The lost art of evaluation in pediatric occupational therapy

This is a topic that is probably long overdue - it is something that I have observed in my geographic area for a long period of time. Based on conversations I have with therapists around the country I know that it is not exclusive to my area.

Increasing demands on therapist time, decreasing reimbursements, and dependence on a non-centralized workforce that is not subject to an intense quality improvement process has contributed to significant changes in how occupational therapy 'evaluations' are completed.

Our agency made attempts to impact this system while contracted to complete some evaluations, but 'contractor status' did not place us into a position to make broad system changes. Now it seems that the entire community is stuck into a cycle of low expectations based on long history. Unfortunately, there is no centralized service delivery system or 'top-down' method of assuring quality control - so I think the only way this can change is for the stakeholders to start increasing awareness of the problem and having a conversation.

Both therapists and parents should be interested in this issue. Therapists should be interested because I am calling the quality of our collective 'evaluation' work into question. Parents should be interested because they should know what to expect out of an occupational therapy evaluation for their children.

The American Occupational Therapy Association publishes standards of practice that outline some basics that should be part of all evaluations - but these standards are not very specific. Many evaluations that I see completed as a part of preschool and school-based practice do not even meet these basic standards. Currently, many evaluations that I am seeing can be outlined as follows:

1. Very general statement regarding the child, including name, classroom, and very minimal if any history
2. Long boilerplate descriptions of standardized tests that were used, followed by a very brief report of the child's performance on those tests
3. A 'summary' section with minimal if any analysis and deferred decision making to the CPSE or CSE regarding eligibility for services.

I understand how 'evaluations' have devolved to this state - there are significant time demands and therapists do not have the time to complete lengthy evaluations. Also, there is no demand from CPSE or CSE for higher quality because the bottom line from the committee perspective is 'are children eligible or are they not eligible.' The committees are not in business to promote best practice; they are in business to determine eligibility. If a committee is receiving an evaluation report from a therapist it is generally making a de facto assumption that the evaluation being handed to them is appropriate and complete. Committees occasionally receive feedback about quality because some parents identify that the 'evaluations' are inadequate - and that causes external data (like a private evaluation) to be brought to the table.

External data in the form of a private occupational therapy evaluation causes a lot of consternation to committees, who don't understand 'what is wrong' with the evaluations completed within the system. That causes committee chairs and their committees to be puzzled at what is documented in a private assessment - and contributes to the general sense of 'that's not the way that we do things in schools' or even more commonly 'that is a clinical evaluation and not a school-based evaluation.' The most discouraging part of this problem to me is the engendered culture of low expectation and how practitioners create these myths about what constitutes acceptable practice.

The role of related service providers and their relative power within schools also contributes to the problem; this group of professionals is generally not in a position to take on the systems where they work and they are not always likely be on the front lines of change promotion within their systems.

Anyone who has been involved in this system for any length of time can identify with this issue.

So what can we do to change this?

I don't want to talk about 'best practice' because the term is overused and I also don't think it represents an intermediate step that we can reasonably take to improve. Let's talk about 'better practice.'

'Better practice' means taking a step forward from where we are now. It might not be best, but it is moving in that direction. From our current position, I propose the following for 'better practice' occupational therapy evaluations completed for CPSE and CSE:

1. Background information including reason for referral, identification of medical issues, and lists of allergies and medications. Birth and developmental history need to be present, including history of CPSE or CSE involvement. The inclusion of developmental and medical history does not make an evaluation 'clinical.' This is basic information that is required to form a contextual understanding of the child's performance difficulties.
2. Description of the child's ability to participate in the assessments. This also provides important contextual understanding of the results.
3. A LISTING of the assessments used. If there is a value to 'explain' the tests for the parent audience then provide the parents with a separate sheet of paper with that information. The evaluation should never be 90% boilerplate explanation of what tests were administered.
4. Direct performance observations AND performance on testing. Organize observations and test data into logical performance categories such as 'Physical skills,' 'Sensory skills,' 'Cognitive skills,' 'Regulatory skills,' and 'Social/emotional skills.'
5. Apply this to actual function in their environment, including observations of how these performance attributes impact participation in personal care, learning, and play or socialization. Here it is likely that school based therapists will limit the 'environment of concern' to the school setting, which is appropriate.
6. Summarize the findings, identifying areas of strength and areas of need. Form a summary opinion of what is happening with this child's life and make referrals for other services as needed.
7. MAKE AN ACTUAL RECOMMENDATION! There is nothing wrong with giving your professional opinion. It is up to the committee to accept or reject your recommendations. That DOES NOT MEAN that you defer recommendations to the committee. This is where many committees fail - because it is absolutely fine for professionals to make recommendations and then for a committee as a whole to review those recommendations and decide what is most appropriate. For example, you may identify that a child's needs are so severe that you recommend OT three times a week. However, you may get to the committee meeting and find out that colleagues in PT, speech, and education made similar recommendations for their domains and in total it would be 'too much' for the child to tolerate in their day. The committee may then consider that a different level of service or an altered service delivery method is needed in consideration of ALL the data on the table. That is fine and is actually the STRENGTH of multidisciplinary planning.
8. Follow up with the parents and teacher and talk to them on a regular basis so that you are not providing or documenting this service in a vacuum.

These are just some preliminary ideas. I am interested in feedback - again with the intention of promoting 'better practice.'

If we take some solid first steps, wouldn't it be nice to have a conversation about 'best practice' next?