R E S E A R C H R E P O R T

Student Outcomes of School-Based

Physical Therapy as Measured by
Goal Attainment Scaling
Lisa A. Chiarello, PT, PhD, PCS, FAPTA; Susan K. Effgen, PT, PhD, FAPTA; Lynn Jeffries, PT, DPT, PhD, PCS;
Sarah Westcott McCoy, PT, PhD, FAPTA; Heather Bush, PhD
Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, Pennsylvania
(Dr Chiarello); Departments of Rehabilitation Sciences (Dr Effgen) and Biostatistics (Dr Bush), University of Kentucky,
Lexington; Department of Rehabilitation Sciences, University of Oklahoma Health Sciences, Oklahoma City (Dr Jeffries);
and Department of Rehabilitation Medicine, University of Washington, Seattle (Dr McCoy).

Purpose: The main purposes were to describe individualized outcomes of students receiving school-based
physical therapy and determine if goal attainment differed by gross motor ability and age. Methods: One
hundred nine physical therapists and 296 students participated. At the beginning of the school year, therapists
translated students Individualized Education Program goals into subgoals using Goal Attainment Scaling
and determined students Gross Motor Functional Classification System level. Researchers categorized goals
(posture/mobility, recreation/fitness, self-care, or academics), and therapists identified students primary goal.
At the end of the school year, therapists scored the goals. Descriptive statistics and 2-way analyses of variance
were conducted. Results: Students exceeded their expected goal level for primary goals and goals categorized
as posture/mobility, recreation/fitness, and self-care and made progress on academic goals. No differences
were found by gross motor ability. Younger students had higher goal attainment for primary and recreation
goals. Conclusion: Students achieve individualized outcomes addressed by school-based physical therapy.
(Pediatr Phys Ther 2016;28:277284) Key words: Goal Attainment Scaling, goals, school-based physical therapy,
student individualized outcomes

INTRODUCTION tion and support individualized outcomes. A major empha-

In the United States, students with disabilities receive
an Individualized Education Program (IEP) that includes
related services to help students benefit from their educa-
0898-5669/283-0277
Pediatric Physical Therapy
Copyright C 2016 Wolters Kluwer Health, Inc. and Academy of
Pediatric Physical Therapy of the American Physical Therapy
Association
Correspondence: Lisa A. Chiarello, PT, PhD, PCS, FAPTA, Depart-
ment of Physical Therapy and Rehabilitation Sciences, Drexel Uni-
versity, 1601 Cherry St, Mail Stop 7502, Philadelphia, PA 19102
(lisa.chiarello@drexel.edu).
The authors declare no conflicts of interest.
Grant support: The research reported here was supported by the Insti-
tute of Education Sciences, US Department of Education, through grant
R324A110204 to the University of Kentucky. The opinions expressed are
those of the authors and do not represent views of the Institute or the US
Department of Education. REDCap was used in the data analysis, which
was supported by NIH CTSA grant number UL1TR000117.
DOI: 10.1097/PEP.0000000000000268
sis of the reauthorization of the Individuals with Disabil-
ities Education Improvement Act (IDEA) of 2004 was on
accountability: student achievement of functional and aca-
demic outcomes.1 School-based physical therapists (PTs)
believe the most important factor in considering termina-
tion of physical therapy are students achievement of their
functional goals,2 which supports the importance of having
explicit measurable goals. Individualized outcomes are im-
portant for evaluation of the effectiveness of school-based
services and progress monitoring of student education. In-
dividualized assessment has gained broader acceptance in
recent years, especially when dealing with heterogeneous
or low-incidence populations,3 and has been shown to be
more responsive than standardized assessment in measur-
ing change over time.4 Individualized outcomes guide the
delivery of educational services and reflect learning that is
meaningful to students education and participation in the
school environment.
Little is known about students individualized out-
comes to school-based physical therapy. One study in

Pediatric Physical Therapy Student Outcomes of School-Based PT 277

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Unauthorized reproduction of this article is prohibited.
Canada evaluated individualized outcomes of 50 students,
5 to 12 years of age, receiving school-based physical, occu-
pational, and speech and language therapy services using
Goal Attainment Scaling (GAS).5 The goals focused on
communication, school productivity, and mobility. Only
26% of the children were receiving physical therapy ser-
vices, and the majority of the children were in kindergarten
to second grade (66%) and had cerebral palsy (52%). After
6 months of services, 98% of the students made progress
on their goals and, on average, exceeded goal expectations
across all disciplines. In the United States, Stuberg and
DeJong6 evaluated progress on individualized objectives
of 566 children, in early intervention through high school,
receiving physical therapy services from 18 therapists in a
Nebraska school district. Each child had 1 to 5 objectives:
53% of the objectives were achieved, 38% had progressed,
and 9% had no change. Progress on objectives for chil-
dren in early intervention and preschool was higher than
progress for students in elementary through high school.
Students receiving special education for multiple impair-
ments had less progress on objectives than students in
other categories. Progress on objectives was lower for ob-
jectives related to impairments of body function and struc-
tures than objectives related to functional limitations and
participation restrictions. These studies suggest that stu-
dents receiving physical therapy services in schools make
progress or achieve their individualized outcomes; yet,
more research is needed to know if these results gener-
alize across the United States.
School-based PTs, whose primary areas of expertise
are motor and adaptive functions, directly support stu-
dent outcomes for adaptive and functional skills7 and
may indirectly support academic outcomes.8 Adaptive and
functional skills specifically include posture and mobility
(maintaining a position and moving from place to place),
recreation and fitness (play, leisure, and physical activi-
ties), and self-care (dressing, feeding, and hygiene). Par-
ents of 276 school-aged children with cerebral palsy (6-
12 years of age) identified self-care, mobility, productivity
in school, and physical recreation as their most frequent
priorities for their children.9 These adaptive and functional
skills enable a child to be active and participate in school
activities. With regard to academics, posture and move-
ment enable children to attend to classroom lessons, follow
directions, experience actions,8 and manipulate materials
for learning. Adaptive and functional skills are critical out-
comes, as childrens mobility, play, and self-care abilities
are a foundation for daily life, fostering self-reliance, partic-
ipation, and quality of life.10-12 These abilities may enable
life experiences that promote the development of skills
for subsequent inclusion and participation in education,
employment, leisure, and social roles.13,14 School-based
physical therapys focus on adaptive and functional out-
comes addresses the stated purpose of IDEA to prepare
students for further education, employment, and inde-
pendent living.1(601,d,1,A)
The main purposes of this study were to describe
the individualized outcomes of students receiving school-
278 Chiarello et al
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Unauthorized reproduction of this article is prohibited.
based physical therapy services and determine if goal at-
tainment, as measured by GAS, differed by gross motor
ability and age. A secondary objective was to explore if
goal attainment differed by diagnostic groups. GAS mea-
sures individual progress toward achievement of individ-
ual goals using a set of specific goals for the student that
typically includes a 5-point possible range of outcomes.15
GAS allows for more robust statistical analysis than the
3-point scale used to measure goal achievement by Stu-
berg and DeJong.6 Additional merits of GAS include that
the measurement process is (1) criterion-referenced, mak-
ing the measurement responsive to individual meaningful
changes, (2) applicable for all levels of functional ability,
and (3) feasible and affordable.15 GAS has been used for
evaluation of pediatric rehabilitation services in many set-
tings including schools.5,16,17 An understanding of goal
attainment for students based on functional level, age, and
focus of the goal will enable PTs to reflect on how stu-
dents change and should provide guidance for establish-
ing and monitoring progress on meaningful individualized
outcomes.
METHODS
Design
This study was part of a national study of school-
based physical therapy services and student outcomes, PT
related Child Outcomes in the Schools (PT COUNTS), us-
ing a practice-based evidence design.18 Our methodology
using this design has been described previously.19 For this
article, a prospective, multisite, longitudinal observational
design was used to describe students individualized out-
comes in a school year and through comparative analyses
determine the effects of gross motor functional level, age,
and medical diagnosis.
Participants
Participants were recruited from 4 regions of the
United States (Northeast, Southeast, Central, and North-
west). Details of our recruitment procedures and attri-
tion of participants have been described by Effgen and
colleagues.19 A sample of 296 students and their 109 PTs
finished the study, with a complete data set of 20 weeks
of documentation of physical therapy services and student
outcomes assessment. Demographic characteristics of the
participants are presented in Table 1. The majority of PTs
were female (96%) and white (96%), with a mean age of
46 years (SD = 9.2). The majority of students were 5 to
7 years of age (58%), male (56%), and white (72%), with
78% of the students at Gross Motor Functional Classifica-
tion System (GMFCS) levels I to III.
Measures
The GMFCS20 is a 5-level system designed to classify
children with cerebral palsy up to 18 years of age on the
basis of performance in daily life. A classification is made
Pediatric Physical Therapy
 TABLE 1 TABLE 1
Characteristics of Physical Therapists and Students Characteristics of Physical Therapists and Students (Continued)

Physical therapists (N = 109) Diagnosis, n (%)b

Age, mean (SD), y 46 (9.2) Cerebral palsy 103 (35)
Sex, n (%) Down syndrome 46 (16)
Female 105 (96) Other genetic syndromes 40 (14)
Male 4 (4) Global developmental delay 32 (11)
Race, n (%) Otherc 75 (25)
White 105 (96) Gross Motor Function Classification System level,
Black 3 (3) n (%)
Other 1 (1) I 113 (38)
Ethnicity,a n (%) II/III 117 (40)
Non-Hispanic or Latino 105 (96) IV/V 66 (22)
Hispanic or Latino 2 (2) Other services received at school, n (%)
Professional degree, n (%) Occupational therapy 256 (86)
Certificate 2 (2) Speech and language therapy 234 (79)
Bachelors 59 (54) Adaptive physical education 123 (42)
Masters 34 (32) At grade level in school,a n (%) 73 (26)
DPT 14 (13) Classroom in which student spends most of the
Highest postprofessional degree day,a n (%)
None 58 (53) Typical classroom 89 (31)
PT clinical masters 5 (5) Special classroom 114 (39)
PT clinical doctorate 25 (23) Combination of both 86 (30)
Academic masters 19 (17) Received additional physical therapy outside of 97 (33)
Academic doctorate (PhD, EdD, DSc) 2 (2) education system,a n (%)
Employment status, n (%)
Full-time 73 (67) Abbreviations: APTA, American Physical Therapy Association; PT, phys-
Part-time 36 (33) ical therapist.
a Data were missing for some participants.
Employment relationship,a n (%)
b Percentages do not equal 100 due to rounding.
Employed by school 82 (75)
c Other diagnoses include autism, learning disability, attention-
Contract with school 11 (10)
Through an agency 5 (5) deficit/hyperactivity disorder, speech-language disorder, developmental
Other 10 (9) coordination disorder, developmental delay due to health conditions,
Years in practice, mean (SD) myelomeningocele, vision disorder, hearing disorder, traumatic brain in-
As a PT 21 (10.4) jury, and limb deficiency.
As a pediatric PT 16 (9.7)
As a school-based PT 13 (9.1)
APTA member,a n (%)
Yes 57 (52) on the basis of current gross motor function in daily activ-
No 50 (46) ities, with emphasis on mobility and sitting. The GMFCS
Pediatric specialist certification, n (%) has evidence of content, construct, and discriminative va-
Yes, current 9 (8) lidity and interrater reliability for children with cerebral
Yes, not maintained 1 (1)
palsy.20-22 While the GMFCS was developed for children
In process 8 (7)
No 91 (84) with cerebral palsy, we wanted to have an indication of
Students (N = 296) overall functional motor ability level for all students in the
Age, mean (SD), y 7.3 (2.02) study. We believe that the GMFCS was the most appro-
Age group, n (%) priate option to describe and group the students on the
5-7 y old 172 (58)
basis of gross motor function. Thus, the GMFCS was used
8-12 y old 124 (42)
Sex, n (%) to classify all students and they were then divided into
Female 130 (44) 3 groups: GMFCS levels I, II-III, and IV-V.
Male 166 (56) GAS23 is an individualized, goal-based, criterion-
Race,a n (%) referenced outcome measure of change in performance of a
White 188 (66)
behavior. Criteria for each level of change must be measur-
Black 34 (12)
Multiracial 27 (9) able and meaningful. The childs performance at baseline
Other 21 (7) is assigned a value of 2, and the expected outcome fol-
Asian 16 (6) lowing intervention is assigned a value of 0. A value of
Ethnicity, n (%) 1 represents progress toward the expected outcome, and
Non-Hispanic or Latino 238 (82)
values of +1 and +2 represent outcomes that are possible
Hispanic or Latino 51 (18)
Geographic region,b n (%) but exceed expectations for the intervention. A value of 3
Northeast 51 (18) can be used to reflect that the child has regressed in func-
Southeast 85 (29) tion on this goal below the baseline. GAS has demonstrated
Central 82 (28) content validity, interrater and intrarater reliability, and re-
Northwest 78 (26)
sponsiveness in studies of children with cerebral palsy, mo-
(continues)
tor delays, and other developmental conditions3,16,17,24,25

Pediatric Physical Therapy Student Outcomes of School-Based PT 279

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and has been more responsive to changes in functional
performance than standardized measures.4
Procedures
Details of the study procedures have been reported
previously.19 Prior to the start of the study, therapists
completed an online training module on GAS and passed
a posttraining assessment. At the beginning of the study,
therapists identified students IEP goals related to partic-
ipation in school activities that were supported by their
physical therapy. Depending on the students IEPs, thera-
pists were asked to identify goals reflecting the following
outcome areas of interest in this study: posture/mobility,
recreation/fitness, self-care, and academics. The research
team systematically reviewed the GAS goals to ensure they
met the criterion for GAS format.15 Of the 498 GAS goals
reviewed for this study, only 19 goals required substan-
tial revisions. Through a consensus process, the research
team confirmed the classification of these goals into the
4 outcome areas and 3 learning levels (acquisition, flu-
ency, or generalization). If a student had more than 1 goal
identified for this study, therapists were asked to select
the goal that was most pertinent to the students participa-
tion in school and to which the physical therapy services
most addressedthis goal was referred to as the primary
goal. Within each outcome area, students had only 1 goal.
After approximately 6 months, therapists determined the
students goal attainment. Goal attainment was verified
by at least 2 IEP team members for the following per-
centage of goals: 78% of the primary goals, 81% of the
posture/mobility goals, 71% of the recreation/fitness goals,
94% of the self-care goals, and 89% of the academic goals.
Data Analysis
Study data were collected and managed using REDCap
(Research Electronic Data Capture) tools.26 GAS was sum-
marized as a continuous variable with descriptive statis-
tics. It was also summarized as a categorical variable with
counts and percentages to provide descriptive details of
student outcomes. Students were grouped on goal attain-
ment as regressed, no change, improving (score of 1),
achieving goals (score of 0), or exceeding expectations
(scores of +1 or +2); achieving and exceeding goals were
also combined. Analyses were conducted for the students
primary goal and for each of the goal areas. As students
had 1 to 4 goals, the analysis for the primary goals re-
flects all the students in the study and the analyses for the
goal areas reflect subsets of the students. Goal categories
are described by both learning level and goal attainment.
Scores were described overall, by age group (5-7 years, 8-
12 years), and by gross motor function (GMFCS level I,
II-III, IV-V). Two-way analyses of variance (ANOVAs),
using age group and GMFCS level as factors, were used
to determine differences in goal attainment between age
groups, gross motor function groups, and whether an in-
teraction existed between age and gross motor function.
280 Chiarello et al
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Post hoc 2-group comparisons were used in the event that
the overall F-test was found to be statistically significant.
In the event no significant effects were found despite an
overall significant model, the model was rerun with only
the main effects. One-way ANOVAs were used to deter-
mine differences in goal attainment by diagnostic groups.
A significance level of .05 was used for all statistical tests.
SAS (version 9.3, SAS Institute Inc, Cary, North Carolina)
was used for all statistical analysis.
RESULTS
Each student had 1 to 4 goals, consisting of 205
posture/mobility goals, 161 recreation/fitness goals, 82 aca-
demic goals, and 50 self-care goals. From these goals, the
primary goals, 1 identified for each student (n = 296),
were categorized as follows: 58% posture/mobility, 33%
recreation/fitness, 5% self-care, and 4% academics.
Therapists reported that for 61% of the students, per-
formance of the primary goal behavior was addressed and
measured within a school activity or routine. Self-care
goals had the highest percentage (94%), addressed and
measured within a school activity or routine, and recre-
ation/fitness goals had the lowest (47%). Sixty-five percent
of the posture/mobility goals and 69% of the academic goals
were addressed and measured within a school activity or
routine.
For the primary goals, 56% were at the acquisition
learning level, 43% at the fluency learning level, and 1% at
the generalization learning level. As presented in Table 2,
the percentage of goals at the acquisition learning level
varied from 47% to 88% for the goal categories. The
recreation/fitness category was the only goal category that
had a higher percentage of goals at the fluency learning
level (53%).
The goal attainment scores for all of the students are
presented in Table 3. Students on average slightly exceeded
their expected goal level for their primary goal (mean =
0.3, SD = 1.17), as well as for goals categorized as posture
and mobility, recreation, and self-care. Students, on aver-
age, made progress but did not meet their expected goal
level for goals categorized as academics (mean = 0.3,
SD = 1.35). Table 4 presents the frequency distribution of
TABLE 2
Learning Level of Goals for Primary Goal and Each Goal Category
Acquisition, Fluency, Generalization,
Goal Category % (n) % (n) % (n)
Primary goal (n = 296) 56 (165) 43 (128) 1 (3)
All goals by category
Posture/mobility 54 (110) 45 (92) 2 (3)
(n = 205)
Recreation/fitness 47 (76) 53 (85) 0 (0)
(n = 161)
Academic (n = 82) 52 (43) 46 (38) 1 (1)
Self-care (n = 50) 88 (44) 12 (6) 0 (0)
Pediatric Physical Therapy
 TABLE 3
End of School Year Goal Attainment Scores for Each Goal Category by GMFCS Level Groupsa

GMFCS Level I, GMFCS Levels II GMFCS Levels IV All Students,

Goal Category Mean (SD) and III, Mean (SD) and V, Mean (SD) Mean (SD)

Primary goal 0.5 (1.17) (n = 113) 0.1 (1.1) (n = 117) 0.2 (1.27) (n = 66) 0.3 (1.17) (n = 296)
All goals by category
Posture/mobility 0.6 (1.26) (n = 49) 0.1 (1.12) (n = 96) 0.1 (1.38) (n = 60) 0.2 (1.25) (n = 205)
Recreation/fitness 0.4 (1.16) (n = 96) 0.2 (0.95) (n = 53) 0.2 (1.59) (n = 12) 0.3 (1.14) (n = 161)
Academic 0.4 (1.35) (n = 39) 0.3 (1.57) (n = 23) 0.4 (1.14) (n = 20) 0.3 (1.35) (n = 82)
Self-care 0.4 (1.20) (n = 18) 0.1 (1.08) (n = 18) 0.6 (1.09) (n = 14) 0.4 (1.12) (n = 50)

Abbreviation: GMFCS, Gross Motor Functional Classification System.

a 0 indicates achieved goal, >0 indicates exceeded goal.

TABLE 4
Percentage of Level of Goal Attainment for Each Goal Categorya

GAS Score, % (n)

Achieved
+ 1 or +2: Goal
Regressed, No Change, 0: Achieved Exceeded (0/+1/+2),
Goal Area % (n) % (n) 1: Improved Goal Goal % (n)

Primary goal (N = 296) 0.3 (1) 6.7 (20) 17 (51) 36 (105) 40 (119) 76 (224)
All goals by category
Posture mobility (n = 205) 1 (2) 8 (16) 20 (41) 30 (62) 41 (84) 71 (146)
Recreation (n = 161) 7 (11) 17 (28) 37 (59) 39 (63) 76 (122)
Self-care (n = 50) 2 (1) 22 (11) 36 (18) 40 (20) 76 (38)
Academics (n = 82) 1 (1) 22 (18) 27 (22) 23 (19) 27 (22) 50 (41)
Total (N = 498) 1 (3) 9 (46) 20 (102) 32 (158) 38 (189) 70 (347)

Abbreviation: GAS, Goal Attainment Scaling.

a Percentages represent percentages for the respective row. Percentages do not add up to 100 because last column reflects the combination of the

2 previous columns.

TABLE 5
End of School Year Goal Attainment Scores for Each Goal Category by Age Groupsa

Goal Category 5-7 y Age, Mean (SD) 8-12 y Age, Mean (SD)

Primary goalb 0.4 (1.15) (n = 172) 0.1 (1.18) (n = 124)

All goals by category
Posture/mobility 0.3 (1.30) (n = 112) 0.1 (1.18) (n = 93)
Recreationb 0.5 (1.04) (n = 102) 0.1 (1.21) (n = 59)
Academics 0.4 (1.38) (n = 48) 0.2 (1.32) (n = 34)
Self-care 0.2 (1.07) (n = 30) 0.6 (1.19) (n = 20)
a 0 indicates achieved goal, >0 indicates exceeded goal.
bP < .05.

students level of goal attainment for each goal category.
Seventy-seven percent to 98% of the students improved on
their individualized goals depending on the goal category,
and 50% to 76% of students achieved or exceeded their
expected goal attainment.
No gross motor function by age interaction was found
for the primary goal or the individual goal categories. Goal
attainment was not significantly different by gross motor
function for the primary goal or the individual goal cate-
gories (Table 3). Goal attainment did vary by age (Table 5)
for the primary goal (F = 4.22, df = 1, P < .05). Students 5
to 7 years of age had higher goal attainment than students 8
to 12 years of age for their primary goal. For the recreation
goal category, no significant effects were found despite an
overall significant model. When the 2-way ANOVA was
conducted without the interaction effect, goal attainment
did vary by age (F = 7.96, df = 1, P < .01). Students 5 to
7 years of age had higher goal attainment for their recre-
ation/fitness goal than students 8 to 12 years of age. Student
goal attainment for the primary goal or the individual goal
categories did not differ by diagnostic groupings.
DISCUSSION
To our knowledge, this study is the first to ex-
amine nationwide in the United States the individual-
ized outcomes of students receiving school-based physi-
cal therapy services. The majority of goals were related
to posture/mobility and recreation/fitness, at the acqui-
sition learning level, and were addressed and measured
within the context of a school activity or routine. Stu-
dents made progress, achieved their individualized goals,

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and many surpassed their expected functional, adaptive,
and academic-related goals. Younger students had higher
goal attainment than older students for their primary goal
as well as the recreation/fitness goal area. These findings
have implications for individualized outcomes assessment
of students receiving school-based services.
The majority of the student goals were related to
posture/mobility and recreation/fitness, with considerably
fewer goals in the area of self-care and academics. This
finding is not surprising, given the physical therapists ar-
eas of expertise. However, it does raise concern that PTs
in school-based practice may not consider their skills in
supporting student outcomes in other related areas. For
the self-care area, we do not know the extent this find-
ing reflects the lack of IEP goals related to self-care or
that therapists did not identify these goals to monitor for
our study because other service providers focused on this
area. In the area of academics, we can assume that the
majority of students had academic-related goals on their
IEPs. McConlogue and Quinn27 similarly found that PTs
were addressing few goals related to academic tasks. While
it is appropriate for therapists to address students needs
for mobility and fitness, we encourage therapists to con-
sider using their expertise in movement and adaptive func-
tion to broadly support student academic and functional
outcomes.
It is promising that the majority of goals were ad-
dressed and measured within the context of a school activ-
ity or routine, thus supporting the students participation
during the school day. This finding is contrary to that re-
ported in previous research27 but aligned with the intent
of IDEA and evidence that therapists are embracing best
practice.7 However, it was surprising that a minority of
the goals for recreation/fitness were addressed and mea-
sured within the context of a school activity or routine, as
recess and physical education class would provide appro-
priate opportunities for PTs to support these goals. Ther-
apists inability to address and measure recreation/fitness
goals in context of the school day may be due to chal-
lenges with scheduling. When our results were presented
at a national conference, SoPAC 2014, school-based PTs
in the audience also shared that some school personnel
are not supportive of therapists providing services within
the classroom. We encourage therapists and teachers to
share their individual perspectives and negotiate appropri-
ate times for therapists to collaborate with teachers and
students during class activities in order to better support
participation.
It was not surprising that the majority of goals were
at the acquisition level of learning, followed by the flu-
ency level. PTs focus on students learning motor skills
and performing them with greater independence, speed,
ease, and safety. It was interesting that recreation/fitness
was the one area where there were more goals at the flu-
ency level than at the acquisition level. This may reflect an
understanding that for skills to be used effectively in the
demanding physical and social environments of the school
setting, students need to be able to perform the skills with
282 Chiarello et al
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greater fluency. The fact that only 1% of the skills were
at the generalization level is concerning, as little atten-
tion may be given to truly ensuring that students use their
skills within a variety of meaningful contexts in the school
environment.
The finding that students receiving school-based
physical therapy services made progress and achieved their
individualized goals is positive, consistent with previous
research,5,6 and suggests that these services support stu-
dent outcomes. PTs were accurate in anticipating expected
progress for students of varying gross motor functional lev-
els and diagnostic categories. The results that goal attain-
ment was not different among children with varying gross
motor functional ability or diagnostic category indicate
that GAS was responsive to changes that individual stu-
dents made and support its use as a meaningful outcome in
school-based physical therapy practice. The slightly lower
level of goal attainment for goals related to academics may
reflect that therapists, along with the IEP team, are not as
accurate in predicting expected outcomes in this area. PTs
also may not have been working on the specificity of the
academic goals, although it can be assumed that other IEP
team members, such as teachers, were directly supporting
these outcomes.
The finding that older students had lower goal attain-
ment for their primary and recreation/fitness goals than
younger students suggests that therapists may need to re-
flect on what supports older students need to optimize
progress. Despite the lower level of goal attainment, on
average, the older students did achieve their expected goal
level but did not exceed that level as the younger students
did. Therapists may have underestimated the progress that
younger students could make, or younger students may
have received more services to support their goals. Related
to our findings, Stuberg and DeJong6 found that elementary
school students had higher goal attainment than students
in middle and high schools. We are currently investigating
the services received by the students to examine whether
older students received less service time than younger stu-
dents. Another consideration is that as learning is non-
linear and complex, students 8 to 12 years old may be
focusing their energies and progressing in other areas of
development, such as academics, and less on mobility and
recreation.
We believe that meaningful intervention starts with
a good outcomes assessment. Developing relevant student
goals is challenging and the use of GAS may promote col-
laboration in identifying and monitoring goals.28 At IEP
meetings, therapists can engage parents, teachers, other
related services providers, and students in discussions to
establish meaningful goals and set appropriate outcome
levels. This process sets the stage for intervention plan-
ning. When working together, GAS can help the IEP team
focus service delivery on a client-centered perspective15
and academic and functionally relevant priorities. Expert
consensus recommends that goals reflect student partici-
pation in school routines and activities to assist them in
benefiting from their education.29 It is important for team
Pediatric Physical Therapy
members to identify goals that reflect priorities for the
student and to establish goals that are integrated across
domains.
GAS is useful for progress monitoring and documen-
tation of outcomes.15,30 Visual graphs of GAS outcomes
can be used by teams to discuss student progress and to
consider whether the intervention strategies are appropri-
ate or need modification. For this study, we do not know
the degree of collaboration in setting goals, but the use of
GAS fostered collaboration in monitoring and determining
goal achievement. Monitoring and documentation of stu-
dent outcomes can facilitate program evaluation at a dis-
trict or school level,6,16 self-evaluation and performance
appraisal of PTs at the practitioner level,30 and progress
monitoring at the student level and may foster greater team
investment in the learning process for students.
Limitations of our study include a smaller percent-
age of students at GMFCS levels IV and V. We also used
the GMFCS, which is validated for children with cerebral
palsy,20 to classify the gross motor function of children
with a range of diagnoses.
CONCLUSION
This study documented the positive progress using
GAS for elementary school students across the United
States on their individualized outcomes addressed by
physical therapy services. We found no effects of GMFCS
level or medical diagnosis on the students goal attainment.
We found an age effect for the primary goal and goals
classified as recreation/fitness, with younger students
having higher goal attainment than older students. Our
research team is currently examining the relationship of
physical therapy services to these outcomes. In addition,
qualitative research is in progress to explore the processes
that therapists experience in goal development and
implementation, as well as the facilitators and barriers
to developing participation-based goals. We hope our
research fosters others to conduct additional studies on
school-based physical therapy practice so that PTs can
truly provide evidence-based services. We encourage
therapists to invest in outcomes assessment, collaborate
with the IEP team, and develop and monitor meaningful
student individualized goals using the GAS system to
optimize students educational experience.
ACKNOWLEDGMENTS
The authors thank Dr Tracy Stoner, Dr Dianne Rios,
and Julia Smarr, for assisting in data management, and
Candace Brancato and Catherine Starnes, for assisting with
data analysis as well as all of the school systems and phys-
ical therapists who participated in the data collection.
REFERENCES
1. Individuals with Disabilities Education Improvement Act Amend-
ments of 2004, 20 USC 1400 et seq. http://www.copyright.gov/
legislation/pl108-446.pdf. Accessed March 13, 2015.
Pediatric Physical Therapy
Copyright 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
2. Effgen SK. Factors affecting the termination of physical therapy ser-
vices for children in school settings. Pediatr Phys Ther. 2000;12:
121-126.
3. Steenbeek D, Ketelar M, Galama K, Gorter JW. Goal attainment scal-
ing in paediatric rehabilitation: a critical review of the literature. Dev
Med Child Neurol. 2007;49:550-556.
4. Steenbeek D, Gorter JW, Ketelar M, Galama K, Lindeman E. Respon-
siveness of goal attainment scaling in comparison to two standardized
measures in outcome evaluation of children with cerebral palsy. Clin
Rehabil. 2011;25(12):1128-1139.
5. King GA, McDougal J, Tucker MA, et al. An evaluation of functional,
school-based therapy services for children with special needs. Phys
Occup Ther Pediatr. 1999;19(2):5-29.
6. Stuberg W, DeJong SL. Program evaluation of physical therapy as an
early intervention and related service in special education. Pediatr
Phys Ther. 2007;19:121-127.
7. Effgen S, Chiarello L, Milbourne S. Update of competencies for physi-
cal therapists working in schools. Pediatr Phys Ther. 2007;19(4):266-
274.
8. Kontra C, Goldin-Meadow S, Bielock S. Embodied learning across
the lifespan. Topics Cogn Sci. 2012;4(4):731-739.
9. Chiarello L, Palisano R, Maggs J, et al. Family priorities for activity
and participation of children and youth with cerebral palsy. Phys
Ther. 2010;90(9):1254-1264.
10. King G, Law M, Hanna S, et al. Predictors of the leisure and recre-
ation participation of children with physical disabilities: a structural
equation modeling analysis. Child Health Care. 2006;35:209-234.
11. Maher C, Olds T, Williams M, Lane A. Self-reported quality of
life in adolescents with cerebral palsy. Phys Occup Ther Pediatr.
2008;28(1):41-57.
12. Palisano RJ, Shimmell LJ, Stewart D, Lawless JJ, Rosenbaum PL,
Russell DJ. Mobility experiences of youth with cerebral palsy. Phys
Occup Ther Pediatr. 2009;29(2):133-153.
13. Lepage C, Noreau L, Bernard PM. Association between characteristics
of locomotion and accomplishment of life habits in children with
cerebral palsy. Phys Ther. 1998;78(5):458-469.
14. OGrady RS, Crain LS, Kohn J. The prediction of long-term functional
outcomes of children with cerebral palsy. Dev Med Child Neurol.
1995;37(11):997-1005.
15. McDougall J, King G. Goal Attainment Scaling: Description, Utility,
and Applications in Pediatric Therapy Services. 2nd ed. London, ON,
Canada: Thames Valley Childrens Centre; 2007.
16. King G, McDougall J, Palisano RJ, Gritzan J, Tucker MA. Goal attain-
ment scaling: its use in evaluating pediatric therapy programs. Phys
Occup Ther Pediatr. 1999;19(2):31-52.
17. Law LSH, Dai MO, Siu A. Applicability of goal attainment scaling in
the evaluation of gross motor changes in children with cerebral palsy.
Hong Kong Physiother J. 2004;22:22-28.
18. Horn SD, DeJong G, Deutscher D. Practice-based evidence re-
search in rehabilitation: an alternative to randomized controlled
trials and traditional observational studies. Arch Phys Med Rehabil.
2012;93(8):S127-S137.
19. Effgen SK, McCoy SW, Chiarello L, Jeffries L, Bush H. Physical
therapyrelated child outcomes in school: an example of practice
based evidence methodology. Pediatr Phys Ther. 2016;28(1):47-56.
20. Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Con-
tent validity of the expanded and revised Gross Motor Func-
tion Classification System. Dev Med Child Neurol. 2008;50(10):
744-750.
21. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi
B. Development and reliability of a system to classify gross mo-
tor function in children with cerebral palsy. Dev Med Child Neurol.
1997;39(4):214-223.
22. Palisano RJ, Hanna SE, Rosenbaum PL, et al. Validation of a model
of gross motor function for children with cerebral palsy. Phys Ther.
2000;80(10):974-985.
23. Kiresuk TJ, Smith A, Cardillo JE. Goal Attainment Scaling: Appli-
cations, Theory, and Measurement. Hillsdale, NJ: Lawrence Erlbaum
Associates; 1994.
Student Outcomes of School-Based PT 283
24. Steenbeek D, Ketelaar M, Lindeman E, Galama K, Gorter JW. In-
terrater reliability of Goal Attainment Scaling in rehabilitation of
children with cerebral palsy. Arch Phys Med Rehabil. 2010;91(3):
429-435.
25. Lowing K, Bexelius A, Brogen Carlberg E. Activity-focused and goal
directed therapy for children with cerebral palsydo goals make a
difference? Disabil Rehabil. 2009;31(22):1806-1816.
26. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde
JG. Research Electronic Data Capture (REDCap)a metadata-
driven methodology and workflow process for providing transla-
tional research informatics support. J Biomed Inform. 2009;42(2):
377-381.
27. McConlogue A, Quinn L. Analysis of physical therapy goals in a
school-based setting: a pilot study. Phys Occup Ther Pediatr. 2009;
29(2):154-169.
28. An M, Palisano RJ. Family-professional collaboration in pediatric
rehabilitation: a practice model. Disabil Rehabil. 2014;36(5):434-440.
29. Dole RL, Arvidson K, Byrne E, Robbins J, Schasberger B. Consensus
among experts in pediatric occupational and physical therapy on
elements of individualized education programs. Pediatr Phys Ther.
2003;15:159-166.
30. Section on Pediatrics. Performance Appraisal of School-based Physical
Therapists: The Link to Student Outcomes. Alexandria, VA: American
Physical Therapy Association; 2013.

CLINICAL BOTTOM LINE

Commentary on Student Outcomes of School-Based Physical Therapy as Measured by Goal Attainment
Scaling

How should I apply this information?

Through the use of goal attainment scaling (GAS), this study demonstrates that students receiving school-based
physical therapy typically meet or exceed goals related to posture/mobility, recreation/fitness, and self-care despite
gross motor level or diagnosis. GAS can be used by school-based physical therapists for a variety of purposes
such as monitoring student progress, promoting collaboration among team members, determining effectiveness
of services, self-evaluation, and program evaluation. GAS allows for individual assessment of progress toward
meaningful functional activities that are integrated into school activities and routines. GAS allows the therapist to
consider personal and environmental factors affecting student progress and can identify functional gains that may
not be reflected when using standardized testing. The study also showed that very few individualized education
program goals were written at the generalization level. Therefore, school-based physical therapists may need to
provide interventions and write goals that ensure that students are able to use mobility, recreation, and self-care
goals within a variety of school-based activities and settings.
What should I be mindful about when applying this information?
Therapists should be mindful that the Gross Motor Function Classification System was used across all diagnoses,
not just cerebral palsy, and data were collected on children between the ages of 5 and 12 years. Thus, the findings
are limited to elementary school children. Although the study showed that younger students had higher goal
attainment than older students with regard to primary and recreation goals, the possible reasons for this trend
are unclear. However, school-based therapists should carefully review the recommended dosage, level of the goal,
and need for activity or equipment adaptations when working with older students to facilitate goal achievement.
As experts in movement and adapted function, school-based physical therapists should address relevant and
functional tasks/routines throughout the school day in both mobility-based and academic activities.

Dawn James, PT, DPT, PCS

West Coast University
Los Angeles, California
Sharon Antoszyk, PT, DPT, PCS
Cabarrus County Schools
Concord, North Carolina
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000288

284 Chiarello et al Pediatric Physical Therapy

Copyright 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.