Journal of Research in Childhood Education 16(1), 28-38 (2001 Fall-Win)
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The purpose of this study was to review the instructor and classroom management procedures of those general education teachers involved in the inclusion of children with Down syndrome who have been rated as successful by the children's parents. Using a parent affiliate list provided by the National Down Syndrome Society, 250 questionnaires were mailed to families in the United States. From this group, 195 parents indicated that they thought their children were included successfully, and they then forwarded questionnaires to their children's general education inclusion teachers. Of those, 189 teachers, from kindergarten through 12th grade, returned their questionnaires. According to the reports from the teachers designated by parents as successfully including students with Down syndrome in their classes, praise was the best motivator for the children with Down syndrome and the most effective learning methods were individual and small-group instruction, hands-on activities, and the use of computers for practice and drill. When asked for recommendations to improve the inclusion model, the teachers suggested more planning time to modify assignments and tests, more individual instruction time built into the schedule, and more information on learning characteristics of children with Down syndrome.
Since the origins of special education, educators' philosophies on inclusion have differed. These differences reflect issues of curriculum change, classifications and labels, assessment, discipline and management, and teacher education. During the 1990s, political and policy debates about inclusion touched off numerous disagreements among parents, special educators, general educators, psychologists, and related service professionals. Research studies have found improved academic outcomes for students with developmental disabilities in general education settings (Fields, Leroy, & Rivera, 1994; Huntington, 1998). With growing concern for diversity in education, inclusion has been accepted as the moral, legal, and practical way to approach special education reform (Gartner & Lipsky, 1987; Perner & Porter, 1998). In the United States, however, only 9.7% of these students have been placed in inclusive settings (U.S. Department of Education, 1998).
Children with Down syndrome have a wide range of functional differences and different learning styles that usually require more planning of curricular choices and experiences, compared to that for general education students (Cicchetti & Beeghly, 1990). These differences often have meant that children with Down syndrome have been placed in segregated educational programs, consisting of specialized services and smaller groupings (Blatt, 1981; Ellis, Deshler, Lentz, Schumaker, & Clark, 1991). Also, the language, motor, and social skill differences that often characterize students with Down syndrome may affect the teacher's choices of instructional methods and behavior management strategies (Fuchs & Fuchs, 1998; Hasselbring & Goin, 1989; Perner & Porter, 1998).
Individual and small-group instruction have been found to improve the learning capacity of children with developmental disabilities (Haring & Brown, 1976; Snell, 1983; Wolery, Bailey, & Sugai, 1988). This was one of the original reasons for the separate, smaller education classes in the 1950s and 1960s, and is also true with general education students (Munk, Van Laarhoven, Goodman, & Repp, 1998). As general education classes are typically larger than traditional, self-contained special education classes, one might conclude that inclusion may not be the best option for the education of children with Down syndrome. There is much more to the education experience than direct instruction, however, and the sole use of individual and small-group instruction may inhibit the development of these children's social skills and ultimate functioning as members of the larger general population (Rosenthal-Malik, 1998).
Research has shown that general education teachers have mixed feelings with regard to the feasibility of balancing the demands of teaching the included students with their other classroom duties (Chira, 1993; Fullwood, 1990; Gersten, Vaughn, Deshler, & Schiller, 1997; Giangreco, Cloninger, & Salce-Iverson, 1993). The inclusion of students with Down syndrome may necessitate the adaptation of, or use of, alternative classroom resources, methods, and materials typically used with the general education populations, which may be frustrating, tedious, and time-consuming for the teacher (Feuer & Fulton, 1993; Sedlak & Sedlak, 1985; Voeltz & Evans, 1983). However, other studies of mainstreaming practices and inclusion have shown that teachers did not find the process to be cumbersome or involve extra work at all (Schulz & Thrnbull, 1984; Stainback, Stainback, & Forest, 1989; Wood, 1992). Surprisingly, despite all these potential classroom modifications, general education teachers are often left out of the conceptualization/decision-making process, yet are faced with the daily implementation of inclusion (Stainback & Stainback, 1992; York, Doyle, & Kronberg, 1992).
The purpose of this study was to ask curricular, instructional, and implementation questions of the general education teachers who, according to parents' reports, are already successfully involved in the inclusion of children with Down syndrome. Successful strategies, learning arrangements, and materials were determined by teacher rating of the top two categories of a Likert scale ranging from not at all successful (1), sometimes successful (2), often successful (3), usually successful (4), and always successful (5). Inclusion was defined as having the students with Down syndrome attend a general education class for at least half a day, five days a week, with or without the support of an extra staff member. The goal of this study was to describe strategies and methods that teachers identified as helping them successfully implement the inclusion of students with Down syndrome in their classes. Questions reflected methods used with all students, but with a particular focus on the students with Down syndrome. Teachers were also asked for recommendations on how they would improve the inclusion process.
The National Down Syndrome Society supported this study by providing a list of affiliates in all U.S. states, as well as from the commonwealth of Puerto Rico. Two hundred and fifty questionnaires were sent to parents who agreed to participate in the study; out of those, 195 rated their child's inclusion experience as successful and forwarded a part of their questionnaire to their child's general education teacher. The design of the questionnaire contained four levels of questioning: 1) background experience of the teacher, including amount of teaching experience, knowledge of special education, and knowledge/attitude toward inclusion; 2) teacher preparation for inclusion by the district and/or parent, and the transition process of the student; 3) classroom information on curriculum used, class arrangement for instruction, and maintenance of therapies and support services; and 4) classroom management issues, including instructional and behavioral management strategies. The objective was to determine what methods general educators felt worked or did not work with the inclusion of children with Down syndrome in their general education classes. The teachers were asked to rate and rank order the effectiveness of different types of learning arrangements and instructional and behavior management strategies used in their classrooms on a scale of 1 (not effective) to 5 (very effective). Reliability checks were conducted on data entered from 20% of the questionnaires. Written responses outside the parameter of choices were forwarded to a general and special educator, and interrater agreement was 99%.
Out of the 250 questionnaires mailed to the parents, 12 parents reported that either their children were not included in general education for at least half a day, or that their child's inclusion experience was not successful. Therefore, these questionnaires were not used for analysis. This left 238 parents who forwarded questionnaires to their child's general education teacher. Twenty-nine teachers left the study over the course of the year because of maternity leave, promotion, or classroom changes. Fourteen questionnaires were not used for analysis because the included student moved or changed class during the year. Six returned questionnaires were unusable because they were not completed properly. This left 189 acceptable responses for data analysis. Statistical correlations among all of the independent variables (teacher characteristics, class size, curricular methods, etc.) were examined. Groups of independent variables were then chosen based on their individual correlations to the dependent variable be ing analyzed (reported successful inclusion by the parent), taking care to eliminate independent variables that showed high correlations to each other (multicolinearity). Some descriptive statistics of the population are as follows: The children's average age was 10 years, 6 months (range 4 years to 20 years old). The average grade level was 3rd grade, 8th month (range was pre-K to 12th grade). Ninety-one percent of the children attended their local neighborhood school. The average class size was 25 pupils (ranging from 15 through 40). Fifty-seven percent of the classes contained more than one included student with disabilities in addition to the child with Down syndrome. The average class had two other children with some form of special learning need, as well as the child with Down syndrome.
Teacher variables showed that 89% of the teachers had a bachelor's degree in education, with extra credits toward a master's in education or toward a second degree. The average number of years' experience teaching was 13 years. Sixty-three percent had some special education training (a minimum of one college course). Fifty-four percent of the teachers reported no inclusion preparation from the school district.
Team teaching occurred in 30% of the classes, and 25% of these teamed up a general education teacher with a special education teacher. Fifty-one percent of the general education teachers reported consulting with a special education teacher during the inclusion experience. Forty-nine percent of the teachers reported using peer tutors. Thirty-six percent of the classes used a resource room or pull-out service for their included children. Eighty-three percent of the classes had an inclusion aide, who also worked with other children. In 78% of the cases, the inclusion aide stayed with the child from year to year, in order to provide programming stability. Computers were used daily in 80% of the classes.
A look at related services indicated that 94% of the students with Down syndrome received speech services, 62% received occupational therapy, and 37% received physical therapy Approximately one half (52%) received pull-out services (resource room and related services and therapies), as compared with (48%) push-in services (extra help came into the classroom). General education teachers reported pull-out and push-in services as having an equal impact on the instructional process. Table 1 is a listing of descriptive statistics of the teacher and student population, as well as of the organization of related services.
Teachers were asked to rate the effectiveness of different types of learning arrangements and instructional and behavior management strategies for children with Down syndrome in their classes on a scale of 1 (not effective) to 5 (very effective). These strategies were ranked in order from those reported as very effective to those reported as not effective. See Table 2 for a listing of the teachers' rank order scores of Best Learning Arrangements, Most Effective Materials, Best Behavior Management Strategies, Best Methods for Grading, and Teacher Requests for Improvement. Teachers reported distinct preferences for certain materials, methods, and strategies, and described why. Teachers also mentioned similar ways to improve the inclusion model. In order to clarify the presentation of the results, these are separated into the following three separate sections.
The most effective learning arrangements reported were first individual and then small-group instruction. Peer tutors, computers, and team teaching were found to be sometimes useful and effective. Large-group and whole-class lessons were reported not to be effective at all for instructing students with Down syndrome who were included in general education classes. A t test was performed to ensure that the ratings for the top and bottom scores were statistically different. The ranking scores between best and worst learning arrangements were statistically significant (t =17; p < .01). Forty nine percent of the teachers reported that inclusion caused extra work in areas of modifying homework, class assignments, tests, and grading procedures, and that it necessitated more contact with the parents.
Classroom arrangements were also examined. Teachers reported that the most effective place for instruction was the students' desk area (as reported by 94% of the teachers). Teachers in the higher grades (7th grade through 12th grade) preferred the blackboard and overhead projector for group instruction, while kindergarten and 1st-grade teachers predominantly used more informal sitting arrangements, such as sitting on a carpet or in a circle.
When asked to rate what materials work best for instruction of students with Down syndrome, "hands-on" or "real" materials were reported to be the most effective for successful inclusion. Computer, paper-and-pencil tasks, and textbooks were sometimes effective (only in the upper grades), and workbooks were reported as not being useful at all for successfully including students with Down syndrome in general education classes. The difference between the ranking score of the most effective and least effective materials used was statistically significant (t = 12; p <. 01). Seventy four percent of the teachers felt that homework was effective for two reasons: 1) to inform parents about what the child was doing in school, and 2) to give the child the necessary extra practice with basic concepts. Out of all the adults involved with the students with Down syndrome, the general education teacher and inclusion aide were reported as the most effective at including the child successfully in lessons, as compared to therapists, team teachers, and consultants. However, 44% of the teachers also wrote that peers were extremely effective as part-time instructional agents.
Teachers reported that praise was the best behavior management strategy or motivator for children with Down syndrome. Use of material rewards, time out, peer pressure, loss of class privileges (such as free time) and teacher contact with parents were reported as sometimes helpful strategies. Teachers said that they did not have to modify their behavior management systems for adequate class control due to the inclusion of the students with Down syndrome. Less effective strategies included ignoring misbehavior, using reprimands or punishment, or, least effective of all, strategies relying on grades as a motivator. Successful teachers preferred more qualitative methods for evaluation, such as projects or class participation. In their written responses, several teachers stated that the students with Down syndrome were unable to link negative consequences with their inappropriate behaviors. The ranking score between the most effective behavior management strategy (praise) and the least effective behavior management strategy (lower grade) was statistically significant (t = 28; p <. 01). Therefore, grades were based on how often the students with Down syndrome participated in class, made an effort to do projects, and kept up with their daily work. Teachers stated that homework and test scores were not related to these students' report card grades, especially in the elementary grades. The difference between the ranking score of a student's daily effort (the most helpful for grading) and homework (the least helpful for grading) was statistically significant (t l8;p <. 01).
Teachers who were rated as successful did not feel that there was unfair attention given to the child with Down syndrome. The teachers' high expectations for these students were unrelated to factors of staff preparation, model of implementation of inclusion, and whether or not the students had behavior problems in class.
When asked for recommendations to improve the inclusion process, the teachers desired, in order from highest to lowest, more one-on-one instructional time, more planning time, and more information on learning characteristics of children with Down syndrome. Extra help in the classroom, less paperwork, and more administrative support were not reported as priorities. The difference between highest and lowest rank order scores was significant (t = 7; p < .01). Sixty-six percent rated the experience as more rewarding than they anticipated, both for themselves and other classmates.
Teachers identified by parents as successfully including children with Down syndrome in their classes reported that some methods and strategies seemed to work better than others when implementing inclusion. The teachers made similar suggestions for the improvement of the inclusion process; these are discussed separately.
As previously indicated by research (Haring & Brown, 1976; Snell, 1983; Westling, 1996; Wolery, Bailey, & Sugai, 1988), the teachers in this study stated that one-on-one instruction or small-group instruction worked much better with children with Down syndrome, as well as with general education students, than did large-group or whole-class instruction. This is only one example of the similarities between the learning styles of the included and the general education students.
Teachers rated by parents as successful reported that materials that worked best for direct instruction were hands-on activities, manipulatives, and computer-assisted instruction and drill. Sometimes the same materials were used in different ways. One teacher reported that while the rest of her 1st-grade class used Uniflex cubes for counting and adding, the child with Down syndrome sorted the cubes by color. Workbooks were not found to be useful at all in classrooms of successful inclusion. This response is not surprising, as most workbooks are either heavily dependent on language comprehension (a problem area for students with Down syndrome), or have too many distractions or problems on a page, which is confusing and overwhelming for the student with Down syndrome (Sedlak & Sedlak, 1985). Doing a workbook page also required an advanced level of independence and motivation. Teachers also stated that written performance in a workbook did not adequately reflect what the student with Down syndrome knew or could do.
Computer-assisted instruction was found to be beneficial for both students with Down syndrome and for the general education students, because it is interactive, non-threatening, and self-paced; in addition, the programs usually contain small, sequenced steps with lots of repetition and drill. However, caution should be taken to ensure that computers are only used as a medium of instruction and not as a replacement for instructional teacher contact, which was rated by successful teachers as a more effective strategy. Also, the humanistic nature of teacher-student interaction is necessary for the development of good social skills (Hasselbring & Goin, 1989; Perner & Porter, 1998), a valuable goal for students with Down syndrome (Haring & Brown, 1976; Huntington, 1998; Snell, 1983; Westling, 1996). A few teachers stated that their students with Down syndrome did not have adequate fine motor coordination to use the mouse or keyboard effectively, in which case adaptive keyboards and materials were necessary. Classroom peer tutors were reported as effective instructional agents for the students with Down syndrome, which supports prior research in the area of peer-mediated instruction (Chalfant, 1987; Guralnick & Weinhouse, 1984).
Successfully rated teachers reported that they used the student's daily physical performance, participation in class, and effort in daily projects in preference to tests or homework when grading a student with Down syndrome. This could be related to the fact that many parents helped their children with homework, and this did not reflect independent work of the included student. However, teachers did feel that homework was very important for the students with Down syndrome, because it helped bridge the gap between home and school, reinforce concepts discussed in class, and inform the parents about what the child was learning. Teachers also stated that this approach was different than their grading policy for the general education students, for whom they relied more on test scores.
Threatening to lower a student's grades was not an effective way to motivate students with Down syndrome to work harder and try their best. Teachers stated that they usually graded the students with Down syndrome against themselves rather than against norms or the other students. This response supports the recent trend to evaluate students through alternative assessments, such as curriculum-based assessment or portfolios (Ezell, Klein, & Ezell-Powell, 1999; Feuer & Fulton, 1993; Fuchs & Fuchs, 1990; Voeltz & Evans, 1983).
Praise from the teacher was by far the most widely reported best practice for inclusion of students with Down syndrome. One teacher with six years of inclusion experience said, "My children with Down syndrome soak up praise -- the more they get, the more they want and the harder they will work to get it."
Punishment (here, the introduction of negative consequences and/or loss of privileges) and ignoring misbehavior were reported as ineffective behavioral management techniques. It is possible that the students with Down syndrome did not automatically understand what they were being punished for; if the punishment was not adequately explained, the undesirable behavior sometimes continued. Ignoring behavior was not reported to be an effective method for learning or for changing inappropriate behavior, possibly because students with Down syndrome generally need highlighted cues and more direct instruction to link concepts of cause and effect (Maag, 1999; Sedlak & Sedlak, 1985; Snell, 1983; Westling, 1996). In other words, the included students may not have understood the relationship between behavioral causes and consequences unless these were explained clearly successful teachers stated that they were better off calmly pointing out what behavior was or was not appropriate and what the immediate consequences were. Also, the teachers reported that following through consistently on rules and contingencies was critical to facilitating the learning of their included students.
Teachers reported that they wanted more individual instructional time with the student with Down syndrome, as well as more planning time for instruction and modifications. This is especially important if the team teaching paradigm is used in the schools. Planning time must be built in for teachers to work together in a consistent fashion (Campbell, Campbell, Collicott, Perner, & Stone, 1988; Giangreco, Cloninger, & Salce-Iverson, 1993; Nolet & Tindal, 1994; Repp & Karsh, 1992). The teachers did not complain about extra work or paperwork, a finding that is consistent with prior research on mainstreaming and inclusion (Schulz & Turnbull, 1984; Stainback, Stainback, & Forest, 1989; Wood, 1992). Teachers also requested more information on the learning characteristics of children with Down syndrome, which could be provided in preparatory teacher training programs and/or workshops (Sarason, 1993). Teachers stated that they did not want more input from the parents, but this statistic could be misleading because 94% of the teachers said that they had already gotten a lot of information from the parents. In 78% of the cases, teachers said that although they were not prepared by the school district for inclusion, parents prepared them informally, with written material and personal information on their children. In 36% of the cases, parents also came into the classroom prior to the onset of inclusion to prepare prospective classmates.
To conclude, the teachers in this study who were rated as successfully including children with Down syndrome in their general education classes indicated which strategies were most effective. These strategies are consistent with good teaching practices in general as recommended in recent research (Kameenui & Simmons, 1990; Perner & Porter, 1998). Teachers reported the experience as challenging, rewarding, and of great value to their general education students as well as to the children with Down syndrome. Caution should be taken to ensure that general education teachers prioritize the included students' Individualized Education Plan (IEP) goals, which may include the less typical areas of language, motor, and social skills, rather than determining the effectiveness or success of inclusion solely from academic standards (Dover, 1992; Smith & Hilton, 1994). However, it has already been shown that included students may have higher academic gains than those kept in more segregated settings (Fuchs & Fuchs, 1998; H untington, 1998; Thousand, Villa, & Nevin, 1994), and this study has indicated valuable aspects of inclusion as well.
In this study, the teachers reported that their most effective methods for facilitating student learning for both Down syndrome and general education students were individual instruction and small-group instruction, especially at the students' desks. If teachers find it difficult to spend much time in direct contact with individual or small groups of students, this study has supported previous research indicating that peer mentors and peer tutors are effective and enjoyable alternatives (Evans, 1993; Fields, Leroy, & Rivera, 1994; Stainback & Stainback, 1992). This study found that the most effective materials reported by the teachers for all of their students were "hands-on" activities or computer-assisted instruction, which supports the recent education trends for the use of cooperative and collaborative learning in groups and the increased push for the use of technology in schools (Aber, Bachman, Campbell, & O'Malley, 1994; Evans, 1993; Hasselbring & Goin, 1989).
A possible inference from this study is that teachers do not need to change their behavior management strategies to include children with Down syndrome in their classes. Praise and small rewards were most effective for motivating all students, including those with Down syndrome. However, the best methods reported for grading by successful teachers of included children with Down syndrome were class participation and effort, rather than homework and tests. This grading policy seemed to differ from that used with general education students.
The most common request for improvement to the inclusion model was for more planning time to be built into scheduling, as well as the possibility for including more one-on-one instruction. This result supports the research calling for more collaboration among education professionals (Campbell et al., 1988; Fullwood, 1990; Giangreco et al., 1993) and the reduction of class size and/or the addition of more staff in inclusive classrooms, to improve the student-teacher ratio (Aber, Bachman, Campbell, & O'Malley, 1994; Kameenui & Simmons, 1990). Teachers in this study overwhelmingly requested more information on learning characteristics of their included students. Unfortunately, this response reveals that despite the proliferation of research and the emphasis on diverse learning styles in teacher education programs, teachers still feel unprepared when it comes to practicing inclusion ("A Higher Mission," 1994; Chira, 1993; Evans, 1993; Gersten, Vaughn, Deshler, & Schiller, 1997). Institutions of higher education may need to rethink their educational training practices to include more planning for universal design of instruction and alternative learning styles throughout all educational pedagogy, and not just in limited "special education" courses.
It is possible that the results of this study are specific to included students with Down syndrome only, and it is possible that the results were skewed by the teachers who returned their questionnaires. Future analysis may also show differences with effectiveness or preferences with instructional methodology used in classrooms, depending on student age, grade, or gender. However, with the inclusion of more students with disabilities in regular classrooms, the results from this study may be helpful to all teachers in inclusive classrooms and to those planning for inclusion.
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Table 1 Teacher and Student Population, Preparation, and Related Services School/Class Factors Mean Maximum Minimum Value Value Value Size of School District 28,769.38 198,000 400 Attending Home School 0.91 1 0 Prior Experience of School Districts 0.69 3 0 With Inclusion Child Age 10.57 20 4 Child Grade 3.81 12 1 Class Size 25.29 40 15 Number of Children With Down Syndrome 1.13 3 0 in Class Other Disabilities Included 0.57 4 0 Preparation for Inclusion by School District: Teachers 0.63 1 0 Aides 0.21 1 0 Child 0.31 1 0 Classmates 0.36 1 0 Parents 0.33 1 0 Teaching Arrangement: Team Teaching 0.30 1 0 Resource Room 0.36 1 0 Special Education Consultant 0.51 1 0 Aide in Class 0.83 1 0 Number of Aides in Class 1.05 5 0 Peer Tutors 0.49 1 0 # Years' Teaching Experience 13.24 29 0 Special Education Training 0.63 2 0 Grade Taught 3.55 11 1 Inclusion Training From District 0.46 1 0 Teacher Feeling of Competence 0.62 2 0 Related Services Speech 0.94 1 0 Occupational Therapy 0.62 1 0 Physical Therapy 0.37 1 0 Computers Used in Class 0.80 3 0 School/Class Factors Standard Deviation Size of School District 51,149.76 Attending Home School 0.28 Prior Experience of School Districts 0.55 With Inclusion Child Age 3.07 Child Grade 2.70 Class Size 5.50 Number of Children With Down Syndrome 0.43 in Class Other Disabilities Included 0.50 Preparation for Inclusion by School District: Teachers 0.49 Aides 0.41 Child 0.46 Classmates 0.48 Parents 0.47 Teaching Arrangement: Team Teaching 0.45 Resource Room 0.48 Special Education Consultant 0.50 Aide in Class 0.37 Number of Aides in Class 0.71 Peer Tutors 0.39 # Years' Teaching Experience 7.39 Special Education Training 0.53 Grade Taught 2.52 Inclusion Training From District 0.50 Teacher Feeling of Competence 0.51 Related Services Speech 0.23 Occupational Therapy 0.49 Physical Therapy 0.49 Computers Used in Class 0.52 Table 2 Rank Order Score of Best Strategies for Inclusion of Students With Down Syndrome Strategy Mean Standard t score Value Deviation Highest/Lowest Best Learning Arrangement Individual 4.46 1.06 t = 16.80 (*) Small Group 3.86 1.12 Peer Tutor 3.39 1.34 Computer 2.98 1.57 Team Teaching 2.95 1.94 Large Group 2.47 1.11 Whole Class 2.05 1.16 Most Effective Materials Concrete Activities 4.28 1.20 t = 12.01 (*) Computer 3.43 1.68 Paper and Pencil 2.98 1.43 Textbook 2.67 1.72 Workbook 2.12 1.57 Other 1.04 1.96 Best Behavioral Management Strategies Praise 4.64 0.58 t = 27.62 (*) Material Rewards 3.40 1.61 Contacting Parent 3.30 1.69 Loss of Privilege 3.15 1.59 Time Out 3.11 1.55 Peer pressure 2.64 1.49 Reprimands 2.45 1.24 Ignoring 2.21 1.37 Punishment 1.66 1.38 Lower Grade 1.35 1.17 Best Methods for Grading Effort 4.48 0.99 t = 18.12 (*) Daily Work 4.20 1.19 Physical Participation 4.08 1.21 Verbal Participation 3.59 1.56 Tests 2.09 1.43 Homework 1.80 1.29 Teacher Requests for Improvement Individual Instruction 3.96 1.32 t = 7.32 (*) More Planning Time 3.89 1.52 Info About Learning Characteristics 3.71 1.30 Additional Help 3.45 1.65 Peer Tutoring 3.28 1.29 Support From School Administration 2.88 1.53 Input From Parents 2.56 1.51 Less Paperwork 2.53 1.68 Scores range from 1 (not effective) to 5 (very effective). (*)significant at .01 level