Objective: Therapeutic disciplines have specific ethical codes. Codes of ethics provide a framework for ethical behavior. They do not offer specific guidelines for application in particular instances. Children with disabilities are eligible for related services in the educational setting, including services provided by occupational therapists (OT), physical therapists (PT) and speech-language pathologists (SLP). This paper refers to these related service therapists as RSTs. In Israel RSTs include expressive art therapists (EAT). The purpose of the present study was to examine the ethical violations and dilemmas RSTs experience in educational settings.

Method: Participants were 16 RSTs (six OTs, eight SLPs, and two EATs) working in the special education system. The Israeli Ministry of Education holds annual training courses for RSTs from the health professions (OT, PT, SLP) and EAT. All participants in the present study studied in a training course for health professionals and expressive-arts therapists under the auspices of the Ministry of Education at the Orot Israel College of Education. As part of the training course, participants had to refer in writing to ethical dilemmas and violations they experienced in delivering services for students with disabilities in educational settings. Content analysis was performed in order to document patterns of participants experience of ethical dilemmas and violations arising in the educational system.

Results: Content analysis yielded five themes related to participants’ service delivery and role within the educational system: a) inconsistency between students’ needs and students’ placement; b) adherence to procedures; c) distortion of diagnosis; d) defaults and unethical demands in the educational setting; and e) the relationship with patients.

Conclusion: RSTs in educational setting experience unique violations of ethical codes and ethical dilemmas.

Ethical Challenges, Educational setting, Service therapists

Goldblat E, Felsenstein R. Ethical Challenges of Related Services Therapists in Educational Settings. Ann Pediatr Child Health 2022; 10(4): 1278.

The term ethics refers to a moral philosophy or a set of moral principles that determines what is right, good, true, virtuous and just. A culture or society defines these moral principles. A Code of Ethics describes the official guidelines of a professional group, reflecting the responsibilities, obligations, and goals of group members. These codes determine the values that the profession considers important to its identity, and guide the professional behavior of group members [1]. An ethical code is formulated by the professional community and represents a particular practice [2]. It has to reflect practice realities rather than positive intentions [3].

Therapists strive to identify and implement services that are ethical and equitable [4]. Therapeutic disciplines and professions have specific ethical codes. An ethical code must be developed by a professional group that represents all members of the professional community. These ethical standards relate to the relationship between therapists and their clients and to relationships between therapists and their professional community. They also have to relate to issues of professionalism and professional responsibility, as well as to the issue of professional standards and qualification. Finally, ethical codes have to find ways to address “grey” areas that defy an answer that is clearly right or wrong [2].

Codes of ethics provide a framework for ethical behavior. They do not offer specific guidelines for application in particular instances nor do they shed light upon moral dilemmas that professionals must contend with practice. An ethical dilemma develops when a conflict arises between competing values represented by different opinions of individuals, or by the competition among various values held by an individual [5].

Children with disabilities are eligible for related services in the educational setting, including services provided by occupational therapists (OT), physical therapists (PT) and speech-language pathologists (SLP) [6]. This paper refers to these related service therapists as RSTs. In Israel related services in educational settings are also delivered by expressive art therapists (EAT) [7]. Special Education settings (whether segregated or inclusive) have become complex systems in which professionals from different disciplines are required to act in coordination [8].

Obviously, RSTs working in schools can face ethically compromising situations [9]. Indeed many dilemmas in special education include an ethical component, implicating professional practice. An ethical decision-making model has the potential for processing dilemmas more completely and for creating better decisions for their resolution [10]. The impact of the institutional environment and cultural dimensions of practice on ethical reasoning has to be addressed [11]. Undoubtedly, the delivery of therapy- related services in an educational setting can potentially raise ethical dilemmas. Yet, little is known about the actual ethical dilemmas and challenges that health RSTs actually face.

The question arises as to what are the actual ethical violations and dilemmas that RSTs experience in educational settings. Some educational ethical dilemmas, such as placement of students are described in the literature [5]. Differences in legislation, funding and culture require caution in applying findings from other countries to local practice. Therefore local research is required to adapt knowledge to the needs of daily practice of therapists in varying educational environments [6].

The purpose of the present study is to examine the ethical violations and dilemmas experience by OTs, PTs, SLPs and EATs in educational settings. The research question is what are the ethical dilemmas and violations that RSTs experience when in educational settings?

Participants

Participants were 16 RSTs (six OTs, eight SLPs, and two EATs) working in the special education system in Israel. No PTs participated in the study.

The Israeli Ministry of Education holds annual training courses for RSTs from the health professions (OT, PT, SLP), and EAT working in the education system. The aim of the course is to provide therapists with knowledge about the uniqueness of their work in the education system and the way that the education system functions.

This course accepts candidates who have completed at least one year of work in educational settings [12]. All participants in the present study studied in a training course for health professionals and expressive-arts therapists under the auspices of the Ministry of Education at the Orot Israel College of Education.

This course accepts candidates who have completed at least one year of work in educational settings [12]. All participants in the present study studied in a training course for health professionals and expressive-arts therapists under the auspices of the Ministry of Education at the Orot Israel College of Education.

Study design

As part of the training course, participants had to refer in writing to ethical dilemmas and violations they experienced in delivering services for students with disabilities in educational settings. They were required to relate to the specific code of ethics of their own professions. After completing the task, participants were contacted via e-mail to authorize the inclusion of their reports in the study. Out of 24 students who submitted papers, 16 approved participation in the study.

Data collection in qualitative research includes varying sources, including objects that individuals make and use. Among them are personal reports, such as the ones used in the present study [13].

Data analysis

Qualitative research methodology (content analysis) was employed. This involves the systematic reading of texts in documents to indicate the presence of meaningful pieces of content [14]. The goal of the current analysis was to document patterns of participants experience of ethical dilemmas and violations arising in the educational system.

Data analysis was performed by the researchers. In the initial analysis, each author performed within-case analysis in order to derive key elements that were present in individual experiences. In the next step each investigator implemented a cross-case analysis, comparing these elements to identify commonalities [15]. An ongoing discussion took place between authors in order to reach agreement on main themes.

Consolidated data for reporting qualitative research was used [16], in order to ensure that study design, data collection, and data analysis complied with standards of qualitative studies. The criterion used included 32 items that described the methodological variables relating to research team and reflexivity, study design and data analysis and reporting.

Content analysis yielded five themes related to participants’ service delivery and role within the educational system: a) inconsistency between students’ needs and students’ placement; b) adherence to procedures; c) distortion of diagnosis; d) defaults and unethical demands in the educational setting; and e) the relationship with patients. Three categories were identified in the last theme. Description of each theme will draw upon quotes from participants.

Inconsistency between students’ needs and students’ placement

Participants described the need to deliver services to students that from their professional perception were not placed in an appropriate educational setting. In cases described participants noted that the students’ function was too low for the setting, and they thought that will negatively affect the habilitation of these children. In the cases described by participants, parents of children refused to move them to a different educational setting, or denied the actual functional condition of their child.

Participants presented the dilemma of delivering services to children that were not gaining adequate outcomes as consequence of inappropriate placement. They were aware of the rights of the parents to choose the placement of their child, but they stated this dilemma violated the ethical principle of their responsibility to uphold the welfare of individuals they serve professionally. This is how Moriya described it:

I treat a child with ASD (i.e: Autistic Syndrome Disorder) who studies in a regular kindergarten with personal related therapy services. The child is quiet and calm so other parents in the kindergarten do not oppose his presence. Nevertheless, since the child is quiet, he disappears and is transparent in the kindergarten. Less work is done with him on the communicational disability as would have been the case in a kindergarten for children with ASD. The parents refuse to send the child to a special education kindergarten claiming that there is a mistake in the diagnosis… The parents have the right to decide where their child will learn. On the other hand there is the value of preventing harm to the child…”

to a child that is not placed in a suitable educational setting as an ethical dilemma. They thought the child was not receiving proper intervention. These dilemmas were not resolved.

Adherence to procedures

Participants did not adhere to procedures due to lack of knowledge or difficulty in their maintenance. When they knew the procedures, but could not fulfill them, they were faced with conflicts they viewed as ethical dilemmas. This is how Anais described it:

During my work at school I take patients with their friends in order to work on social skills. Part of the procedure is to ask for general permission of the parents in the class…Unfortunately the principal did not send the consent form to the parents and therefore it is not possible to take children out of class. This is a very important and meaningful part of the intervention…I could ask the principal again, but it did not work out…Since I did not succeed through direct action, I turned to the second option – taking children out of lessons without explicit approval. I consulted with the teacher, and also with the OT, who takes patients out without consent and without feeling badly about it”.

From the point of view of participants such a situation poses a conflict between delivering the best service for patients on the one hand and compliance with elements in the professional code of ethics such as informed consent and confidentiality of patients, on the other hand..

In addition, participants described dilemmas that involved conflict between requirements of the educational system and personal circumstances. For instance, Elisheva described working in several educational settings, requiring mobility between schools and kindergartens, when in some cases she had only one patient at a certain place. Given her limited time constraints, she faced the dilemma of whether to be present at the various venues despite the limited patients allocated to her which made for greater work efficiency on the one hand but impaired her integrity on the other. Other participants described conflicts between commitment to performing all tasks and personal circumstances. This is how Mirit described her personal conflict:

Since this is my second year as an OT…and I am a mother to three young children I am faced with a constant dilemma – how much to invest…efforts in professionalism compared with keeping my strength, joy of life, and balance between work to my private life.

Distortion of diagnosis

Participants noted that either parents or educators required them to write reports that reflect a lower functional status of the child instead of the actual state of function. Parents required such reports in order to gain higher degrees of service entitlement for children for services, either within the educational system or through health insurance services. Educators required such reports in order to convince parents that their child was in need of intensive habilitation. This is how Nira described it:

At the beginning of the year I performed an evaluation of a child (using informal assessment tools, so that there was no precise score) and it was my impression that he functioned at a certain level. When the teacher asked me to add my professional opinion…I wrote my opinion. Afterwards the teacher turned to me and said that it would be advisable to describe his function as lower than in reality since his parents were convinced that he had severe language disabilities. In in order for him to qualify for therapy through health insurance, our recommendation would have to describe his difficulties as significant.

In sum, participants were asked to write professional reports that did not reflect the actual abilities of children for the purpose of qualifying for treatment. They viewed such request as immoral.

Defaults and unethical demands in the educational setting

Participants noted ethical violations and dilemmas that arose from actions of members of the multidisciplinary team or the educational system in which they operated. For instance, Michal, an OT, was asked by the kindergarten teacher to replace the EAT who was on maternity leave. She was asked to incorporate art in her therapy, to emphasize self expression of the children instead of graph-motoric skills.

Another ethical violation was presented by EATs. For them the protection of clients’ artwork is a core part of the ethical code. Technical reasons caused violation of storage of artwork in educational settings by a third party. This is how Tali described the violation of storage of her clients’ artwork in school:

As an EAT one of the first things I ask for in the therapy room is a closet with a lock for the safe keeping of the patients’ artwork. In one of the educational settings in which I worked there was a therapy room with a…closet for storing artworks. After a few months of work, a fire broke out in the room next to the therapy room…the therapy room had to be renovated. The maintenance man moved the equipment to another classroom…When I arrived at the new classroom I discovered that the artwork of my patients had been scattered and mixed-up. That day I canceled the therapy sessions and dedicated the time to reorganizing the room and restoring the order of the artwork in order to maintain an optimal therapeutic setting.

In sum, participants were faced to deal with request for unethical practice or violation of their code of ethics due to actions of other staff members in the educational setting.

The relationship with patients

Participants indicated ethical dilemmas that arose from their actual interaction with their patients in educational settings. Three categories emerged from this theme: retaining patients’ privacy, ethical dilemmas concerning conduct with the patient and contact with patients outside the educational setting.

Retaining patients’ privacy

Participants described situations where the privacy of children in therapy was violated due to the fact that the educational setting exposes the therapy to staff members and to other students. Moriya expressed her feelings about this issue as follows:

It is very hard to ensure privacy related to the fact the child is receiving therapy. We come to the classroom to call the child. All of his friends know that he is receiving therapy. At the beginning of the year I ask older children

…if they want me to pick them up from the classroom or if they prefer to come by themselves. I don’t start a conversation with a child in the corridor unless he initiates it.

Ethical dilemmas concerning conduct with the patient

The participants described dilemmas that involved actions that may undermine a patient or violate patients’ autonomy. Mirit described a situation involving an ethical dilemma from her point of view:

I witnessed severe outbursts in which it seemed that there was no choice but to physically hold the…child in such a way that he wouldn’t harm other children, but it seemed that he himself was in distress.

This is what Elisheva wrote regarding violating a patient’s autonomy:

I arrived at the kindergarten especially for the purpose of delivering therapy to a child…and he refused to participate. I tried to recruit him for therapy by means of an interesting activity or a promise of a reinforcement surprise at the end of the session… In order to do my duty and administer the therapy to which he is entitled, I presented to him the fact that the therapy session was taking place and that he had to participate…even though this violates the autonomy of the patient.

Contact with patients outside the educational setting

Most participants in the present study lived in rural areas. Some of them described meeting their patients in their neighborhood while trying not to violate medical confidentiality. Others found themselves delivering related therapy services to children of friends or neighbors. Tali described the dilemma she faced:

At one the school settings…I received a list of candidates for therapy. I was familiar with one of the girls from the place where I live. I knew that professionally it was not correct for me to treat the child since I am friendly with her parents. I shared the dilemma with the girl’s teacher. While she understood the conflict she said that the child needed therapy…

Another issue was professional interference with patients from educational institutions after school hours or after retiring from the school system. This is how Gal described it:

Many colleagues of mine are EATs in publicly-funded special education settings. I met…therapists who also do private work in parallel with children from the education system.

In sum, participants indicated different ethical dilemmas that arose from their relations with patients in educational settings, including violating privacy and autonomy of patients, concerns relating to prior acquaintance with the child’s family, and the delivery of services privately to students outside the educational setting as well as during school hours.

Therapeutic disciplines and professions have specific ethical codes. These ethical standards relate to the relationship between therapists and their clients and to relationships between therapists and their professional community [2].

Codes of ethics provide a framework for ethical behavior. They do not offer specific guidelines for individual instances of practice nor do they shed light upon moral dilemmas professionals must content in practice. Therapists in the education system demonstrate a unique service delivery model [17]. The question arises as to what ethical violations and dilemmas do related services providers experience in educational settings. Thus, the purpose of the present study is to examine these predicaments. The research question was which ethical dilemmas and violations related services providers depict in providing services in educational settings. In order to answer the research questions, a content analysis was performed on written reports of OTs and SLPs who participated in a training course for health professionals on behalf of the Israeli Ministry of Education. The main themes that emerged related to the inconsistency between students’ needs and students’ placement, adherence to procedures, distortion of diagnosis, cutting corners in the face of circumstances, defaults and unethical demands in the educational setting and the relationship with the patients.

Participants described dilemmas concerning delivering the best service to children that, from their professional point of view, were not placed in educational settings commensurate with their level of function. This finding is consistent with findings reported in the literature regarding appropriateness of educational settings for children with disabilities [18], especially in rural areas [5].

In the present study participants stated that parents were responsible for placement of their children in settings that were not appropriate for their (low) functional level. They felt responsibility for the well-being of their patients but were faced with an ethical dilemma concerning a conflict between their professional values and the parents’ values. Government regulations require placement of children with disabilities in the appropriate least restrictive environment and parents have the right to challenge these placement decisions. Nevertheless, this issue raises awareness of possible conflicts between regulations and ethical principles of professional practice. The educational system is required by law to accommodate shared decisionmaking by parents of children receiving special education and school personnel when determining appropriate programs and related services. Disagreements between parents and school personnel may occur [19] leading to conflicts between competing values represented by different opinions of individuals.

Participants described dilemmas concerning adherence to procedures in the educational setting. In some cases they were not aware of procedures. Once they found out that they had violated a certain procedure they experienced a violation of professional ethics. In other cases the system did not cooperate with professional procedures causing RSTs to experience an inner conflict between competing ethical principles. To the best of our knowledge such ethical references have not yet been described in the literature. The literature relates to challenges facing RSTs in educational settings, such as logistical barriers and the need for flexibility in providing services [6]. Studies conclude that therapists should be aware of a different service delivery model in the education system [17]. Researchers also point out that reform of programs that train therapists is needed to prepare them for work in educational settings [20]. Describing ethical violations and dilemmas as a cause of violation of procedures in the education system adds to the knowledge of complexity of service delivery in educational settings.

In this context participants described dilemmas that involved conflict between requirements of the educational system and personal circumstances. These conflicts violated their integrity and commitment to optimal service delivery. Perhaps this type of ethical dilemma reflects the unique environment of the special education system, such as delivering services in multiple settings. Previous studies concluded that therapists should be aware of the necessity for a different service delivery model in the education system [17]. Dilemmas presented in the current study emphasize the need to adhere to the special characteristics of RSTs in education settings. In this respect, research reports that younger and less experienced clinicians with specialized training and with lower role overload, reported engaging in a higher quality of care of students within special education [21]. The current study supports the findings regarding the relationship between quality of service and lower role overload. Our findings do not support results regarding younger therapists administering greater qualitative care of students. Most of the participants in the current study were young but they were also mothers to more than one young child. Perhaps the profile of therapists in Israel differs to that of therapists in other western countries in that young therapists are also young mothers. This dual role poses ethical dilemmas in service delivery in the presence of their family obligations.

Requirement for distortion of diagnosis, either by parents or teachers, was mentioned by several participants. Obviously such demands pose clear violations of professional ethical principles, such as integrity, responsibility and accountability. They represent conflicts between competing values represented by different opinions of individuals. They might also generate inner conflicts, when therapists are aware that children might benefit from reports describing lower functional state than actually exists. Ethical codes do not offer specific guidelines for dealing with these kind of moral dilemmas faced by therapists.

Participants noted ethical violations and dilemmas arising from actions of members of the multidisciplinary team in the educational system. One example was a request that an OT will replace the EAT who was on maternity leave. She was asked to use arts in her therapy, but to emphasize self expression of the children instead of grapho-motoric skills. Cases in which staff members at educational settings delivered services in other professional fields have been described in the literature [5]. Such practices in the educational system violate the professional integrity of therapists.

Participants indicated ethical dilemmas that arose from their interaction with their patients in educational settings. Three categories emerged within this theme: retaining patients’ privacy, ethical dilemmas concerning conduct with the patient, and contact with patients outside the educational setting. Participants indicated different ethical dilemmas resulting from their relations with patients in educational settings, including violating privacy and autonomy of patients, concerns with former acquaintance with the child’s family, and delivering services privately to students outside the educational setting as well as during school hours. While former acquaintance with patients and the private delivery of services outside the system can be justified in different rehabilitation systems, it seems that privacy and autonomy of patients is easily violated in educational settings. When parents take their child to a certain therapist operating in the local community their privacy can be maintained. In educational settings all the children and staff members know that the child is receiving therapy. This is especially true when therapists recruit children out of classes. It seems that participants in the present study were engaged in individual service-delivery in the therapy room in the school setting, forcing them to violate the privacy of patients. The need to create an alternative to the traditional model of taking children out of the classroom for individual diagnosis and therapy has been previously reported in the literature (17, 6).

In Israel the preferred model of therapy delivery is an ecological model providing therapy in the child’s natural setting [8]. The work of therapists in the education system is shifting from a traditional medical pull-out service delivery model to a classroom-based model [6]. In line with the medical model, the emerging therapy model involves the withdrawal of children from the classroom to the therapy room.

Delivering related therapy services in the education system according to the ecological model requires assessment, intervention and reinforcement of skills in the natural environment of classrooms and playgrounds [17]. Often the ecological approach is not supported by the general educational staff. The literature reports unresponsiveness on the part of teaching personnel, particularly veteran educators, to implementing therapists’ recommendations and making changes to work outlines [22]. Such gaps have been previously described in the report of the Public Committee for the Examination of the Special Education System in Israel, chaired by (retired) Supreme Court Justice Dalia Dorner, in its reference to special education schools [8]. The report noted that special education schools have become complex systems, absorbing employees from different disciplines, who are required to act in coordination. The prominent problem in the context of the required coordination arises in view of the differences between different professionals. These differences stem from professionals’ different position in the organizational hierarchy, their role, and the contribution expected of them (the Israeli Ministry of Education, 2009). The privacy of patients could be enhanced if therapists and educational systems jointly implemented an ecological model of related services delivery.

The current study involved mainly junior therapists at the onset of their careers in the educational system. Thus findings can not be generalized to the entire population of therapists in educational settings.

OTs PTs and EATs reports all were infused in this research paper, without relating to each profession separately. Therefore, the general conclusions may not apply in the same manner to all of the therapy fields.

This study did not differentiate between various educational frameworks and the professional training of the teachers involved, whether general or special education. The therapists did not indicate these details in their reports. Seemingly, this background information may be of some importance, while drawing conclusions and working towards minimizing professional ethical dilemmas of the therapists

The current study highlights ethical dilemmas therapists experience in educational settings. The way therapists deal with these dilemmas is unknown. It is recommended that future studies examine the way such dilemmas are addressed.

The current study highlights specific ethical aspects of delivering related services in the educational system by OTs, PTs, SLPs and EATs. Further research is needed in order to bridge the gap between framework for ethical behavior and actual practice in specific situations in the field.

1. Kummer AW, Turner J. Ethics in the practice of speech-language pathology in health care settings. Sem Speech & Language. 2011; 32: 330-337.

2. Berger R. Developing an ethical code for the growing nature therapy profession. Australian J Outer Education. 2008; 12: 47-52.

3. Whalley Hammell K. Client-centered practice: ethcal obligation or professional obfuscation? British J Occupational Therapy. 2007; 70: 264-266.

4. Chabon s, Brown JE, Gildersleeve-Neumann C. Ethics, equity, and English- learners: A decision-making framework. The ASHA Leader. 2010; 15.

5. Berkely TR, Ludlow BL. Ethical dilemmas in rural special education: A call for a conversation about the ethics of practice. Rural Special Education Quarterly. 2008; 27: 3-6.

6. Tracy-Bronson CP, Causton JN, MacLead KM. Everybody had the right to be here: Perspectives of related service therapists. Int J Whole Schooling. 2019; 15: 132-174.

7. Israeli Ministry of Education. The Special Education Law 5758. Jerusalem, Israel. 1988. (In Hebrew).

8. Israeli Ministry of Education. The Public Committee for the Examination of the Special Education System in Israel. Accountability. Jerusalem, Israel. 2009. (In Hebrew).

9. Wiechmann J. Ethical issues of working in special education. Perspectives. 2022; 7: 13-17.

10.Power-deFur L. Ethical challenges in special education? An approach for resolution. Perspectives. 2022; 7: 1-5.

11.Carpenter C, Richardson B. Ethics knowledge in physical therapy: a narrative review of the literature since 2000. Physical Therapy Reviews. 2008; 13: 366- 374.

12.Israeli Ministry of Education. Calls for a training course for educational staff from the health professions in the education system for the year 2009/10. Jerusalem, Israel. 2018. (In Hebrew).

13.Damico JS, Simmons-Mackie N. Qualitative research and speech language pathology. Am J Speech-Language Pathology. 2003; 12: 131- 143.

14.Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P, editor. Handbook of research methods in health social sciences. Singapore: Springer. 2019; 843-860.

15.Ayres L, Kavanaugh K, Knafl KA. Within-case and across-case approaches to qualitative data analysis. Qualitative Health Res. 2003; 13: 871-883.

16.Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19: 349-357.

17.Hasselbusch A, Penman M. Working together: An occupational therapy perspective on collaborative consultation. Kairaranga. 2008; 9: 24-31.

18.Oluwole JO. A principal’s dilemma: full inclusion or student’s best interest? J Cases in Educational Leadership. 2009; 12: 12-25.

19.Leiter V, Wyngaarden Krauss M. Claims, barriers, and satisfaction: parents’ request for additional special education services. J Disability Policy Studies. 2004; 15: 135-146.

20.Elledge D, Hasselbeck E, Hobek A, Combs S. Perspectives on preparing graduate students to provide educationally relevant services in schools. Perspectives on School-Based Issues. 2010; 11: 40-49.

21.DeCarlo Santiago C, Kataoka SH, Forness SR, Miranda J. Mental health services in special education: An analysis of quality of care. Children & Schools. 2014; 36: 175-182.

22.Bose P, Hinojosa J. Reported experiences from occupational therapists interacting with teachers in inclusive early childhood classrooms. Am J Occup Ther. 2008; 62: 289-297.