The perils of mediocrity and the pursuit of a Centennial Vision
By definition, mediocrity implies ordinary or unremarkable quality. For occupational therapy to achieve the centennial vision that is proposed by AOTA I believe that the profession needs to move far beyond mediocrity.
This week I experienced mediocrity in occupational therapy and in educational systems - it was concerning, so I wanted to share it here.
A parent asked me to attend a meeting at school in preparation for a CSE meeting. The parent was informed that occupational therapy services would be discontinued for her daughter. I won't even argue the child's needs here - but rather will point out the process by which this determination was made.
The child has an IEP but there are no statements on the IEP that indicate her present levels of performance as they relate to her occupational therapy needs or her academic functioning. There are also no goals on the IEP that relate to any needs that might be typically associated with occupational therapy as a related service. Still, the child was being seen for OT twice weekly because the service was listed on the IEP - I really don't know what they were doing all year because there are no progress notes. The therapist verbally states (there is no written discharge note or recommendation) that the child should be discharged. The OT recommended that the child should participate in home economics where she can get practice in functional measurement and fine motor skills instead of skilled occupational therapy.
I raised the point that in order to determine if someone was ready for discharge that there needed to be some statement of their level of functioning, and hopefully some record of progress related to goals that were established to improve functioning. The occupational therapist and the school team could provide neither. There is no written record of anything.
Instead I was told that this particular child had fewer needs than other children who are in special education and even those other children weren't receiving occupational therapy. Does this mean that we should lower our standards to the lowest level of care that is provided? Does it mean that if a district decides to only provide services to children who are profoundly delayed that the parents of children with severe delays should be told to stop 'forcing' districts to provide services?
Later in the week, in an unrelated case in the same district, a parent is trying to get their child out of regular education and into a self-contained classroom. The child has severe physical disabilities and does not fit into the regular education class. As the years go by it is more and more evident that the child can not meet the demands of the curriculum. In my opinion the child needs a 12:1:1 class - still academically oriented but moving at a slower pace. Also, I was hopeful that a self-contained class would be taught by a special educator and there would be a greater chance that the teacher would understand the nature of the child's disabilities - this way the needed physical accomodations would be more likely to occur. For example - after four years in the school there is still no written evacuation plan for this child. Although he can walk (slowly) he is not able to physically navigate stairs or busy hallways in an emergency. This is one small example of how the child needs educators who understand his physical disabilities.
The district wants to maintain the child in the regular education classroom, but reluctantly agreed to tour the parent through a 12:1:1 class. The parent asked me to accompany her on the tour: the class has six kindergarten and first grade students, one in a wheelchair, one with Down Syndrome, a couple with autism, and most non-verbal. The one outlying child in the class is in fifth grade - somehow the district got a 'variance' for this class so they can include this much older students with the non-verbal K and 1st graders. The district is 'willing' to place the student in the class, if that is what the parent wants.
The problem here is that there is such an amazing disconnect between what this child needs and the current program - and perhaps an even larger disconnect if the district thinks that the K-1 12:1:1 class full of profoundly disabled children would work for this third grader. What amazed me was that the teacher conducting the tour indicated that the district believed that the child should stay in regular education. When asked if they had a more appropriate 12:1:1 class they just shrug their shoulders - this will mean sending the child out of the district and it will require 'administrative approval.' Should we hold our breath?
Most parents are not keen on self contained or restrictive environments, but sometimes it is necessary. Other times parents want regular education but just want appropriate supports (including appropriate related services, properly written IEPs, and goals). What does it say about a district when it fails to meet the needs of children on so many different levels and in so many different ways??
Worse, I don't know how professionals work in these places. Is anyone who works there willing to stand up and question the way that the district operates? Why aren't there goals? Where is the district OT to advocate for the needs of this child - and why does the parent have to bring in an outside person?
This OT doesn't represent the entire profession and this district does not represent all of education, but these stories are in no way uncommon. I witness this kind of mediocrity - and sometimes even ineptitude - on a frequent basis. I understand that my private practice draws those families who are not satisfied with the regular process - but is the system really aware of how many families are overtly dissatisfied with special education in general and school-based occupational therapy in particular???
Can OT achieve its centennial vision when it fails to meet the basic needs of people in this way?
This week I experienced mediocrity in occupational therapy and in educational systems - it was concerning, so I wanted to share it here.
A parent asked me to attend a meeting at school in preparation for a CSE meeting. The parent was informed that occupational therapy services would be discontinued for her daughter. I won't even argue the child's needs here - but rather will point out the process by which this determination was made.
The child has an IEP but there are no statements on the IEP that indicate her present levels of performance as they relate to her occupational therapy needs or her academic functioning. There are also no goals on the IEP that relate to any needs that might be typically associated with occupational therapy as a related service. Still, the child was being seen for OT twice weekly because the service was listed on the IEP - I really don't know what they were doing all year because there are no progress notes. The therapist verbally states (there is no written discharge note or recommendation) that the child should be discharged. The OT recommended that the child should participate in home economics where she can get practice in functional measurement and fine motor skills instead of skilled occupational therapy.
I raised the point that in order to determine if someone was ready for discharge that there needed to be some statement of their level of functioning, and hopefully some record of progress related to goals that were established to improve functioning. The occupational therapist and the school team could provide neither. There is no written record of anything.
Instead I was told that this particular child had fewer needs than other children who are in special education and even those other children weren't receiving occupational therapy. Does this mean that we should lower our standards to the lowest level of care that is provided? Does it mean that if a district decides to only provide services to children who are profoundly delayed that the parents of children with severe delays should be told to stop 'forcing' districts to provide services?
Later in the week, in an unrelated case in the same district, a parent is trying to get their child out of regular education and into a self-contained classroom. The child has severe physical disabilities and does not fit into the regular education class. As the years go by it is more and more evident that the child can not meet the demands of the curriculum. In my opinion the child needs a 12:1:1 class - still academically oriented but moving at a slower pace. Also, I was hopeful that a self-contained class would be taught by a special educator and there would be a greater chance that the teacher would understand the nature of the child's disabilities - this way the needed physical accomodations would be more likely to occur. For example - after four years in the school there is still no written evacuation plan for this child. Although he can walk (slowly) he is not able to physically navigate stairs or busy hallways in an emergency. This is one small example of how the child needs educators who understand his physical disabilities.
The district wants to maintain the child in the regular education classroom, but reluctantly agreed to tour the parent through a 12:1:1 class. The parent asked me to accompany her on the tour: the class has six kindergarten and first grade students, one in a wheelchair, one with Down Syndrome, a couple with autism, and most non-verbal. The one outlying child in the class is in fifth grade - somehow the district got a 'variance' for this class so they can include this much older students with the non-verbal K and 1st graders. The district is 'willing' to place the student in the class, if that is what the parent wants.
The problem here is that there is such an amazing disconnect between what this child needs and the current program - and perhaps an even larger disconnect if the district thinks that the K-1 12:1:1 class full of profoundly disabled children would work for this third grader. What amazed me was that the teacher conducting the tour indicated that the district believed that the child should stay in regular education. When asked if they had a more appropriate 12:1:1 class they just shrug their shoulders - this will mean sending the child out of the district and it will require 'administrative approval.' Should we hold our breath?
Most parents are not keen on self contained or restrictive environments, but sometimes it is necessary. Other times parents want regular education but just want appropriate supports (including appropriate related services, properly written IEPs, and goals). What does it say about a district when it fails to meet the needs of children on so many different levels and in so many different ways??
Worse, I don't know how professionals work in these places. Is anyone who works there willing to stand up and question the way that the district operates? Why aren't there goals? Where is the district OT to advocate for the needs of this child - and why does the parent have to bring in an outside person?
This OT doesn't represent the entire profession and this district does not represent all of education, but these stories are in no way uncommon. I witness this kind of mediocrity - and sometimes even ineptitude - on a frequent basis. I understand that my private practice draws those families who are not satisfied with the regular process - but is the system really aware of how many families are overtly dissatisfied with special education in general and school-based occupational therapy in particular???
Can OT achieve its centennial vision when it fails to meet the basic needs of people in this way?
Comments
Thank you so much for opening up this dialogue on mediocrity in occupational therapy. I am a school-based therapist in a large school district and encounter mediocrity on a daily basis from my colleagues. We are in constant discussion regarding "best practices" and creating an "evidence-based practice". All are in agreement that this is the future and yet no follows through with this ideal. I have serious concerns that school-based practitioners are littered with therapist with no knowledge of what "evidence-based practice" means or how to encorporate it into their practice. It also appalls mean that "inclusion" is such a misunderstood and misused term. Doing "Handwriting Without Tears", "Brain Gym" exercises or "co-treatment" in the classroom with an SLP does constitute inclusion or even a therapeutic intervention if done with the entire class. What also disturbs me is the misuse of central theories such as sensory integration. Just because Billy doesn't like tags in his shirt or messy hands should he be considered SID. I have been to too many IEP's where an OT qualifies a student with no discernable academic deficit related to OT. They may qualify purely on the basis of a fine-motor/visual motor subtest score. Of course the IEP will reflect this with goals/objectives such as:"Student will catch a ball 4/5 times, "do 10 push-ups with good form" or wheelbarrow walk for 10 feet". Unfortunately none of these reflect academic function. I would love to have the time to properly work with the students who need me. The student recently diagnosed with autism, MD, CP, SPI, ED, BD. Somehow we have been reduced to the "handwriting teachers".
Our "Centennial Vison" must include a hard and honest look at our current practice. We must celebrate our success and how we positively impact on human life, but temper it with the realization that we can do better, much better.
Fred, OT in the