Medical Students’ Knowledge About Children With Disabilities, Special Education Laws, and Social Ser

BRIEF REPORT

Medical Students’ Knowledge About Children With Disabilities, Special Education Laws, and Social Services: A Preliminary Scale Development and Pilot Study

Nancy Vitalone-Raccaro, PhD; Mary Erin Sheppard, EdD; Jacqueline M. Kaari, DO

Context: In order to design undergraduate medical education responsive to the American Academy of Pediatrics’ recommendation that physicians learn about special education law and practices, it is important to understand medical students’ baseline knowledge about children with disabilities, special education law, available services, and the sources of this information.

Objectives: To develop an instrument to measure what second-year medical stu- dents know about children with disabilities, special education law, and available ser- vices; to determine the most common sources of this information; and to establish a baseline on which to design curricula that address this topic.

Methods: This study adopted a survey design. The survey took place in 1 school of osteopathic medicine in a Northeastern state of the United States. One hundred fifty medical students in their second year of full-time enrollment were invited to complete the survey. The instrument designed by the authors consisted of 30 items organized into a demographics section and 3 domains: (1) perceived level of knowledge about children with disabilities, (2) sources of information about children with disabilities, and (3) actual knowledge about children with disabilities and special education.

Results: Ninety-eight students (65%) participated. Although students were accurate in self-assessment, their source of knowledge was limited. Medical students who identified personal experiences (t=1.64) and coursework as their source of knowl- edge had more correct responses (t=2.62).

Conclusion: This preliminary study demonstrated a lack of knowledge among second-year medical students with regard to children with disabilities, special educa- tion laws, and social services. Curricula emphasizing disabilities and special educa- tion along with longitudinal experiential training may be effective methods to deliver these topics.

J Am Osteopath Assoc. 2019;119(10):674-681 doi:10.7556/jaoa.2019.115

Keywords: Individuals With Disabilities Education Act, medical education, pediatrics, special education

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From the Casperson School of Graduate Studies at Drew University in Madison, New Jersey (Dr Vitalone-Raccaro); the Special Education Department at Saint Joseph’s University in Philadelphia, Pennsylvania (Dr Sheppard); and the Cleveland Clinic in Twinsburg, Ohio (Dr Kaari). These data were presented as preliminary findings in poster format at the Society for Developmental and Behavioral Pediatrics 2015 Annual Meeting in Las Vegas, Nevada, and CEC Special Education Convention and Expo 2016 in St Louis, Missouri.

Financial Disclosures: None reported.

Support: None reported.

Address correspondence to Nancy Vitalone-Raccaro, PhD, Drew University, 36 Madison Ave, Madison, NJ 07940- 1434.

Email: nvitaloneraccar@drew. edu

Submitted March 16, 2018; final revision received December 7, 2018; accepted December 26, 2018.

The American Academy of Pediatrics endorses family-centered care, community- based supports and services, and accessible, coordinated, and continuous

12 support, with a focus on special education law and services as attributes of

quality health care for children with disabilities. Physicians actualize these attributes by

identifying children with developmental delays, facili- tating referral to early intervention (EI) or special edu- cation services3 and promoting the well-being of all children in the educational setting and in health care.2

Children with disabilities are protected under 2 federal laws: The Individuals With Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973. The IDEA ensures that people from birth to age 21 years with diagnosed dis- abilities are provided with a free appropriate public edu- cation in the least restrictive environment.4 Free appropriate public education mandates the provision of special education without cost to families in an appro- priate school setting. The least restrictive environment mandate calls for children with disabilities to be edu- cated with nondisabled peers to the maximum extent appropriate. A student is eligible for special education under IDEA if a disability has been diagnosed, the dis- ability adversely affects educational performance, and specially designed instruction is required.

Early intervention for children from birth to 3 years of age is a component of IDEA that is intended to reduce potential adverse effects and enhance development.5Children qualify for EI services if they have a develop- mental delay or a diagnosed condition that results in a high probability of developmental delay.6 Although states have discretion in setting eligibility criteria, IDEA guarantees supports and services for infants and toddlers and their families.7 In the event a person aged 3 to 21 years is not deemed eligible for special education ser- vices yet still needs accommodations to access the school curriculum, Section 504 of the Rehabilitation Act of 1973, a civil rights law designed to prohibit discrimin- ation based on disability status, mandates provision of the necessary accommodations through a 504 Plan.8

Physicians who understand special education laws and practices can help parents access services for their children, monitor school progress during well-visit appointments, increase collaboration with schools, and assist in the planning for the transition of older children with disabilities to adult services. Understanding special education, resource availability, and the impact

of disability can benefit physicians who work in spe- cialties such as internal medicine, family medicine, surgery, and psychiatry,9 where they will likely encoun- ter children or adults with disabilities or their family members.

The number of people with disabilities across the age span is growing, validating the need for physicians to be prepared to meet their health care needs. During 2014-2016, the prevalence of children aged 3 to 17 years with a diagnosed developmental disability such as autism spectrum disorder, intellectual disability, communication disorders, and learning disabilities, increased from 5.76% to 6.99%.10

Currently, most training for physicians in the area of developmental disability and special education occurs during pediatric residency or residency periods for spe- cialty areas (eg, developmental pediatrics, family medi- cine), with training often dependent on mentor contributions.11-14 Research on training is primarily focused on medical students’ attitudes toward people with disabilities rather than on their knowledge of special education law and practices.15 A study by Shah et al16 demonstrated a disconnect between pedia- tricians’ attitudes about special education and reported practices. The authors speculated that a lack of specific training regarding the special education process may explain the discrepancy. Moreover, primary care physi- cians recommended modifying their medical school experience by including experiential learning3 and expanding disability-specific education to better equip them to care for patients with disabilities.17

We are currently developing curricula to improve medical students’ knowledge, attitudes, and skills in the area of treating children with disabilities and collab- orating with these patients’ families. The objectives of the current study were to develop an instrument to measure what second-year medical students knew about children with disabilities and special education law and available services, to determine the most common sources of this information, and to use the pilot data to establish a baseline on which to design curricula.

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Methods

Study Design

This pilot study used a nonexperimental survey design with a convenience sample of second-year medical stu- dents from a school of osteopathic medicine in the Northeastern United States in April 2015. The study received approval by the institutional review board. Students nearing the end of their second year were asked to complete an online survey as a part of their coursework in either the traditional curriculum or problem-based learning curriculum. Participation was not mandatory. A Qualtrics survey link was provided through Blackboard as part of a pediatrics course taught by one of the authors ( J.M.K.). One follow-up email was sent via a course-embedded announcement through Blackboard 5 days after the survey was deployed. Participation was anonymous. Incentives for participation were not provided, and students were expected to complete the survey within 1 week.

Instrument Development

A review of the medical literature did not yield any validated instruments to measure knowledge related to special education law and practices designed specific- ally for medical students. Two previously published instruments for practicing physicians3,16 were used to inform survey development and provide validity. Items related to sources of information about children with disabilities were adapted from the Beginning Teacher Candidate Autism Spectrum Disorder Knowledge Survey.18

Twenty-one survey items were organized into a demographics section and 3 domains. Domain 1 mea- sured perceived level of knowledge about children with disabilities with 1 item: “How much do you know about children with disabilities?” Respondents were asked to rate their knowledge on a Likert scale with the following choices: nothing, a little, quite a bit, and a great deal. Domain 2 addressed sources of information about children with disabilities with 1 question: “What are your sources of knowledge about children with disabilities?” Given 5 options, respon-

dents checked all that applied: mass media, disability awareness training, personal communication, personal experience, and coursework. Respondents indicating mass media specified media type(s), and respondents indicating personal experience were asked to clarify the relationship. Domain 3 measured knowledge about children with disabilities and special education through 10 items. Five questions regarding special education knowledge were used with permission from the survey by Shah et al.16 We developed 5 additional questions to address EI, 504 plans, autism spectrum disorder prevalence and treatment, and whether parents would ask physicians about special education services for their children (Table 3).

StatisticalAnalysis

Descriptive statistics were used for demographics and question responses. Correlational analysis was com- pleted to assess relationships between questions. t tests were also used to assess mean differences in perceived knowledge questions. P=.05 was used to establish stat- istical significance. The Cronbach α was used to assess internal consistency. The data were analyzed by com- paring the student responses in Domains 1 and 2 with the number of correct responses in Domain 3. Independent samples t tests were used to compare the mean correct responses of each source group to mean correct responses of students who did not select that as a source of information.

Results

Of 150 students invited, 98 participated, providing a 65% response rate. The characteristics of this sample (Table 1) were representative of the second-year class of medical students as a whole.

Perceived Knowledge About Children With Disabilities Most students (76 [77.6%]) reported that they knew a little about children with disabilities, 11 (11.2%) reported knowing quite a bit, 7 (7.1%) reported that

Table 1. Demographic Information of Respondents to Survey Assessing Medical Students’ Perceived Knowledge of Children With Disabilities (N=98)

Table 2. Domain 1 of Survey Assessing Medical Students’ Perceived Knowledge of Children With Disabilities: How much do you know about children with disabilities? (N=98)

Characteristics

Gender

Female

Male

Racial/Ethnic Group

African American Asian or Pacific Islander Hispanic/Latino Mixed race White Prefer not to respond

Majora

Biology Chemistry Health and Exercise Science Liberal arts Neuroscience Public health

No (%)

48 (49.0) 50 (51.0)

5 (5.1) 41 (41.8) 4 (4.1 1 (1.0 35 (35.7) 12 (12.2)

58 (59.2) 3 (3.1) 13 (13.3) 15 (15.3) 8 (8.2) 1 (1.0)

Knowledge of Children With Disabilities

I know nothing about children with disabilities.

I know a little about children with disabilities.

I know quite a bit about children with disabilities.

I know a great deal about children with disabilities.

Total

Sources of Knowledge

No. (%)

7 (7.1) 76 (77.6) 11 (11.2) 4 (4.1)

98 (100)

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aBiology majors included biochemistry, biological engineering, biological science, cell biology, cellular and molecular biology, and genetics. Liberal arts majors included anthropology, classics, ecology, economics, engineering, English, environmental studies, humanistic studies, sociology, and Spanish.

they knew nothing, and 4 (4.1%) reported that they knew a great deal (Table 2). A Pearson r used to compare the relationships between these responses with the number of correct responses showed that perceived knowledge was positively correlated to actual knowledge (r=0.197, P=.05).

Knowledge of Special Education

Mass media and personal communication were most often identified as sources of knowledge (Table 4). Students who identified personal relationships and those who identified coursework as a source of infor- mation had the most correct responses in Domain 3. Students who identified mass media and disability awareness training as sources of information had the fewest correct responses. The only significant differ- ence was found between the mean correct responses of students who identified coursework as a source of information and those who did not (t =2.62, P≤.01).

Psychometric Analysis

The Chronbach α for the 10 knowledge questions was 0.781 for standardized items. This value fell within the acceptable range of 0.70 to 0.95, indicating satisfac- tory reliability. The item analysis found that the removal of no single item would significantly affect the Chronbach α, and the small range of values (0.749-0.777) demonstrated consistency across items.

The students knew little about special education pol- Discussion

icies and practices (mean [SD] correct responses out of a possible 10, 2.38 [1.67]). The mean (SD) out of a possible 10 for each were also calculated for incorrect responses and “uncertain” (Table 3).

In this study, 98 respondents from a second-year pediat- ric course shared their baseline knowledge about chil- dren with disabilities, special education law, available services, and the sources of this information. Topics

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Table 3. Domain 3 of Survey Assessing Medical Students’ Perceived Knowledge of Children With Disabilities: Overall Level of Knowledgea (N=98)

Item

Each child with a disability must have an individualized education program (IEP).

According to the Individuals with Disabilities Education Act (IDEA) of 2004, each child with an IEP should receive special education services in a separate classroom designed to meet the needs of his/her disability.

Children with a genetic complication (eg, Down syndrome, fragile X) automatically qualify for special education services.

Parents may be financially responsible for “related services” (eg, transportation services, parent training) included in an IEP.

A physician’s prescription for an IEP mandates that the school develop an IEP for a child.

In order for a child to receive early intervention services, he or she must have an identified disability.

An IEP and a 504 plan afford a child with disabilities the same level of legal protections.

Discreet trial training is the only evidence-based practice that is effective for teaching children with autism.

Parents of children with disabilities will consult their doctors on matters of therapeutic and educational options for their children.

According to the Centers for Disease Control and Prevention, what portion of children is estimated to have autism?

a Data are given as No. (%) unless otherwise indicated.

Correct Response

False False

False

False False False False

True

1:68

Responded Correctly

16 (16.3) 27 (27.6)

14 (14.3)

16 (16.3)

15 (15.3) 13 (13.3) 16 (16.3) 17 (17.3)

68 (69.4)

29(29.6)

Responded Incorrectly

51 (52.0) 33 (33.7)

55 (56.1)

46 (46.9)

39 (39.8) 55 (56.1) 30 (30.6) 13 (13.3)

8 (8.2)

37 (37.8)

Uncertain

31 (31.6) 38(38.8)

29 (29.6)

36 (36.7)

44 (44.9) 30 (30.6) 52 (53.1) 68 (69.4)

22 (22.4)

32 (32.7)

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included IDEA, the individualized education program, 504 plans, EI services, and the role of physicians in assisting families with these issues. These topics had not been previously addressed in the first- and second- year medical school curriculum for these participants and are not topics that have been widely included in medical school curricula.19

The perception of knowledge and actual knowledge among the medical students surveyed was congruous. Yet although students were accurate in their self-

assessment, their actual fund of knowledge regarding children with disabilities was found to be limited. The deficit in knowledge regarding eligibility for special edu- cation services and specific interventions was evidenced in the few correct and many uncertain responses to most questions. However, most students understood the need for inclusion of these topics in the medical school curriculum,14 as 69.4% of them correctly responded true to the statement “Parents of children with disabil- ities will consult their doctors on matters of therapeutic

Table 4. Domain 2 of Survey Assessing Medical Students’ Perceived Knowledge of Children With Disabilities: Mean Responses: Examined in the Context of Sources of Knowledge

Source Used

BRIEF REPORT

Sources of Knowledgea

Correct Responsesb

Mass media Disability awareness training Personal communication Personal experiences Coursework

Incorrect Responses

Mass media Disability awareness training Personal communication Personal experiences Coursework

Did Not Know

Mass media Disability awareness training Personal communication Personal experiences Coursework

Yes Mean (SD)

2.32 (1.69) 2.36 (1.78) 2.46 (1.75) 2.68 (1.68) 2.94 (1.88)

4.05 (2.45) 3.57 (2.55) 3.48 (2.32) 3.34 (2.22) 3.55 (2.13)

3.63 (3.03) 4.07 (3.14) 4.06 (2.92) 3.78 (2.91) 3.5 (2.27)

No Mean (SD)

2.49 (1.63) 2.39 (1.58) 2.17 (1.44) 2.13 (1.63) 2.05 (1.44)

3.23 (1.96) 3.91 (2.1) 4.41 (2.18) 4.09 (2.34) 3.87 (2.41)

4.29 (2.49) 3.7 (2.61) 3.41 (2.66) 3.97 (2.81) 4.08 (2.92)

t (97)

0.483 0.088 0.786 1.642 2.625c

1.70 0.722 1.856 1.617 0.65

1.083 0.627 1.021 0.343 0.971

a Participants were allowed to select multiple sources.
b Out of a possible 10.

c P≤.01.

and educational options for their children.” This finding demonstrates the need for intervention.

Personal relationships and coursework seemed to provide more accurate information about children with disabilities and special education. Mass media and dis- ability awareness training were limited as sources of information. Coursework yielded the most accurate knowledge regarding children with disabilities. The positive association between coursework and accurate information indicates the importance of implementing effective curricula.

This study demonstrated that second-year medical students enrolled in 1 school of osteopathic medicine lacked knowledge regarding disabilities and special education. The students were aware of the gaps in their knowledge but also appreciated that as physicians, they would be consulted in these matters by patients and families. These data illustrate the need for training medical students in this area. However, residency edu- cation in developmental/behavioral pediatrics, where this topic has traditionally been introduced, has been found to be deficient for many practicing physicians.20

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The absence of comprehensive training on the topics of disabilities, including screening, interventions, commu- nication, and providing appropriate medical care has led to health disparities in this population.21 These dispar- ities further exemplify the need for the earlier introduc- tion of these topics in medical education to ensure that they are addressed and reach the broadest group of future physicians. Personal relationships and course- work are effective in conveying information about chil- dren with disabilities and special education. Such findings provide a framework on which to deliver this material to medical students. Curricula that emphasize this topic along with longitudinal experiential training are effective instructional methods.19

The context of osteopathic medicine as a distinct form of medical practice is vital when discussing study findings and significance. Osteopathic physicians value the person as a unit of body, mind, and spirit and are trained to integrate the comprehensive treatment prin- ciple into the provision of collaborative and culturally competent care.22 Touch and empathetic communica- tion create a bond that enriches the patient-physician relationship.23 These principles extend to the care of children with disabilities and their families. Osteopathic medical students will enhance their inter- personal and communications skills, their diagnostic acumen, their ability to form a clinical question, and their ability to collaborate as a member of an interpro- fessional team. Expanding these skills will further develop competence in entrustable professional activ- ities as they learn about children with disabilities and special education law.24

Limitations

The sample size and focus on 1 school of osteopathic medicine are limitations to the study. The findings, although not generalizable, are applicable to the institu- tion where the study took place and can serve as a model for other medical education programs. It should be noted that not all students who enrolled in the course submitted a survey response, which may reflect a lack of investment in the content. Self-reported data

obtained through a survey design can contain potential sources of bias, such as selective memory and diverse interpretations of questions that can affect responses. These limitations were considered prior to drawing conclusions.

Directions for Future Research

This pilot study serves as a baseline on which to build novel educational experiences in our program. In add- ition to the acquisition of new information, we believe that active learning is required for the application of the knowledge and use of critical thinking.25 Therefore, proposed curricular changes will balance coursework with personal experiences through experi- ential learning.

Future directions include the revision of the survey tool. When considering the pattern of responses to the true/false questions, most of the correct responses were false. We acknowledge the need to avoid a dispropor- tionate number of true or false statements.

Conclusion

The results of this survey, along with prior research,20-22 provided evidence needed for revision of the curriculum at 1 particular school of osteopathic medicine to include the topics of disability and special education. It is especially significant that second-year medical students recognize that physicians are an important resource for families when discussing dis- abilities and special education. Further research is needed with regard to effective instruction and to deter- mine whether the early introduction of this education will better prepare physicians to be competent in treat- ing children with disabilities, working with their fam- ilies, and collaborating with teachers and school personnel.

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