Wednesday, January 28, 2009

Psychosocial occupational therapy in schools

I am not certain how many problems can be solved at odd hours of the morning, but it is 4:30am and I can't shake some concerns I have about psychosocial intervention models in schools.

According to all data, occupational therapists are not frequently employed in psychosocial practice settings. There are all kinds of complexities behind this including

  1. historical lack of parity for reimbursement in mental health systems that drove professionals out of psychosocial practice
  2. lost opportunities for OTs to have legislative inclusion as QMHPs
  3. lack of vision and leadership in articulating the occupational therapy scope of practice
  4. analysis paralysis and inability to implement plans to reverse negative practice trends
  5. lack of mental health fieldwork mandates for occupational therapy students

These contributing factors can all be debated - and there are chicken and egg conversation to be had - but these still represent some of the most salient issues.

Pragmatically I see that there are rather large system needs. School systems become the de facto point of intervention for many mental health conditions (much to the dismay of schools who are poorly equipped to provide these services). The American Academy of Pediatrics wrote an interesting policy paper on this subject but I am not sure how well this has translated into action - and by action I mean movement toward sophisticated and functional interventions for mental health problems in schools.

We are lacking practice models and this is an uncomfortable position to start from. As the rest of the educational community evolves conversations about outcomes assessment and RTI models in special education I am not sure that we even have basic agreements about mental health interventions in schools. Certainly these fall within the special education purview, but what is the occupational therapy model? If a seven year old child has a bipolar disorder we assess their perceptual and motor and sensory processing skills that impact occupational participation - most OTs have training to understand that much - but how do we assess social functioning and ability to self regulate? And if we are lacking those assessment tools then how does our intervention fit into an RTI model?

It gets worse - because when the seven year old turns fourteen the problems have different complexity: now the child may have drug use, impulse control difficulties, physical or behavioral aggression, or worse. The way that a child holds a pencil doesn't seem to have the same relative level of importance in adolescence in context of more complex problems. Since we don't have many standardized assessments that measure self esteem, decision making, social skills, and progression in an occupational choice process - what does the occupational therapist do?

Now I know the answer to this question - because I am old and I went to school 20 years ago and I had a mental health fieldwork. I understand mental health interventions and although there may be a paucity of good adolescent mental health assessment tools I can fudge it in the interest of working on the problems and hope for a day when I have better tools to work with. This puts me at odds with a system that is going to demand outcomes based assessments but I can make it work.

However, young therapists don't have the contextual understanding of occupational therapy as a mental health intervention - and don't have those same practice models to fall back on. The danger of this is that children, at their most vulnerable states, will be at risk of occupational therapy that 'misses the mark.' Occupational therapists who don't know mental health interventions will only assess the fine motor skills of adolescents and there will be a real risk that they will not develop interventions that address the most salient needs of the children.

As a corollary - there was an interesting study by Liberman et al (1998) where there was a comparison of a creative arts based OT program and a pragmatic living skills training that was carried out by paraprofessionals under the supervision of an OT. The article states that the creative arts based program focused on participation in arts and crafts and discussion of feelings and goals. Not surprisingly the living skills training program was more effective across several measures - but the authors oddly concluded that paraprofessional living skills training was more effective than OT. A more correct conclusion is that OT focusing on living skills training was an effective intervention model - and it could be carried out with the use of paraprofessionals at a low cost! That interpretation was not offered - and I am certain that there was untold damage when many psychiatrists saw an abstract that showed how OT was ineffective in a well designed RCT.

School based practitioners who use an inappropriate model of intervention for children and adolescents with mental health problems run the risk of similar marginalization. How long will it be before someone completes a study that compares school based OT (that will invariably involve Brain Gym and Wilbarger Deep Pressure Protocols) with a functional living skills curriculum? Of course the school based OT will be determined to be 'less effective' and another opportunity to offer a functional service to a needy population will be lost.

We can work on this problem by articulating functional practice models that make sense and address mental health concerns of children in schools. We can strengthen our professional skill set by reinforcing psychosocial practice during fieldwork mandates. We can work toward using or if needed developing standardized assessments so that our mental health interventions in schools can move toward a level of sophistication where we can participate in reliable outcomes assessment.

If we fail to act we will be replaced. That doesn't matter for us nearly as much as it matters for children who can benefit from psychosocial occupational therapy interventions in schools.



References:

Committee on School Health (2004). School-based mental health services. Pediatrics, 113, 1839-1845.

Liberman, R., M.D., et.al. (1998). Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. American Journal of Psychiatry, 155, 1087-1091.

2 comments:

AFD said...

"Of course the school based OT will be determined to be 'less effective' and another opportunity to offer a functional service to a needy population will be lost." Of course, as always, school-based OTs just aren't as good as clinic-based OTs? I'm not sure why I keep reading, I just get more discouraged.

Christopher Alterio said...


Hi AFD,

No one said that school based OTs aren't as good as clinic based OTs. I don't even understand the distinction, to be honest, because I work in both settings. The problems are that school systems are poorly organized to meet the mental health needs of children.

I encourage you to read, but I encourage you to try not to personalize the message. If I have a beef with a therapist I assure you that I would be very clear. In a lot of my writing I am criticizing our SYSTEMS and whether or not they are correctly configured to solve the problems they are established to help with.