A quantitative analysis of client and service data from a PAIR program. (Analysis of Client Service).

It is estimated that 43 million Americans have one or more physical or mental disabilities (Americans with Disabilities Act of 1990; Brown, 1995). Individuals with disabilities have historically confronted discrimination in all facets of their lives (Chism & Satcher, 1997; Mikochik, 1991; Pfeiffer, 1994; Taylor, Kagay, & Leichenko, 1986), and this discrimination continues to be a serious and pandemic problem (Americans with Disabilities Act of 1990; Brown, 1995; Bryan, 1996). The Protection and Advocacy of Individual Rights (PAIR) program strives to improve the quality of life for persons with disabilities through providing legally-based advocacy services that address:

1. allegations of abuse or neglect of persons with disabilities; or

2. violations of rights guaranteed to persons with disabilities; or

3. discrimination based on disability (Advocacy Training/ Technical Assistance Center [ATTAC], 1998).

The PAIR program operates nationally within a social or minority paradigm in which disability is conceptualized as a social construct (Hahn, 1993; Mackelprang & Salsgiver, 1999; Siegel & Sleeter, 1991). Within this paradigm, the limitations of disability result from society's denotation of disability rather than any visceral characteristic of disability (Mackelprang & Salsgiver, 1999; Siegel & Sleeter, 1991). Thus, program interventions are not directed toward persons with disabilities, but toward society's majority (i.e., persons without disabilities) who conceive and maintain the definition (Mackelprang & Salsgiver, 1999). In other words, the majority's attitudes and structures are perceived as responsible for many of the barriers to integration faced by persons with disabilities (Hahn, 1993). Consistent with the recommendation of Brzuzy (1997), the PAIR program works to mediate these barriers in an effort to ensure that persons with disabilities have equal access and opportunity in the economic, political, social, cultural, and educational mainstream of American society.

PAIR provides a number of services on behalf of persons with disabilities in each state. These include individual representation, education of policy makers, advocacy for groups, information and referral services, rights education, and self-advocacy training (Gross, 1998; U.S. Department of Education, 1996). Westat (1999) reported that other than unpublished program performance reports, scant quantitative data are available on PAIR programs. Therefore, the purpose of the present study was to examine empirical client and service data from a PAIR program in a southern state.

Background

The Rehabilitation Act of 1973 was amended by Congress in 1978 to create a Protection and Advocacy (P&A) program at the state level. This program, Protection and Advocacy of Individual Rights (PAIR), was initially funded as a discretionary grant program in 1991 (Westat, 1999). Passage of this legislation was followed in 1992 by amendments which significantly modified the program and called for PAIR funds to be allocated based on a mandatory formula. PAIR then became a formula grant program in 1994 (Westat, 1999) and, as authorized under Title V, section 509 of the 1992 Amendments to the Rehabilitation Act of 1973, was designed to protect the legal and human rights of eligible individuals with disabilities. PAIR grants support most of the Protection and Advocacy (P&A) work aimed at securing rights conferred under the 1988 Amendments to the Fair Housing Act of 1968 and the Americans with Disabilities Act (ADA) of 1990 (Gross, 1998). The goal of such Protection and Advocacy services is to reduce barriers to integration faced by persons with disabilities. The PAIR program is statutorily structured to serve individuals with disabilities who:

1. are ineligible for P&A services provided under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 1975;

2. are ineligible for P&A services provided under the Protection and Advocacy for Mentally Ill Individuals Act of 1986; and

3. need P&A services that are beyond the scope and authority of those provided by the Client Assistance Program (CAP) under Section 732 of the Rehabilitation Act of 1973 (Westat, 1999).

Prior to the advent of PAIR, many individuals with disabilities did not have access to P&A services due to the narrow eligibility requirements of the programs comprising the P&A system. Persons with physical disabilities, head injuries, and significant learning disabilities, as well as those with mental illness who resided in the community, often met the preceding criteria and therefore did not qualify for P&A services. PAIR filled the eligibility gap in the P&A system through the provision of services designed to enable these individuals to participate freely in community life.

Federal statutes require that PAIR be a part of the P&A system in each state (Westat, 1999). The P&A system additionally includes the Protection and Advocacy for Developmental Disabilities (PADD) program, the Protection and Advocacy for Individuals with Mental Illness (PAIMI) program, the Protection and Advocacy for Assistive Technology (PAAT) program, and, in some states, the Client Assistance Program (CAP) (Westat, 1999). Together, these programs constitute the source for the greatest provision of legally-based advocacy services to individuals with disabilities in the United States (Gross, 1998). While the PAIR program is funded at a much lower level than the PADD and PAIMI programs, it is an exceptionally important element of a broad effort to advocate for the rights of individuals with disabilities because it is the only component of the P&A system available to persons with disabilities, other than those with developmental disabilities or mental illness, to protect and enforce their rights under the ADA, the Fair Housing Act, and other disability rights laws (Gross, 1998).

The Rehabilitation Services Administration (RSA), authorized by Congress to carry out specified portions of Title V, Section 509 of the Rehabilitation Act of 1973, funds 56 PAIR programs. In addition to the 50 states, the District of Columbia, Puerto Rico, Guam, American Samoa, the Virgin Islands, and the Northern Mariana Islands each have their own PAIR program (Westat, 1999). Title V, Section 509(f) of the Rehabilitation Act of 1973, requires PAIR programs to:

1. establish a system to protect and advocate for the rights of persons with disabilities;

2. pursue legal, administrative, and other appropriate remedies or approaches to ensure the protection of, and advocacy for, the rights of eligible individuals with disabilities within State;

3. provide information on and making referrals to programs and services addressing the needs of individuals with disabilities within the State;

4. coordinate the protection and advocacy program with the advocacy programs under CAP, the State long-term care ombudsman program, the PADD program, and the PAIMI program;

5. develop annually a statement of objectives and priorities and a plan for them;

6. provide to the public an opportunity to comment on the objectives and priorities; and

7. establish a grievance procedure for clients or prospective clients of the program to ensure that they are afforded equal access to its services (Westat, 1999).

In summary, the PAIR program's focus is the protection of the human, legal, and civil rights of persons with disabilities in areas such as access to programs and buildings, housing, employment, education, and transportation. PAIR serves individuals with disabilities who are not eligible for the Client Assistance Program or the P&A programs for persons with developmental disabilities or mental illness. Persons eligible for PAIR services include those with spinal cord or head injuries, sensory impairments, multiple sclerosis, HIV infection and AIDS, psychiatric conditions that do not require 24-hour treatment, cancer, mobility impairments, and learning disabilities (Gross, 1998). The goal of such services is to promote individual choice, self-determination, and the maximum integration of these individuals into all aspects of community life.

Purpose and Hypotheses

This research examined empirical client and service data from a PAIR program in a southern state. Specifically, the primary research question was: "What are the characteristics, problem/sub-problem areas, and case outcomes of clients served by the PAIR program?" It was predicted that client disability as well as problem and sub-problem areas would vary greatly because PAIR is designed to serve the largest number of individuals with disabilities within the P&A system (National Association of Protection and Advocacy Systems [NAPAS], 1997). For purposes of this study, an unsuccessful case resolution was an outcome that did not result in an improved quality of life for a person with disabilities. It was also predicted that substantially more client cases would be resolved successfully than would be resolved unsuccessfully. This prediction was based on the assumption that, in general, PAIR program involvement often leads to successful and valued outcomes for persons with disabilities.

A second question was: "What are the PAIR methods for resolving cases?" It was predicted that the intervention strategies would vary greatly due to the predicted nonuniformity of client problem areas. A tertiary question was: "What, if any, is the association between case outcome, client age, and the service variables of PAIR attendance at a client meeting (meaning, for the purposes of this study, a meeting between the client and a third party), number of client meetings attended by PAIR staff in each case, PAIR telephone call(s) on a client's behalf, and PAIR correspondence on a client's behalf?" It was predicted that there would be a significant positive correlation between PAIR staff attendance at a client meeting and successful case outcome due to previous research supporting the efficacy of fieldwork interventions on behalf of persons with disabilities (Barr-Mazzuca, Farris, Mendenhall, & Stoupa, 1997; Brantner, 1992; Left, 1982). It was also predicted that there would be a significant negative correlation between client age and PAIR staff attendance at a client meeting due to federal laws requiring service meetings on behalf of children with disabilities (Individuals with Disabilities Education Act of 1975). By answering these questions and testing these hypotheses, it is hoped that PAIR service and research will be enhanced.

Method

Data Collection

The sample for this study consisted of all the client cases closed (N = 58) by this selected PAIR program during fiscal year 2000 (October 1999-September 2000). A closed case was a successfully or unsuccessfully resolved matter in which a service of more than two hours was provided by PAIR staff which was designed to benefit one or more individuals with disabilities. The study utilized data obtained from the individual client closure reports found on the Disability Advocacy Database (DAD) for the state. The database is a comprehensive, standardized system of statistical reporting on the complete advocacy process for every individual coming into contact with the state P&A agency, from first referral to final closure (National Association of Protection and Advocacy' Systems [NAPAS], 2000). Client anonymity was assured because the research methods did not allow the clients' names to be linked to their advocacy data. The study employed a combination descriptive and correlation research design (Pedhazur & Schmelkin, 1991). The sample size (N = 58) was deemed appropriate for the chosen design, following the procedure outlined by Gay (1995).

Of the 58 sampled clients, 20 or 34.5% were African American individuals, 37 or 63.8% were European American individuals, and 1 or 1.7% was identified as Pacific Islander. The gender breakdown was 35 or 60.3% male and 23 or 39.7% female. With respect to the geographic location of clients, 20 or 34.5% of the clients lived in rural areas (i.e., population less than 50,000), and 38 or 65.5% of the clients lived in urban areas. Ages of the clients ranged from five to 56 years of age (M = 20.45, SD = 13.96).

Data Analysis

The 58 selected cases were examined and recorded to reflect the primary disability and problem/sub-problem areas of the clients served. Problem and sub-problem areas were operationally defined as areas in which obstacles were present that blocked or stood in the way of the attainment of desired outcomes that would result in an improved quality of life for persons with disabilities. The cases were also analyzed and coded dichotomously on the nominal scale to reflect the case outcome (1 = unsuccessful; 2 = successful). For the purposes of this study, the case outcome, whether successful or unsuccessful, consisted of the particular PAIR staff member's concluding evaluation as reflected on the DAD. For each case under consideration, the most labor intensive PAIR intervention strategy was examined, coded on the nominal scale, and broken down into seven levels: 1 = legal remedies, 2 = administrative remedies, 3 = negotiation/mediation, 4 = abuse/neglect investigation, 5 = informal resolution, 6 = short-term assistance, and 7 = technical assistance.

Legal remedies consisted of legal representation on behalf of clients in litigation processes concerned with rights, grievances, or appeals of such rights or grievances (National Association of Protection and Advocacy Systems [NAPAS], 2000). Administrative remedies represented the use of any systems for formal appeal within an agency or facility which did not involve adjudication by a court of law (NAPAS, 2000). Negotiation/mediation was operationally defined as formal intercession with another party to a dispute involving a PAIR client in an attempt to resolve the dispute without resorting to litigation. Abuse/neglect investigation was defined as "a systemic and thorough examination of information, records, evidence, and circumstances surrounding an allegation of abuse and neglect" (NAPAS, 2000, p. 24). Abuse/neglect investigations required a significant amount of time and constituted the interviewing of witnesses, the gathering of evidence, and the provision of a written report. Informal resolution consisted of non-legal intervention by PAIR staff to assist the client in resolving problems with service delivery staff or other agency representatives (NAPAS, 2000). Short-term assistance, as defined by NAPAS (2000), was "time limited advice and counseling assistance that included reviewing information, counseling a client on actions one may take, and assisting the client in preparing letters, documents, or making telephone calls to resolve the issue" (p. 27). For purposes of this study, short-term assistance also included PAIR staff attendance at a client meeting. Lastly, technical assistance constituted the provision of information, referral, or advice to a client by PAIR staff (NAPAS, 2000).

The service variables of PAIR attendance at a client meeting, PAIR telephone call(s) on a client's behalf, and PAIR correspondence on a client's behalf were nominal and dichotomous with two levels (1 = no; 2 = yes). According to Stockburger (1996), correlation coefficients computed on this type of data can be safely interpreted because the interval property is assumed to be met for these variables. Because the interval property was assumed to be met for meeting attendance, number of meetings attended, telephone call, correspondence, client age, and case outcome, bivariate correlations as well as descriptive statistics (e.g., frequency distributions and percentages) were used to analyze the data within the descriptive and correlation research design. In addition, a chi-square analysis was used to test the validity of one result. In order to establish maximal control for internal validity, the researcher selected only those cases in which a PAIR staff member attended a client meeting (n=30) in order to evaluate the relationship between number of client meetings attended and case outcome. Due to the size of the data set (N = 58), a significance level of .05 was used. The Statistical Package for the Social Sciences, descriptive and correlation procedures (SPSS, 1995), was employed in these calculations.

Results

The results answered the research questions and supported the hypotheses. The primary disability for each client varied greatly. Nearly half (26 or 44.8%) the clients had emotional/behavioral disorders, 8 or 13.8% had a mental illness, 5 or 8.6% had learning disabilities, 5 or 8.6% had mental retardation, 5 or 8.6% had a physical/orthopedic impairment, 4 or 6.9% had Attention Deficit Hyperactivity Disorder (ADHD), 2 or 3.4% had hearing impairments, 1 or 1.7% had abused substances, 1 or 1.7% had genitourinary conditions, and 1 or 1.7% had deafness. A descriptive analysis revealed nonuniformity in the problem and sub-problem areas of the clients served (see Tables 1 and 2). The largest numbers of clients experienced problems in the areas of abuse/neglect (36.2%) and education (31%). Within these broad problem areas, clients experienced a number of more specific problems identified in the sub-problem areas. For instance, within the problem area of education, clients experienced sub-problems that included Individualized Education Program (IEP) development, higher education accommodations, Free Appropriate Public Education (FAPE) access, and inappropriate discipline of students with disabilities. The sub-problem areas were more evenly distributed than the problem areas, with the largest numbers of clients experiencing sub-problems in the areas of abuse/neglect (24.1%), access to appropriate services (17.2%), and inappropriate discipline of students with disabilities (13.8%).

With regard to case outcomes, 45 or 77.6% of the cases were closed successfully, whereas only 13 or 22.4% were closed unsuccessfully. Common reasons for unsuccessful case closure included client disengagement, no client right to action in light of federal regulations, issues falling outside PAIR priorities, ineligibility for services, non-meritorious claim, and services no longer needed (i.e., death not associated with problem area or relocation). The intervention strategies utilized by PAIR in the cases under consideration also varied greatly. PAIR staff used assistance as an intervention strategy in 37 or 63.8% of the cases, negotiation/mediation in 10 or 17.2% of the cases, informal resolution in 5 or 8.6% of the cases, technical assistance in 3 or 5.2% of the cases, abuse/neglect investigation in 2 or 3.4% of the cases, and legal remedies in 1 or 1.7% of the cases, Administrative remedies were not utilized as an intervention strategy in any of the cases.

PAIR staff attended client meetings in 30 or 51% of the cases under consideration. The number of client meetings attended by PAIR staff in these 30 cases totaled 50 and ranged from one to four (M = 1.67, SD = .96). PAIR staff attended one client meeting in the majority (18 or 60%) of the cases, two client meetings in 6 or 20% of the cases, three client meetings in 4 or 13.3% of the cases, and four client meetings in 2 or 6.7% of the cases.

According to Heppner, Kivlighan, and Wampold (1999), process has traditionally been connected to outcome using a correlation strategy. Consistent with this approach, two-tailed correlations for case outcome and the PAIR service variables of meeting attendance, number of meetings attended, telephone call(s), and correspondence are presented in Table 3. The relationships were primarily small (Schloss & Smith, 1999) and non-significant with the exception of meeting attendance and case outcome. The correlation for these two variables was positive and significant (p = .000) with meeting attendance accounting for 22% of the variance associated with case outcome. In other words, clients who had a PAIR staff member attend a meeting on their behalf were significantly more likely to .achieve successful case closure than clients who did not.

A bivariate correlation for client age and meeting attendance yielded a coefficient of -.38. The inverse relationship was significant (p = .004) with client age accounting for 14% of the variance in meeting attendance. That is, younger clients were significantly more likely to have a PAIR staff member attend a meeting on their behalf than were older clients.

Discussion

The results of the current study indicated that the selected PAIR program served individuals with varying types of disabilities; however, nearly 45% of the individuals served had emotional and/or behavioral disorders. This high percentage was explained by the fact that this particular PAIR program, through a class action lawsuit, advocated on behalf of a group of children with emotional and/or behavioral disorders who were in the state's child welfare system (Bazelon Center for Mental Health Law, 1998). Mental illness was also a major disabling condition in a number (13.8%) of the PAIR cases under consideration. Since the PAIMI program advocates only on behalf of those individuals who live in or who have recently been released from institutions (Westat, 1999), this PAIR program served the remaining individuals with mental illness who had established residences in the community. Clients with learning disabilities, heating impairments, physical/orthopedic impairments, ADHD, substance abuse, genitourinary conditions, and deafness were also served by this PAIR program because these disabling conditions would not typically meet the definition of "developmental disability" as defined by the Developmental Disabilities Assistance and Bill of Rights Act of 1975. Due to the fact that PAIR is not required to represent individuals who are eligible for the PADD program (Westat, 1999), it was interesting to note that individuals who had mental retardation were also served by PAIR. It was likely that these individuals were provided services because their disability was not severe enough in order for them to qualify for PADD assistance. In addition, these individuals were probably experiencing problems in an area that was within PAIR's scope and authority.

A great deal of variability was found with respect to the problem and sub-problem areas of the clients served. Of the cases sampled, abuse/neglect was the most prevalent problem (36.2%) and sub-problem (24.1%) area. This result was consistent with previous research which indicated that P&A agencies play a major role in abuse and neglect prevention despite few staff members and limited resources (Zuckerman, 1986). It can be inferred from the data concerning case outcomes (i.e., almost 78% successful) that this PAIR program was effective in its advocacy on behalf of persons with disabilities. Short-term assistance was the most often utilized intervention strategy (63.8%). Given the assumption that more labor intensive intervention strategies would more likely lead to successful outcomes, these results were surprising. Perhaps this indicates a fear of litigation on the part of other parties to disputes involving PAIR clients or a willingness by these parties to rectify disability discrimination upon the first point of contact with the PAIR program.

The results also contribute to knowledge about PAIR service correlates of client case outcome. Although number of client meetings attended by PAIR staff, PAIR telephone call(s), and PAIR correspondence did not significantly influence client case outcome, PAIR staff attendance at a client meeting was found to be a significant predictor. A reason for this may be that face to face interaction between the PAIR staff member and the other party to a dispute involving a PAIR client was more likely to lead to a valued and successful outcome on behalf of the client. Based on this result, it is recommended that PAIR program staff become actively involved in fieldwork on behalf of their clients with disabilities. This could include attendance and involvement at client treatment team meetings, client special education meetings, or any other type of client meetings with responding parties.

Last, this study found that younger clients were significantly more likely to have a PAIR staff member attend a meeting on their behalf than were older clients. In order to test the validity of this result, the researcher separated the sample into two groups: (1) clients under 18 years of age, and (2) clients 18 years of age or older. Thirty-five or 60.3% of the clients were under 18 years of age, whereas 23 or 39.7% of the clients were 18 years of age or older. This difference was not statistically significant [[X.sup.2](1, N = 58) = 2.48, p = .12], indicating no sample bias toward juvenile clients.

The significant inverse relationship between client age and meeting attendance may be due to the fact that students with disabilities must have, at least annually, an Individualized Education Program (IEP) meeting (Ordover & Boundy, 1991). Additionally, the class of children with emotional and/or behavioral disorders served by this PAIR program were required, by court order, to have Individualized Service Plan (ISP) meetings every six months (Bazelon Center for Mental Health Law, 1998). Much of the work done by this PAIR program consisted of attending these meetings and advocating on behalf of children in the special education and child welfare systems.

As a result of the preceding significant associations (e.g., meeting attendance/case outcome and meeting attendance/client age), data regarding attendance at a client meeting for juveniles (i.e., clients under 18 years of age) were removed from the subsequent analysis. A bivariate correlation for PAIR attendance at a meeting for clients 18 years of age or older (n=23) and case outcome yielded a coefficient of .43 (p = .04). Hence, when juveniles were removed from the analysis, a significant correlation was maintained.

Based on these findings, it is recommended that PAIR staff attend more meetings on behalf of their older clients with disabilities. If a meeting is not mandated by federal law for the older client, PAIR staff may want to contact the other party to a dispute involving the older client and set up a meeting on the older client's behalf. Such meetings may prove effective in facilitating successful case outcomes for older PAIR clients.

The present study was limited in several ways. First, it should be emphasized that the number (N = 58) of closed cases, forming the basis of this research, in no way reflects the entire work product of the particular PAIR program from which the cases were selected. This same PAIR program, for example, handled an additional 108 cases, provided over 800 information and referrals, and conducted 94 outreach/training activities during fiscal year 2000. This extraordinary amount of advocacy activity on behalf of persons with disabilities was not included in the data analysis.

It is likewise important to note that no objective definition of the case outcome variable was established. Rather, the study adopted as the definition of this variable the subjective outcome designation of the particular PAIR staff members as reflected in their closure reports. Furthermore, the study was made up of a small sample of clients from a single PAIR program in one southern state. This limits the applicability of the study. Consequently, researchers are urged to replicate this study using clients served by PAIR programs in other areas of the country. If the results are similar, cross-validation will have occurred which increases the ability of the researcher to generalize (Moore, Flowers, & Taylor, 2000). It is also recommended that future studies examine a larger sample of adult clients. Such research may prove effective in supporting this study's recommendation that PAIR staff attend more meetings on behalf of older clients.

Conclusions

This study, along with the results from Westat's (1999) nine state study, supports a number of conclusions. First, PAIR programs serve individuals with many different types of disabilities and problem/sub-problem areas. Second, PAIR programs are effective in their advocacy efforts and utilize a wide variety of intervention strategies on behalf of their clients with disabilities.

This research also supports two additional conclusions. Firs for this particular PAIR program, PAIR staff attendance at a client meeting had a significant positive influence on client case outcomes. In the context of this particular PAIR program, younger clients were significantly more likely to have a PAIR staff member attend a meeting on their behalf than were older clients. Although meetings with younger clients were most likely the consequence of legal conditions, the results of this study support the second conclusion that meeting attendance benefitted older clients served by this PAIR program as well. As a broad generalization, these conclusions may be helpful to both PAIR programs and the individuals they serve. These findings, however, should be considered within the context of the limitations of the study. Clearly, further research is needed to determine the relationship between PAIR service variables, client age, and client case outcomes.

Table 1
Problem Areas of Clients Served (N=58)

Problem                   Frequency   Percent

Abuse/Neglect                21          36.2

Education                    18          31

Services                     10          17.2

Employment                    3           5.2

Transportation                2           3.4

Housing                       2           3.4

Financial
Entitlements                  1           1.7

Healthcare                    1           1.7

Total                        58         100
Table 2
Sub-Problem Areas of Clients Served (N=58)

Sub-Problem               Frequency   Percent

Abuse/Neglect                14         24.1

Access to
Appropriate Services         10         17.2

Inappropriate Discipline      8         13.8

IEP/IFSP/ISP
Development                   5          8.6

Sexual Assault                3          5.2

Physical Assault              3          5.2

Higher Education
Accommodations                2          3.4

Transportation                2          3.4

Free Appropriate Public
Education (FAPE)              2          3.4

Personal Assistance           2          3.4

Personal Care                 1          1.7

Employment Benefits           1          1.7

Other Financial
Entitlements                  1          1.7

Employment Termination        1          1.7

Architectural Barriers        1          1.7

Employment
Accommodations                1          1.7

Housing
Accommodations                1          1.7

Total                        58        100
Table 3
Correlations for PAIR Service Variables and Case Outcome

Service Variables             Outcome

Attend Meeting                 .47 *

Number of Meetings Attended    .13

Telephone Call                 .13

Letter                         .16

* p<.05, two-tailed.

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David Gamble, M.A., CSESS, ADAP The University of Alabama, Box 870395, Tuscaloosa, Al 35870395