Thursday, February 26, 2009

The equivocal value of (some) school-based occupational therapy

Occupational therapy, at its best, is a change-enabling service that helps people accomplish goals that are personally meaningful and relevant to how they occupy their time. For kids in school, this means being able to learn and socialize and develop skills for future citizenship.

Therapists routinely wring their hands over issues of eligibility criteria for said services and balance this out against spoken and unspoken procedural rules that are generally applicable only within their own school systems. The interesting aspect to this is that any given school based OT will then believe that the way THEIR school district operates must represent the way that ALL school districts operate (and for that matter, how they are SUPPOSED to operate). Those of us who have the opportunity to interact with dozens or scores of districts across wide geographic areas have wider exposure to the variety of ways that districts interpret presumably identical criteria and rules.

Twice this year I have thrown in the towel at CSE meetings and told the school-based therapist that I concur with their recommendation to discontinue therapy, even though the children arguably had needs that would make them eligible for services. I also followed up by stating that there is little point in arguing for a service when the service provider wants to discontinue a service. This has generated some puzzled looks from the districts who are generally more accustomed to some measure of protestation.

I'm not sure what is different this year in my approach. I am seeing little value in having a child pulled from a classroom (because that is a typical model) to practice some skill or subset of skills in isolation of every other need that is screaming to be met in the classroom. I see little value in trying to convince another professional of a child's needs. I see little value in trying to contact the OTRs who are supposedly supervising the COTAs who make these discharge recommendations - because by the time anyone finds the OTR the meeting is over. I see little value in continuing to suggest that there be some kind of consistent eligibility criteria - because the conversation just seems to get lost when a therapist is convinced that you can meaningfully track a child's progress through a triennial evaluation process. I just don't see the point in trying to educate people about this any longer - because I just can't do it myself.

So the new reality dictates that until situations change I will sometimes tell parents not to bother with school based OT - because sometimes the service has equivocal value. We are finding that we can accomplish more by working with the parents and teachers directly ourselves - even when we are off site. That is the current unfortunate reality.

Three step solution:

1. updated AOTA direction and guidance on philosophical and practice models for school-based OT services, including clear recommendations for OTR/COTA role delineation, general service eligibility parameters, and evidence-based practice guidelines

2. statewide (e.g. NYSOTA) roundtables and plenaries that review the recommendations and 'stamp' them as approved after additional modifications as needed to address state by state regulatory and procedural differences

3. local/regional study groups that meet to develop plans to implement the recommendations


Margaret said...

I wholeheartedly agree with your post. In our recent survey, approximately 40% of school based OT's and PT's have no entrance criteria (go to for more info). When they did report entrance criteria I was shocked to read some of the responses (my personal favorite - availability of therapist). Therapists need to take action and collect evidence that our services in the school are working.

Buckeyebrit said...

Hear hear - this is a great post Chris! would love to have it as part of the carnival?

AFD said...

Again, very negative and condescending to school-based OTs. We are of no value?

Christopher Alterio said...


The concern is nothing personal about individual therapists. The concern is the systems that the therapists are trying to operate within. Also, you will note that I said '(some)' school based occupational therapy.

Monica said...

As a school-based therapist, I (sadly) agree with this post. We are spread so thin and have so little follow-through when we're not around. How can that model effect change? I see the most progress in the classes where I treat the most students. This obviously makes sense since I spend the most time in those rooms and therefore have the most collaboration with the teachers and other classroom staff, which leads to them incorporating my recommendations into their daily activities. I wish I could spend more time in every one of my students' classrooms, but I'm having to rush to the next school, next meeting, next duty... you get the point. Also, if I'm pulling students out, I barely get to know the teachers, so why should they trust me? They're so strapped for time as it is, why would they want to add more responsibilities because some random person is telling them it will help their students?

I once upon a time worked for a school that was all special ed. Almost all the students received some sort of OT service, most more than once a week. The growth we saw was impressive, but it's just not the reality in most schools. I agree with you that something needs to change.