Wednesday, October 05, 2011

An open letter to an occupational therapy evaluator

Dear Evaluating Occupational Therapist,

You evaluated a preschool child who has been receiving private occupational therapy for a year. I referred the family to their local school district because I thought it would be a better option for the family to receive services this way. Your evaluation was thorough and a fair representation of how that child functions - which is always good to see because sometimes evaluating preschoolers is tough and their performance can be variable. I was a little disappointed that you didn't make any attempt to contact me and get any input on the case. I think it is important for evaluating therapists to talk to previous therapists especially when high stakes decisions are being made, like eligibility for services through a system.

The agency that you work for sent a very nice person to the CPSE meeting to represent all of the evaluations that were completed. I asked the representative person what their position and role was at your agency and I learned that this person was a representative. I asked a second time and was told that the person was a representative for CPSE and CSE meetings. I didn't want to ask a third time because it might have been embarrassing - so I am not sure if it was a janitor or the executive director from the agency. They were very nice though.

The Representative read selected portions of all the evaluations at what I would call breakneck speed and it was very difficult to process the information that was provided so rapidly. I read over all of the evaluations prior to the meeting so I would be fully prepared to discuss them and am very familiar with all of the contents. What came across in the rapid review was not fully representative of what you and some of your colleagues documented in the evaluations. It was close, but it was not really accurate. At this point in the meeting I started to worry a little.

The CPSE chairperson was also very kind and friendly. I was happy that they asked me for my input. I explained that I worked with the family for a while and encouraged them to pursue services through the CPSE. I told them my own evaluation findings which were pretty close to yours. I spent some time going over the ways that this child would have difficulty in a pre-academic context, because it really wasn't explained all that well by the Representative.

I think that the CPSE chairperson was pre-disposed to finding the child eligible because no questions were really asked - which was good, because the evaluations that were completed really did support the child's classification. You didn't put any recommendations for services in your evaluation - I know that a lot of therapists don't because they are told not to put recommendations into their assessments. I understand that the idea is that final determination of eligibility and services provided rests with the CPSE - which is fine - but I still stand quite firm in the belief that the recommendations should be made and then the committee should be responsible for accepting, rejecting, or modifying those recommendations as the full committee sees fit.

I find that committees don't like to have dissenting opinions in the room, and I think that is unfortunate because when everyone is agreeing it really undermines the collaborative planning process that is actually supposed to be occurring. It really would have been OK for you to make some recommendation - and then the whole group can decide what the best solution is in context of all the other information on the table. Something bad happens when you don't make any recommendations at all - and I think you really need to know about it.

So the good evaluation that you completed was reported a little inaccurately because you weren't at the meeting. The janitor or executive director representative really didn't understand the full nature of this child's difficulties, but it was mostly ok because I tried to fill in the gaps and thankfully the CPSE chairperson was in essential agreement anyway. Something odd happened though because there were no recommendations about frequency or duration of service from you - so the CPSE chairperson turned to the district speech pathologist who has never before met the child and said

What do you think?? Once a week or maybe twice a week??

Well you can thank this very nice speech pathologist who never met the child before because they thought the child should get OT services at least twice a week. I have absolutely no idea why the CPSE chairperson would ask the district speech pathologist this question but in this situation it worked out ok.

So I know this is a long letter, Evaluating Occupational Therapist, and you are probably really busy and perhaps being so busy made it impossible for you to represent your evaluation at a child's meeting. I just thought you might want to know that THIS TIME all the stars aligned:

  1. even though you didn't contact me about the child's therapy history and performance
  2. even though the agency representative didn't represent your evaluation very clearly
  3. even though you didn't make any recommendations in your report
  4. even though some random speech pathologist made the determinative statement on how much OT the child should receive
So EVEN THOUGH all these factors were working against this child today I certainly know better than to open my mouth and stop something that just happens to be working in a child's interest. Call it good fortune. I prefer calling it divine intervention. Either way, it worked for a child today.

It might not work out so well next time - so I thought you might just want to be aware of this story.

11 comments:

Your Therapy Source said...

I am laughing out loud right now. I know all to well the asking others for recommendations. Makes absolutely no sense. But then again many recommendations that are suggested by some OTs and PTs (ie three times per week for a lifetime) don't have much research to back them up either so why not roll the dice and ask the speech therapist. Do you think therapists should be required to attend all meetings where changes will be made? I do but understand that sometimes that can not be the case. - Margaret

Anonymous said...

Are you a school based therapist? It does sound like this therapist made some errors during the evaluation process, but the model used in school based practice is different than the model used in the clinic. I am a school based therapist. Are time is stretched way too thin. I often want to call the early intervention O.T. but there is not enough time, plus you have to have the parents sign a form for clearance and often you can't get this signed easily. I've stuck to not getting the form signed unless it's a very complex diagnosis. I find that too many EI therapists advise parents there child will qualify for school based services. This makes things very difficult when the child has needs that can be addressed in the classroom with support from the O.T. Also, some of us are told not to put recommendations in the report because this is a team decision. And in regards to meetings, when you have 5 meetings scheduled in one day, sometimes you have to pick and choose. I'm sorry, I love your blog, but this post struck a cord. Please think about the work environment and dynamics of the school based therapist. We can't make our schedules the way private clinics can. It often frustrates me that we don't have support from AOTA. Our caseloads are way too high and they preach "caseload vs. workload". School districts don't understand that. Keep churning out the good stuff, it keeps me enlightened.

Chris said...

Dear anonymous,

I am currently an EI therapist, a CPSE therapist, a school based therapist, and a private practice therapist. I am currently working in all of these practice settings.

I guess that means that I have a lot of opinions from different perspectives. I don't claim to be right about anything - I just claim opinions.

I know that time is stretched thin for my school based colleagues - but that is why I encourage you all to have conversations with supervisors in your settings about appropriate levels of staffing so that you can attend to important non-direct service functions of your jobs.

Also, regarding recommendations, they are ONLY recommendations. That leaves the decision to the CSE and educational team. There is value in at least putting a recommendation that serves as a basic starting point for team discussion. A team can agree or disagree with a recommendation - in any direction. The conversation should be part of the record of the meeting.

So if I struck a chord - good!! I want to encourage thinking about what we are doing and how we are doing it in these different practice environments. We can only begin to improve the quality of what we do by examining it, talking about it, and acting on our conversations.

Working in schools is difficult. I know. There are many forces that work against the provision of 'better practice.' There are two ways to interpret that challenge.

The first would be to succumb to those forces and allow the system to dictate the quality of your practice.

The second would be to look at every single problem that exists as an opportunity to really change things and improve the way children are receiving their services. You might not change them all right away, but over time you have the opportunity to really force a sea change in the way things happen in your own environment.

Best of luck, and thank you for taking the time to send a note!

Emily said...

I wanted to also comment as well. For myself, reading "an open letter" to a probably stressed out, overly scheduled occupational therapist doesn't help the situation but is an attempt to stroke your own ego at how clever and witty you are in expressing a point.

I left the schools because I could not take it anymore. Essentially you are saying the OT did a good job in evaluating the child but then spend the rest of your time 'cleverly' showing how the person who came to read the report was clueless.

I did school based OT for ten years and only recently left. I had parents and teachers requesting me and I felt like everytime I tried to get out they kept pulling me back towards school based. But finally, I could not do it anymore.

Likely what happened, as I'm sure you are well aware, is the OT had zero time to call past therapists, however, I am sure they looked at your report if it was made available by the parents. If the OT had in fact a reasonable caseload with all the time in the world, I am quite sure they would have contacted you. That's why there are reports to read from said previous therapists like yourself.

Likely the district that the OT works for policy is NOT to put recommendations in writing because if the district does not agree, a parent sees the OT's recommendation and then sues the district for said recommendations. If your employer directly says you cannot put recommendations, you can't put recommendations. Yes, you can argue your point, make your case, etc etc, but at the end of the day, if you don't follow the policy it is grounds for termination.

Lastly, as stated by another person, the evaluating OT probably had treatment sessions that day, at least one a 'high profile' case of a suing family so therapy could not be missed, or other IEPs to attend.

If other IEPs had sue happy families and lawyers involved, which meeting do you think the OT will be forced to go to?

Putting others down, especially others in your profession, does not help the situation, does not make you clever, rather, it shows your inability to help solve the actual problem.

Chris said...

Hi Emily,

You seem a little angry and it also seems like you perceive that families do the things they do because they are 'sue-happy.' With that much negativity it might be best that you are not working in schools any longer.

I fully understand that school districts might have a 'policy' (probably unwritten) that says therapists should not make any recommendations. If that is true, then don't you think that the therapist should at least be required to attend a meeting to help participate in the decision making?

What often happens is that the decisions about eligibility and service provision are often made (formally or informally) long before the meeting - or as in this case - are made haphazardly with no real consideration of the evaluating therapist's recommendations.

You have a very curious understanding of what a parent could bring legal action over. A parent can not 'sue' if a committee does not follow an OT's recommendations. The committee holds the final power of determining what services are needed. Any individual recommendations might be increased, decreased, modified from direct to indirect to consultative to a program modification based on the conversation of all the relevant people around the table who are presenting information. The parents are supposed to have a voice too.

The fact that many meetings lack any real group planning is probably what causes you to consider the possibility as being so foreign and unimaginable. It is kind of sad, actually.

If schools have 'policies' that restrict your practice which in turn limits your ability to follow the intent of the law (IDEA) - then you should be trying to change them. If over time you find that you can't change them, you should go find somewhere to work that actually respects the intent of IDEA.

As for trying to solve the problem, I have attended countless meetings in schools helping parents interact constructively with their districts. I assure you that I have never met a 'sue happy' parent. I have met parents who are sad, angry, depressed, outraged, worried and many other emotions but I have never met a 'sue happy' parent.

If the system worked better than it does - which would include a functional level of decision making and group planning - many parents probably wouldn't reach the point of despondency, or in your perspective, being 'sue happy.'

Anyway, I will go to work on Monday and will continue to work with my families and help them interact constructively with their school districts. I will continue to serve as a resource person to my colleagues (those who work with me and those who work for other agencies). I will also continue to attend school meetings and try to encourage dialogue and discussion about the challenges of our systems. I'll continue to blog about the problem. I'll participate in online conversations about these challenges on the AOTA forums. I'll also teach pediatrics courses at a local college and attempt to give future therapists the tools they need to interact within these systems. All of this will be driven by my strong desire to 'solve the problem.'

Thanks for thinking I was clever or witty. That wasn't my primary intent. I could just leave it all because I can't take it anymore, but that doesn't seem to be particularly constructive. Thanks for writing!

Emily said...

Telling a therapist that perhaps she should leave an area of OT and then spouting a resume response of everything YOU do to make the world great is not helpful.

Being condescending also does not help matters.

On my end, you have a curious understanding of what a parent can sue over. Parents can take school districts to fair hearing for anything. I have seen it time and time again. I have seen parents not sign IEPs for almost a year.

Your telling me how IEP meetings work with everyone deciding based on all IEP members opinions as if this is not understood shows me the lack of understanding with reality. Yes, all team members give their opinions and that is what the decision is supposed to be based on. In reality, depending on what district you are in, lawyers or advocates are present and the parent can refuse to sign the IEP and / or take to fair hearing.

Do I think OTs should be required to attend IEP meetings to give their input? Of course. When I could not attend IEPs, I contacted the parents to go over my report. In the perfect world, yes, OTs would attend every IEP meeting to represent their findings and recommendations. In reality, this does not happen every time due to circumstances I described before.

I feel for these parents, I feel for their situation. I felt I helped a lot of kids. For me though, from my personal point of view, working in school based OT is too fraught with too high caseloads, fair hearings, walking on egg shells, hands tied, that isn't changing.

If a therapist is hurting or burnt-out, attempting to talk down to them and the proceeding to list all the great things you do helps no one but yourself.

Is your blog about helping occupational therapists support each other in a positive way or is it about trying to prop up your ego?

Chris said...

Hi again Emily,

I really struggled with whether or not I was going to publish your comments because it is actually against my own policy to publish ad hominem attacks unless the person identifies themselves. I think your attacks reflect the nature of the problem though so there is probably value in people seeing the pot shots so others can see the struggles that practitioners have with school based practice.

I'm sure that you are probably a very nice person and I am also sure that you probably are just stressed out and didn't have access to any means to improve your situation.

Just to clarify, this blog represents an ongoing experiment in a mostly open-source exploration of occupational therapy. As I said, I have lots of opinions - and I don't claim to be any more 'right' than any other person. I blog about things that happen. I actually don't blog about them to 'prop up my ego.' I listed the things I do for you so you could better understand my motivations and my actions - because the whole point of this for me is transparency and an honest look at what happens in our profession.

Sometimes people won't like what I say - and then that opens it all up for good conversations. Sometimes instead of conversation people think they should just use ad hominem attacks. I don't mind though, really - it just makes me a little sad that people won't approach the merits of the argument and instead have to descend to personal attacks.

So I don't know you Emily, but you sure can know a lot about me. I made the observation that you are a little angry and I suggested that it would be hard to be effective working in schools with that much anger toward families. That is not a personal attack on you - I was just holding a mirror up to your own statements so you can see what you are saying.

Sorry if that upset you. My ego has no place in this - in fact I purposefully lost it around 2002, but that story would be TMI for the purposes of this blog!

I really encourage you to reconsider the concept that parents are 'sue-happy.' I am not commenting on the motivations of individual people who I don't know, but the vast majority of parents access their due process rights because they think there was a flaw in the determination of what services are being provided or in their actual delivery.

That is their right and we should respect the system that affords them those rights. We should also do everything we can to help parents avoid getting to that level of dissatisfaction with services.

Think about it - we have systems that don't allow practitioners to operate the way that they really should, and then we call the parent's 'sue-happy' when they access their rights??

And now we have people calling me out as propping up my own ego just because I pointed to the problem.

Sigh.

Anonymous said...

We are living in a "real World" Sir.Condescending doesn't help.I am sorry but I too would leave if you were my supervisor.Humility goes a long way in building trust and feels goos too.You should try it!Oh, and by the way,You can decide "not to publish my comment" if it doesn't suit your ego.At least you DO have control of that much.Thanks for the opporutniy to express my opinions freely.God bless America.
OT.

Christopher Alterio said...

Dear Anonymous,

Thanks for your post and I am glad that you are such a patriotic person. I am too, so we probably have something in common.

As I have previously indicated, I don't have an ego. Maybe you didn't read that part. Ironically when people do have an ego that is easily bruised they tend to leave anonymous hate posts on people's blogs. That's ok though - I don't mind being here for you.

If you want you can always come back and stick your name on your comments instead of staying anonymous. Well, people should know that they are only partially anonymous, because the site logs your IP, where you are geographically, and lots of other fun tidbits. Don't worry - I won't publish your details though. You came to the blog looking for information on a "DOE letter to work with early intervention children as an OT." I don't think you found that in this post, but if I can help feel free to leave your name and email and I probably could help you out.

I know it must be frustrating to be looking for information and not being able to find it - and instead finding something that hurts your feelings. Let me know if I can help. - Chris

AFD said...

Do you like school-based OTs? Whenever I read something that you write about school-based OTs, it always seems to be negative. I'm just wondering why? I'm a school-based therapist, and when I read your blog, which I come across during Google searches, I always leave feeling down and like I'm just not a good therapist. Do you have anything positive to day about school-based therapy?

Christopher Alterio said...


Hi AFD,

The issue is not the skill of the therapist at all and this post has nothing to do with anyone 'liking' school based therapists, whatever that means.

The issue here is that the school based therapist was not allowed to make recommendations because the SYSTEM they worked it disallows it. Also, the SYSTEM that they work in sends a rep who knows nothing about the child.

The problem is not the school based therapist in this situation, other than that they should have called me as the referring provider. I imagine that they probably would have, except that their SYSTEM makes it near impossible to do that because of productivity requirements, traveling between schools, etc.

So again the beef I have is not with therapists as much as it is with the SYSTEMS that they are working in. If there is a beef that I have, it is that people choose to continue to work in these environments that are not always meeting the needs of children.

If there is something to be done, it starts with the professionals working within those systems. The SYSTEMS need to improve, and that has to happen with participation from people working inside those systems.