Law, 1991; Rogers, 1982). The term environment is defined to include physical, social and cultural elements. Models in occupational therapy describe a persons occupational
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behaviour as an interaction between the person, the task and the environment (Canadian Association of Occupational Therapists (CAOT), 1997; Dunn et al., 1994; Kielhofner; 1995, Law, 1991). The person, the environment and the occupation are seen as inseparable and interrelated to each other. A person-environment fit is achieved when the skills and abilities of the person are balanced with the demands of the environment to promote effective engagement in occupation (CAOT, 1997; Dunn et al., 1994; Kielhofner; 1995, Law, 1991). Occupational therapy researchers have highlighted the need for environment-centred assessments and intervention strategies in the area of school-based practice (Broillier, Shepherd & Markley, 1994; Clark & Miller, 1996; Griswold, 1994; Hemmingsson & Borell, 1996; Kalscheur, 1992; Orr & Schadke, 1997; Rourk, 1996). Dudgeon, Massagli and Ross (1996) examined the educational participation of children with spinal cord injury. They found that accommodation in schools supported program completion and advancement to higher levels of education. Niehus, Bundy, Mattingly, & Lawlor (1991) and CaseSmith (1997) examined the nature of occupational therapy practice in public schools and identified variables related to successful school-based practice, as perceived by occupational therapists. These studies found that effective and successful occupational therapy practice included reframing the students behaviour so that it became understandable for other members of the school team.This reframing minimised the discrepancy between what the educational team members thought the students should be able to do, and what the students actually were accomplishing at school. The importance of team work and a collaborative approach for successful intervention in the school setting has also been noted by other researchers in the area of school based practice (for example see Clark & Miller, 1996; Kellegrew & Allen, 1996; Kemmis & Dunn, 1996). While occupational therapy researchers have proposed an environment-centred approach to school based therapy, studies concerning the student environment fit and demands in the school setting, as perceived by students with physical disabilities, are lacking. Studies of students accommodation needs in the school setting and the ability of the school environment to meet these needs are urgently needed. Knowledge and understanding in this area could improve the occupational therapy interventions and facilitate cooperation among the teachers, the students, the parents, and other members of the team. The aim of this study was to identify accommodation needs in the school setting for students with severe physical disabilities attending a specially adapted upper secondary school. The study sought to examine occupational behaviour areas to determine where a good student-environment fit is achieved or lacking.

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Method
Participants
All students with physical disabilities (n=51) who were attending their first semester in one of the four specially adapted upper secondary schools in Sweden, during the actual year of the study, were asked to participate in the study. Forty-eight (94 %) students, 28 boys and 20 girls, with various diagnoses, agreed to participate. A majority of the students had special educational needs due to their disabilities. Only 15 of the 48 students were attending an ordinary program in regular classrooms. The students characteristics are shown in table 1. Of the 48 students, 34 (71%) used a wheelchair for transportation. Two of the students, who used a manual wheelchair, needed assistance to propel the wheel chair. Four students (8%) used alternative communication devices, such as Bliss symbolic technology or a word table. The students level of disability was classified according to criteria used by the nationally based government admission committee (see table 2) (SOU 1996:167).The basis for the classification was the students application information. As table 2 shows, one third of the participants in this study needed assistance throughout the 24 hours.

Table 1 Participants characteristics N=48

Characteristics Gender Boys Girls Educational participation Regular classroom Special classroom Diagnosis Cerebral palsy Spina bifida Brain tumour Congenital abnormalities Hemiparesis Muscle diseases Arthritis Freidrich ataxia No diagnosis Mode of Locomotion Walking Manual wheelchair Power wheelchair Use of alternative communication devices n (%)

28 20

(59) (41)

15 33

(31) (69)

20 8 3 3 2 4 4 3 1

(42) (17) (6) 6) (4) (8) (8) (6) (2)

14 20 14

(29) (42) (29)

Schools
This study investigated Swedish upper secondary schools especially adapted for the needs of physically disabled students (which will be referred to as specially adapted upper secondary schools in this paper) (SFS 1985:1100).The specially adapted upper secondary schools are physically integrated within regular upper secondary schools in four cities throughout Sweden. In these particular settings, a student can choose to attend a regular class with non-disabled peers or a special education class. These schools are accessible for wheelchair users and the students who attend them are guaranteed adapted schedules within the national upper secondary programme. Assistance and therapeutic services are available during the school day for students who need these services (SOU 1996:167) and, if desired, the student may live in a boarding house with special care (SFS 1985:1100).

(8)

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Instrument and procedure

The School Setting Interview (SSI) (Hemmingsson, 1998) is designed to assess the accommodation needs of students with physical disabilities in the school setting. The SSI is based upon concepts from the model of human occupation (Kielhofner, 1995), specifically the models conceptualisation of the environment (i.e., objects, spaces, forms and groups) and Canadian concepts of client-centred practice (Law, Baptiste & Mills, 1995). SSI uses a collaborative approach to
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assessment, that enables small teams of persons with diverse expertise (e.g., the student and the occupational therapist) to mutually define problems and generate creative solutions (Hemmingsson, 1998). The SSI is a semi-structured interview that covers 11 content areas (see table 3). For example, the therapist gets information about the students ability to write, read, verbalise, remember things and do homework.The SSI also gives information about the students classroom functioning, exam-taking, going on field trips, doing math, need of assistance and participating in sport, art and music. The content areas are expressed in everyday language to increase the students understanding of the interview questions. For each content area, the assessment includes openended questions that result in one of the following ratings: a) no accommodation needs, b) accommodation needs fulfilled, c) accommodation needs unmet. If the student needs accommodation in the school setting (either fulfilled or unmet needs), these needs are documented on the form in order to record detailed information about the type of problem the student is experiencing. The presence of unmet accommodation needs indicates a need for occupational therapy intervention.

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Table 2 The Level of Physical Disability, as Classified by the Admission Committee

Level 1 Definition Relatively good ability to manage daily living tasks. n %

Table 3 The 11 Content Areas and Guiding Questions of the SSI

1. write,

(8)

Ability to partly manage daily living tasks independently but needs extensive assistance and/or assistive devices. 27 Requires 24-hour assistance with all activities. Fluctuation between level 1 and 3, for example the students with an arthritis diagnosis.

make notes, write a composition. Have you tried any technical aids? Are you in the habit of using computers? Which software have you been using? Are you using any special equipment? aloud during the lesson, short texts, a great number of, studying for an examination. Enlarged text or taped books. How do you carry all the books and pick up the ones you need? answer a question, join in the debate, participate in group work, call for assistance. the timetable, different classrooms, your homework, special appointments. Do you use an agenda? what kinds of assistance do you need and from whom? Do you have the use of a computer or taped books?

(56)

2. read,

15

(32)

2 48

(4) (100)

3. say something,

Total

4. remember things, A test of reliability and validity of SSI has been conducted (Hemmingsson & Borell, 1996). Regarding interrater reliability, a kappa between .76 and 1.0 was found, indicating a good agreement between pairs of raters. When all content areas together were examined, the SSI demonstrated a sensitivity of 0.96 and a specificity of 0.80. Thirteen occupational therapists and a panel of experts investigated content validity. Separately they judged the content areas to be adequate for the assessments intended purpose. Data were collected with the SSI by 14 occupational therapists who worked in the selected schools. All occupational therapists were very experienced having worked as school-based occupational therapists for an average of 14 years. The occupational therapists read the SSI manual and participated in a 1.5 hour training session in which they learned how to administer the SSI.

5. do homework,

6. maths, physics, chemistry,

drawing a curve, formula. Calculators, extra heavy rulers, special equipment? which different ways of taking examinations have you tried? Oral examination, written or by a computer. The need for more time, privacy or assistance. in which ways do you participate? The use of any special equipment like drawing-table, splints, software. private chairs or desk, special working place, the blackboard. Classroom for practical subjects. Transfer between classrooms. the use of public transport? Different wheelchairs for different occasions, assistance? how do you usually get your assistance? How satisfied are you with the way you get the assistance?

7. examinations,

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8. sport, art, music,

Analysis of data
1. The number of students with accommodation needs (either unmet or fulfilled) was calculated for each content area. 2. Proportion of students with accommodation needs fulfilled versus the number of students with accommodation needs unmet was determined for each content area. 3. The term student-environment fit is used to describe the degree to which the conditions of the school met the students accommodation needs. Therefore, for each content area, the frequency of students with accommodation needs fulfilled, in relation to all students who

9. the classrooms,

10. field trips,

11. assistance,

(Hemmingsson, 1998)

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Table 4 Students in Need of Accommodations, and Student-Environment Fit (Unmet and Fulfilled Needs) (N=48)
Content area Students reporting need for accommodations n 37 35 35 34 34 31 29 28 27 24 12 Student-environment fit Fulfilled needs Unmet needs n %* n %* 21 20 22 26 27 15 13 24 14 11 5 (57) (57) (63) (76) (79) (48) (45) (86) (52) (46) (42) 16 15 13 8 7 16 16 4 13 13 7 (43) (43) (37) (24) (21) (52) (55) (14) (48) (54) (58)

write the classroom home work assistance field trips examination read sport, art, music count remembering things say something

* Reflects the unmet/fulfilled needs in relation to the total number of students who reported accommodation needs in the particular content area.

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indicated accommodation needs in that content area, was tabulated and converted into a percentage. One hundred percent can be interpreted to mean that the school met every students accommodation needs in this content area, indicating a perfect student-environment fit.The more students with accommodation needs unmet in relation to all students with accommodation needs, indicates a misfit on an increasing scale. Fifty percent would indicate that half of the students accommodation needs were unmet and zero percent would indicate that the school met none of the students accommodation needs. 4. When an accommodation need was identified on SSI, the open-ended questions were coded by grouping similar responses into matching categories (Polit & Hungler, 1995).

ed accommodation ranged from 0-11, with a median of 7. The need for accommodations (including both fulfilled and unmet needs) was most frequent in the areas of writing, classroom, homework and assistance (Table 4). Seven students indicated that their accommodation needs were met in all areas and they were therefore, satisfied with the student-environment fit. Forty students (83%) reported unmet accommodation needs. Altogether, the students reported 326 different areas where accommodation was needed. Of these, 198 needs were fulfilled and 128 needs were unmet.The number of content areas with unmet accommodation needs per student ranged from 1-11 with a median of 2.

Accommodation needs for writing

Thirty-seven students (77%) reported accommodation needs in writing. All these students were already using adaptive writing techniques. Among the students in need of assistive devices for writing, only ten indicated their devices made them independent in writing tasks. Many students reported the use of more than one strategy for being able to do writing tasks. The major strategies used for notetaking, and creative or report writing, respectively, are shown in table 5.

Results
Students Accommodation Needs
In total, 47 out of 48 students (98%) reported accommodation needs in the school setting. Of the 11 content areas in SSI, the number of content areas in which each student need-

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Table 5 The major writing techniques used in two writing tasks by students requiring an assistant or assistive devices
Writing technique Notetaking Creative writing, report writing 13 2 2 20 37 2 16 5 14 37

Table 6 Type of assistance required at compulsory school and upper secondary school
Compulsory school Upper secondary school 1 25 10 0 12 48

Self-writing with device Computer Computer with assistance* Assistance Total *Needed help from start to finish

Personal assistant Class assistant Pool of assistants Friends, teachers No assistance Total * One missing answer

24 9 0 4 10 47*

An assistant who wrote for the student was a common accommodation, especially in notetaking. Thirty-five students needed assistive devices in writing, most commonly a computer. Frequently special equipment for the computer was needed (for example an adaptive computer interface, headgear, mouth stick, forehead stick, and special control devices like a joystick or puff-suck switches). Other assistive writing devices reported were special pencils, pencil holders and mobile arm supports. Sixteen students reported unmet accommodation needs in writing.The majority of these students needed to add something to the accommodations they already had. Additional required accommodations included special equipment for the computer, software, pencil holders or information to assistants and teachers about their assistive devices. Six students were dissatisfied with the accommodation they had. All of these wanted to have access to a personal computer in regular classrooms.

Other accommodations requested by students were a locker, work space for a computer, better information on the part of assistants and teachers, and strategies, like visual clues, for easier orientation within the school environment.

Accommodation needs for assistance

Thirty-four students (71%) reported that they needed assistance during the school day. All of them had access to a pool of assistants. Despite this access to assistants, eight students believed their needs were not being met. The majority of the students wanted the occupational therapist to inform the assistants about their activity limitations and special needs. This information most often concerned the students perceptual/cognitive problems, such as problems in orientation, memorising or understanding written language. Others wanted the assistants to know more about the high technology assistive devices that students used. Some students wanted to discuss how to be enabled to manage better with less assistance. For many of the students, the system for providing assistance had changed from upper level of compulsory school to upper secondary school (table 6). In upper level of compulsory school, most students were accustomed to having a personal assistant employed for the particular student. In the specially adapted upper secondary schools they had class assistants or a pool of assistants available for the students with disabilities. Only one student reported having access to a personal assistant in upper secondary school, compared to 24 students (50%) in compulsory school. Nevertheless, a majority of the students stated that they preferred the system used in the specially adapted upper secondary school where they freely drew from a pool of assistants. Only one student indicated that he preferred the system that provided students with an assigned personal assistant.

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Accommodation needs in the classroom

The students major concern about the classrooms was the furniture. Eight students, six of whom were attending a regular classroom, were dissatisfied with their desks. The students in power wheelchairs needed a desk which was higher than the standard desk height and the students using manual wheelchairs needed desks which were lower than standard. Four students reported that they needed a special chair in the classroom. The students in regular classrooms changed classroom several times every day for different subjects. Four students in regular classrooms reported that some of the classrooms were outside the school building and not accessible for wheelchair users because of stairs, lack of door openers or steep ramps. These students indicated that they wanted to change classrooms.

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Table 7 Examples of Accommodations Available in the Specially Adapted Schools

General Elevators Spacious areas Automatic door-openers Group Special educational classroom Sport activities arranged for students with disabilities Free access to a pool of assistants Individual Special chairs and desks Assistive devices Use of alternative strategies

Student-Environment Fit
The specially adapted upper secondary schools, which were physically integrated into regular schools, had important accommodations to suit the students they served. The accommodations available in these schools could be described as general, group or individual (table 7). General accommodations were those that could be used by anyone in the setting, even if they were of special importance for the students with physical disabilities. Group accommodations were arranged for and available only for students with disabilities. Individual accommodations were those arranged for and used by a specific student (for example, see table 7). The findings (see table 4) indicate that the schools were most successful in meeting students accommodation needs in sport, art, music, field trips and assistance. In these content areas, the schools offered important accommodations for disabled students as a group, meeting more than 75% of the students accommodation needs. According to these findings, group accommodations in these content areas suited the students very well. On the other hand, student-environment fit in reading, remembering and speaking (i.e. saying something) was unsatisfactory. Only 50 % of the students accommodation needs were fulfilled in these three areas. The discrepancy between the schools expectations and the students ability to meet these expectations was most notable in these areas. The results indicated that the students activity limitations in these areas were mostly related to problems of a cognitive/perceptual nature rather than motor problems. For example, one frequent problem reported was inability to remember the things that were expected. As many as seven students wanted to learn how to use an agenda in order to be more independent in time-management. Some students needed personal assistance when reading and/or to get written material audiotaped as they were unable to read the expected quantity of written material. In these areas, the schools general and group accommodations did not fully meet these students needs. Although most of the students were attending a special education classroom (a group accommodation), they still reported unmet accommodation needs. Several of these students with accommodation needs in reading, remembering and speaking wanted the occupational therapist to inform the educational team about their
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activity limitations so that the schools expectations could be more in accord with each students ability. Another interesting finding was that every student with accommodation needs in reading (n=29), also had accommodation needs in writing. Moreover, every student with accommodation needs in speaking (n=12), needed accommodation within both writing and reading. No other strong relationships between areas of need were found. It was also found that students with accommodation needs in reading and speaking tended to report accommodation needs in more content areas than other students do. For the students with accommodation needs in reading, the number of content areas with accommodation needs per student ranged from 3-11 with a median of 9. For the students with accommodation needs in speaking, the number of content areas with accommodation needs per student ranged from 6-11 with a median of 10. Thus, students with accommodation needs in reading and speaking were the students who needed the most accommodation and had the most unmet needs.

Discussion
The areas the specially adapted upper secondary schools had adjusted with most success were a) sport, art, music, b) field trips and c) assistance. In these areas, the schools offered important group accommodations that suited students with disabilities very well.These findings were interesting, since several studies have found that in the regular school system both field trips and physical education are usually the areas in which students with disabilities do not participate, or in which they experience most problems (Barron, 1995; Mattsson, 1995; Stukt, 1985; Whitehouse, Shope, Sullivan & Kulik, 1989). This finding illustrates the interrelationship of environmental factors and disablement (CAOT, 1997; Dunn et al., 1994; Kielhofner, 1995, Law, 1991; WHO, 1997). Contrary to findings in other studies, the school personnel in the schools in this study were successful in creating environments that enabled the engagements of students with severe physical disabilities in extra curricular activities. Group environmental accommodations in these content areas, were a notable adaptation by the school personnel. Another successful type of group accommodation was
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the system of having class assistants or a pool of assistants available for the students with disabilities. A majority of the students stated that they preferred the system used in the specially adapted upper secondary school where they freely drew from a pool of assistants, indicating a preference for a group solution rather than a more individual one. This finding corresponds with Barron (1995), who found that a personal assistant could be experienced as an obstacle for autonomy by the disabled youth. According to Barron (1995), the close contact between the assistant and the disabled youth could mean that the role of assistant and friend became intertwined. The person who is dependent on the assistant may be afraid of hurting the assistants feelings by complaining. It is possible that having class assistants or a pool of assistants, which eliminates the students dependence on one single person, decreases the students feeling of emotional dependence. Assistance appeared to be an especially complex issue. For the student with severe physical disability and additional impairments, having assistance in daily living activities and school tasks may be inevitable (Barron, 1995; Dudgeon et al., 1996; SOU 1996:167; Stukt, 1985). However, the students need of assistance in academic tasks as well as in self-care activities within the school environment, places heavy demands on the pool of assistants employed by the school. Although the assistants have a key role in the educational process, there is no minimal education required for assistants. Most have limited understanding of the students underlying problems and how to manage them. Several students identified this lack of understanding as a problem and also wanted the occupational therapist to inform the school staff about their activity limitations. Therefore, to improve the assistants understanding of the individual students specific problems, supervision and guidance by the professional staff is extremely important. The occupational therapist, who has knowledge of medical conditions and the psychosocial problems associated with disability, as well as expertise in assistive devices and environmental accommodations, is well suited for serving as consultants for this group of assistants. As Niehus et al. (1991) and Case-Smith (1997) found, reframing a students behaviour can minimise the discrepancy between what the educational team members think the student is able to do and what the student actually is able to accomplish. Consultation and co-operation between the occupational therapist and the assistant, as well as the teachers, could enhance the students well being and accomplishments in the school environment. Another important point seems to be to increase the students capability to negotiate with professionals to get the support and accommodations they needed by promoting self-advocacy. As teenagers, these students probably need training in self-advocacy skills, for example being able
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to explain how a specific accommodation will help them or being able to describe their disability, to enhance personal self-advocacy. It could be one important issue for the schoolbased occupational therapist to help these adolescents develop skills in self-advocacy, skills that they indeed will need throughout their lives (Schlaff, 1993; Vessey & Miola, 1997; West et al., 1993). Some of the most important accommodations in the schools were probably the general accommodations of the physical environment. In studies of disabled students in regular schools, architectural barriers have been mentioned frequently as obstacles (Dudgeon et al., 1996; Korpela & Koivikko, 1992; Mattsson, 1995; SOU 1996:167; Turner et al., 1996). These accommodations seemed to be well integrated into the schools included in this study, since students did not always experience them as accommodations but just as part of the usual environment, indicating a good student-environment fit. Students mainly recognised the absence of architectural accommodations but took their presence as something natural. For example, only a few students mentioned wheelchair accessibility as an accommodation they needed even though it was indispensable for about 70% of the students. Students who mentioned that they needed accommodations to provide wheelchair accessibility were those who experienced barriers, e.g., stairs, steep ramps or a lack of door openers. On the other hand, the students would not have experienced some of the unmet needs as such if the schools had offered more general accommodations by creating a more enabling environment. Six students reported they wanted to have access to a computer in the classroom to be more independent in writing tasks, and eight students reported unsuitable desks. We did not expect to encounter these conditions in schools specially adapted for severely disabled students. If, for example, all regular classrooms had been equipped with one or two special desks and a computer free to use when needed, some of the students with disabilities would have used those general accommodations rather than wanting an individual solution. The insufficient student-environment fit in the areas of reading, remembering and speaking, was especially disquieting as these content areas are related to skills necessary for success in many academic tasks. It is possible that the misfit indicates that the students with accommodation needs in these content areas are the students more in need of individual solutions and individual support. Obviously general and group accommodations available in these schools were not enough for these students. Regardless of the need for additional individual accommodations, general and group accommodations could be improved. Our findings indicate that accommodation needs in reading, and speaking, should be considered key factors in ensuring educational success for these students. Therefore it
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is an urgent need to develop accommodations that fit these studentsneeds both on a general, group and individual level. Maybe this is an area to which extra attention should be paid in the future. Removal of architectural barriers is not enough to fulfil the need for accommodation experienced by students with physical disabilities in the school setting. There is a need to develop accommodations to meet students needs in more academic tasks like reading and remembering things. This suggestion also corresponds with the literature in the field. Paulsson & Grip (1976) and Stukt (1985) state that it is not solely the physical disability that causes problems in school. Rather, it is the combination of a physical disability with additional impairments that causes the most important problems in the educational situation. If, for example, students with a physical disability and limited reading skills had the right to free taped text books, provided by the government, it would be an effective way of meeting unmet needs in the area of reading. Although general accommodations and group accommodations seemed to be extremely important for students with disabilities, they were not enough. This study indicates that general and group accommodations had to be combined with an assessment of each students needs to create individual solutions when needed. A proper assessment of each students individual accommodation needs before attending the schools would indeed be of great value for the student. For example, assistance is sometimes given in a rigid way without careful attention to each students own desires or without references to specific activity demands. Several students who needed assistance indicated that they wanted a more individualised solution. This study has identified accommodation needs and environmental solutions important for the understanding of school performance for students with physical disabilities.The students investigated were well represented as 94% of the possible population participated. Types of diagnoses represented by the participants correspond with the known distribution for the population of students with physical disabilities in Sweden (Skolverket, 1996; Billie & Olow, 1996). However, the participants physical disability was more severe and the need for assistance in school tasks was more frequent, compared to students with physical disabilities in regular school. The fact that this study was conducted in Sweden means that replication is needed in other countries in order to establish the potential for generalisation. One limitation of this study could be the influence of one specific European society and its laws and regulations, as well as the way this specific society interprets physical disability. However, the need to further clarify the role and interrelationships of environmental factors and disablement are international (WHO, 1993). The instrument used in this study is another factor for attention when considering the results of this study. The
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School Setting Interview (Hemmingsson, 1998) is a clientcentred assessment, built upon a semi-structured interview. In such an assessment, the relationship between the interviewer and respondent, as well as the occupational therapists skills in interviewing could influence the result. In this study, the occupational therapists conducting the interview had an ongoing professional relationship with the respondents. This situation meant that 13 different persons were involved in collecting data for this study. The relatively large number of people involved in data collection could be a limitation as the interpretation of the manual and the trainingsession, as well as the occupational therapy perspective, is individual for each person, and could influence the result. It is possible the result would be somewhat different if the interviewer had been the same person and somewhat unknown by the students. In our view, this limitation was balanced by the assumption that a closer relationship probably encouraged the students to more truly express their needs as they could see the direct use of speaking up about their problems. There is a growing trend of inclusion of students with physical disabilities in regular classrooms in many countries. For example, currently about 90% of Swedish students with physical disabilities are attending a regular class in their neighbourhood compulsory school (Skolverket, 1996). Some of these students have a severe physical disability as well as additional impairments. Whether such students experience barriers in regular schools and whether the schools meet such students needs for accommodations requires further investigation. These findings indicate that physically disabled students need a combination of general, group and individual accommodations. It would be useful to employ this categorisation in an investigation of the student-environment fit in regular schools. This investigation could provide knowledge about students accommodation needs and identify possible improvements in the school setting on general, group and individual levels for students with physical disabilities in regular schools. How students with disabilities experience general, group or individual accommodations, and if and how these accommodations contribute to participation in school activities, is another area that needs further investigation. Occupational therapists traditionally help clients on an individual level. The findings indicate that students with physical disabilities need a combination of accommodations, on different levels, to increase their participation in school activities. Therefore it is suggested that occupational therapists take more responsibility for barrier removal and environmental modifications in a broader sense that may be beneficial for the whole society. It is important that occupational therapists offer society their expertise. Co-operation with other professionals in the field, as well as with the students, concerning when and how to adapt the physical and social environment can remove obstructions or restrictions to the full participation of people with disabilities in life activities.
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Acknowledgements
This study was supported by grants from the Karolinska Institute in Stockholm, Sweden. The authors also wish to thank the occupational therapists working in the upper secondary schools especially adapted for the needs of physically disabled students, for their active contribution to this study.

with physically disabled students. Scandinavian Journal of Occupational Therapy, 3, 156-162. Jongbloed, L., & Chrichton, A. (1990). Difficulties in shifting from individualistic to socio-political policy regarding disability in Canada. Disability, Handicap & Society, 5, 25-36. Kalscheur, J. A. (1992). Benefits of the Americans with Disabilities Act of 1990 for children and adolescents with disabilities. American Journal of Occupational Therapy, 46, 419-426. Kellegrew, D, H., & Allen, D. (1996). Occupational therapy in full-inclusion classrooms: A case study from the Moorpark model. American Journal of Occupational Therapy, 50, 718-723. Kemmis, B. L., & Dunn, W. (1996). Collaborative consultation: The efficacy of remedial and compensatory interventions in school contexts. American Journal of Occupational Therapy, 50, 709-717. Kielhofner, G. (1995). A model of human occupation: Theory and application (2nd ed.). Baltimore: Williams & Wilkins. Krefting, L., & Krefting, D. (1991). Leisure after a stroke: An ethnographic approach. American Journal of Occupational Therapy, 45, 429-436. Korpela, R. A., & Koivikko, M. J. A. (1992). Regional survey of technical aids used by handicapped children in day care and at school. Disability and Rehabilitation, 14, 16-22. Law, M. (1991). The environment: A focus for occupational therapy. Canadian Journal of Occupational Therapy 4, 171-179. Law, M., & Dunn, W. (1993). Perspectives on understanding and changing the environments of children with disabilities. Physical and Occupational Therapy in Pediatrics, 13, 1-17. Law, M., Baptiste, S., & Mills, J. (1995) Client-centred practice: What does it mean and does it make a difference? Canadian Journal of Occupational Therapy, 62, 250-257. Lie, H. R. (1993). Disability and coping. From department of Paediatrics, University of Lund, Sweden: Grahns boktryckeri. Madill, H., Tirrul-Jones, A., & Magill-Evans, J. (1990). The application of the client-centred approach to school-based occupational therapy practice. Canadian Journal of Occupational Therapy, 57, 102-108. Mattson, E. (1995). Elever med rrelsehinder p grundskolans mellanstadium-delaktighet och social gemenskap [Students with disabilities in compulsory school participation and social integration]. (Report No. 8). Gteborg :SIH lromedel. Niehus, A. N., Bundy, A., Mattingly, C., & Lawlor, M. (1991). Making a difference: Occupational therapy in public schools. Occupational Therapy Journal of Research, 11, 195-212. Orr, C., & Schadke, J. (1997).The impact of the classroom environment on defining function in school-based practice. American Journal of Occupational Therapy, 51, 64-9. Paulsson K., & Grip L-G. (1976). Skolintegrering av rrelsehindrade barn och ungdomar. [Integration of children and youth with disabilities] ( Report No. 73). Mlndal: University of Gotenburg, Institute of Pedagogic. Polit, D., & Hungler, B. (1995). Nursing research: Principles and methods (5th ed.). Philadelphia: Lippincott. Rogers, J. C. (1982).The spirit of independence:The evolution of a philosophy. American Journal of Occupational Therapy, 36, 709-715. Rourk, J. D. (1996). Roles for school-based occupational therapists: Past, present, future. American Journal of Occupational Therapy, 50, 698-700.
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