Unconventional occupational therapy assessments

I attended a meeting today in support of a child receiving occupational therapy to develop accommodations to the middle school curriculum. A school-based therapist completed an occupational therapy evaluation and it contained many assessments that are generally appropriate for children of that age. The school based therapist did not believe that the child qualified for occupational therapy.

The child is 12 years old and the evaluation included the Developmental Test of Visual Motor Integration, the Motor Free Visual Perception Test, and portions of the Bruininks-Oseretsky Test. By all of these measures the child was functioning within appropriate developmental parameters. The school OT reported that the child could write legibly, could change for physical education class, and manipulate all school materials functionally.

So why was I recommending accommodations to the middle school curriculum?? It is true that the child had excellent grades and good handwriting - but these were not the real problems. The problem could be found in the child's inability to participate.

My OT evaluation included a review of the child's attendance record. New York State mandates a minimum of 180 days of instruction, and this particular child missed either part or full day of instruction on 52 days, for a total absentee impact of approximately 30%. The child has severe migraine headaches and an underlying seizure disorder. The neurologist believes that triggers for the migraines include eye strain, high contrast visual input, and light.

So as long as the child is not having migraines, participation and performance is excellent. As soon as the child has a migraine, participation and performance plummets. So the problem with the OT evaluation completed by the school therapist is that it was done under non-migraine conditions and was swinging at the wrong issues at the wrong time.

Now I don't advocate testing when a child is having a migraine headache, but in this case the most appropriate assessment tool is the attendance record that clearly shows how this disability impacts the child's abilty to participate in the curriculum. The migraine and seizure disorder are new conditions and certainly the child will be at risk for more severe and long term deficits if this high level of school absence continues. The parents have been working near full time to keep the child 'caught up' with school work, but of course all the increased stress at home contributes to migraine incidence. This kind of intervention plan is not functional for the long term.

The child requires accommodations including preferential seating while copying, increased time for testing, use of sunglasses in school, use of colored paper for handouts, and anti-glare screens on computers. Other specific issues will likely come up so the OT needs to be involved on a consultative level on an ongoing basis. Some of these strategies may hopefully decrease triggering events that can lead to migraines, and subsequent loss of participation.

So just because the test scores are all normal does not always mean that participation and function are normal. And sometimes the evidence can be found in places where we are not typically accustomed to looking.

In the case the occupational therapist needs to help the educational team understand the impact of the disability on participation. Too often, schools look at situations like this and don't want to provide assistance because the child is 'doing fine.' Again, the concept of 'doing fine' can't be always narrowly interpreted as how a child performs on a typical standardized test at a specific point in time.


LisaO said…
Would you qualify the student under a 504? In Wisconsin, OT is a related service and not a stand alone program.
State regulations vary - in NY, related services are defined as developmental, corrective and other support services required to assist a student with a disability to benefit from instruction. Based upon a student's Individualized Educational Program (IEP), related support services may be provided.

Related services can be provided alone or in combination with any other services that are determined to be required.

There are interesting case examples in Wisconsin you might want to reference. IHOs in Wisconsin have made statements that services need to be individually determined, and blanket eligibility or ineligibility is unlawful. One particularly interesting case can be viewed at http://dpi.wi.gov/sped/complaints/com00011.html

I am not well versed in Wisconsin state special ed regs, but based on this kind of opinion I wonder about the appropriateness of a policy that would deny related services if they 'stand alone.' I would be interested to see the state regs that prohibit 'stand alone' related services.

All that aside, the higher value (in most states) of an IEP is that there are procedural safeguards in place so that parents can have their concerns addressed. With a 504 plan, parents are essentially restricted to addressing concerns through good faith with their districts or via lawsuit.
I received this in regular email:

I am currently studying for a Bsc Hons in OT in the UK, and while searching on the internet I came across a blog in which you work with a child suffering from a migraine. Currently in the UK there are no OTs that I have found working within this area. Currently the advise is mainly medication, as a migraine sufferer myself the impact on lifestyle and identification of triggers and coping strategies seem well placed within the realms OT. This is the topic for my research and having limited OT research produced on this topic to work with and no contacts within the UK in this field, I was wondering if you could help. I understand your very busy, but would really appreciate any nudge in the right direction.
Many Thanks

Dear Nichola -

I don't have a lot of experience in this area myself - but the point of the blog post was to underscore the impact that the migraines had on participation, almost in an all-or-none context. The child didn't have ongoing performance problems as much as there was a condition that COMPLETELY precluded participation on an unpredictable basis.

Unless there are associated neurological performance deficits, I suggest looking at overall participation rates as was done informally in this case study. It would be interesting to know how many people who have migraines are unable to participate in their occupations, and what accommodations help to prevent migraine attacks.


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