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The Occupational Therapist
âSeeing students develop the skills to be more successful in their classrooms and develop independence was satisfying. I loved it. I knew that I chose the right profession. That is, until our family relocated to another state, causing me to switch schools. The new schoolâs principal required mostly classroom-based occupational therapy provision. What a change. This required more work, planning, collaboration, and co-teaching than my previous position. Nobody told me this change would be easy . . . but, let me tell you, it was worth it!â
âTiffany (occupational therapist)
Like Tiffany, many school-based occupational therapy practitioners find themselves having to negotiate schools at which administrators or other school personnel envision innovative or changing service provision models for supporting students with disabilities. This book is meant to provide essential knowledge and guidance about 1) what it means to be an occupational therapy practitioner in an inclusive school setting, 2) special education basics, 3) inclusive education, 4) how to work within a collaborative team, 5) ways to think and talk about the students to whom you provide services, 6) how to provide social supports, 7) implementing occupational therapy school-based practice that aligns with academic goals, 8) behavioral supports, and 9) how to take care of yourself while doing this important work.
Letâs start by meeting a student named Helena.
In this kindergarten classroom, 9:00 is writing workshop time. Helenaâs general education teacher finishes a mini-lesson focusing on creating diagrams with labels in their nonfiction books. Each partnership looks at their mentor text to see the diagrams used. Helena is laughing as she points to the diagram of the spider. She is lying on her side on the carpet using a wedge to keep her propped; her friend Evan reads the labels aloud, pointing with his finger as he does.
The lesson ends and the teacher gives directions for the workshop stations. Students begin making the transition. The paraprofessional assists Helena back into her wheelchair, and Helena begins to drive the wheelchair back to her table. On the way, Helena gets stuck on the easel and the teacher pushes it two inches so her wheels can get through. The occupational therapist (OT) enters the room. The teacher calls across the room, âCan you help me rearrange the desks later?â
Each adult leads a station. The paraprofessional leads a station lesson on adding visual details to the diagram drawings. The teacher leads a station lesson on constructing a sentence caption under the diagram. The OT leads a station lesson on using the technology software Kidspiration to create a diagram for the studentsâ nonfiction stories. Helena is strengthening fine motor skills and learning to use a computer to record ideas; this lesson focuses on using one clip-art picture and writing at least three labels. Students rotate through the stations. The OT stays for 30 minutes, and then the general education teacher manages two centers for the rest of writing workshop.
Later in the day, the OT brings to the classroom a different wedge that is higher and asks the teacher and paraprofessional to try it for the next few days. She thinks having Helenaâs body positioned more upright might be helpful when working with peers. At lunch, the adults spend 5 minutes rearranging the furniture in the room to make the key parts of the classroom accessible to Helena using her wheelchair.
Because of the nature of her physical disability, Helenaâs OT is vital to her getting the most out of school. As you can see in the preceding example, the OT problem-solves about seating and positioning strategies, considers environmental movement factors, and incorporates purposeful ways to use computers within academic content. This is just one small example of the contributions OTs make on an educational team. This chapter will familiarize you with the evolving role of school-based occupational therapy practitioners. We will outline a brief history of occupational therapy, the definition of occupational therapist, the roles of school-based occupational therapy practice, the benefits of occupational therapy in the school system, the different types of settings in which OTs work, the scope of practice for occupational therapy practitioners in schools, and some commonly asked questions.
The History of Occupational Therapists in Schools
The responsibilities of OTs have changed over time. OTs have long had roles in hospitals and other settings, providing rehabilitative care to wounded individuals and fostering their ability to return to work. In 1917, OTs joined to create a professional association called the National Society for the Promotion of Occupational Therapy (NSPOT) with an aim to outline a role in the health care community. During World War I, this association lobbied General John Pershing to hire 5,000 people to provide occupational therapy to wounded individuals. Having a greater presence in the health care community was important to this occupational therapy association. Having changed its name to the American Occupational Therapy Association (AOTA) in 1923, the association helped institute the Vocational Rehabilitation Act (also known as the Smith-Fess Act; PL 66-236, 41 stat. 735) that created occupational therapy roles in hospitals and lobbied colleges and universities to design professional courses of study for occupational therapy practitioners. The first registry for OTs was developed in 1931, and later, educational standards for qualified occupational therapy professionals were drafted (AOTA, 2012). âOccupational therapy practitioners began working in schools after 1935 when federal grants to states created Crippled Childrenâs Services under the Maternal Child Health Program of the Social Security Actâ (Hanft & Place, 1996, p. 2). From this time to the 1970s, therapists primarily used a medical-model approach with children with significant disabilities, rather than the current educationally relevant therapy services provided to help students benefit from special education.
The history of inclusive education has had a large impact on the role of school-based OTs. It has only been since the passage of the Education for All Handicapped Children Act of 1975 (PL 94-142) that students with disabilities have had a legally protected right to attend public school. Historically, students with disabilities were educated mainly in the home, in separate segregated schools, or in institutions. As a result, OTs primarily worked in these separate settings only for children who required their services. As public schools became more inclusive of students with disabilities, OTs began to work in such settings.
In the 1970s and 1980s, a strong, parent-driven push initiated education of children with disabilities in general education settings alongside students without disabilities. At this time, the regular education initiative began (Will, 1986), and parents began to learn about the idea of mainstreaming or inclusion. The role of OTs shifted accordingly, as students with disabilities began participating in general education classrooms.
By the 1990s, a wider array of students with more significant disabilities was included in classrooms across all grade levels in school. From 2000 to the present, inclusive education has been more of a legal mandate. The Elementary and Secondary Education Act, now called the No Child Left Behind Act (NCLB) of 2001 (PL 107-110) initially set accountability and educational standards for all children, including students with disabilities. The federal legislation that had a particular impact on students with disabilities was the reauthorization of the Individuals with Disabilities Education Improvement Act (IDEA) of 2004 (PL 108-446), which established outcome expectations for students with disabilities receiving special education and related services. In the Findings section of IDEA 2004, Congress acknowledged that the purpose was to âensure that all children with disabilities have available . . . a free appropriate public education that emphasizes special education and related services designed to meet their unique needs . . .â (20 U.S.C. 1400 [c]). Therefore, students with disabilities were entitled to receive related services. That is, under federal legislation, the role of OTs is to âassist a child with a disability to benefit from special educationâ (IDEA, 2004, 20 U.S.C. §602 [26][A]) and to ensure these students have âaccess to the general education curriculum in the regular classroom, to the maximum extent possibleâ (IDEA, 2004, 20 U.S.C. §601[c][5][A]). As the historical context has evolved and students with significant disabilities are being included in general education settings, it is clear that OTs who work with children primarily work under the provisions of IDEA, and their services now take place in schools (Swinth, Spencer, & Leslie, 2007). Presently, âmore than 20% of the occupational therapy workforce in the United States provides services in Americaâs public schools, and more than 60% of the occupational therapists who work in schools are employed directly by local educational agencies or school districtsâ (AOTA, 2010a, p. 10).
We now consider what the role and profession of occupational therapy means in educational settings.
What Does Occupational Therapist Mean?
OTs within educational settings support the occupational performance of students with disabilities to engage in daily school activities, including academic, social, extracurricular, and self-care activities (Swinth et al., 2007). Supporting students and school staff to facilitate student participation and independence in their student role at school is the purpose. OTs are assets to educational teams because they have specialized knowledge in the following areas: 1) social and emotional learning and regulation; 2) task analysis, including sensory, motor, cognitive, and social components; 3) assistive technology; and 4) activity and environmental modifications (AOTA, 2009b). The job title occupational therapist is described in section 300.34 of IDEA 2004 as a related service. âRelated services means . . . supportive services as are required to assist a child with a disability to benefit from special educationâ (20 U.S.C. § 300.34). Specifically, the definition of occupational therapy is in section 6 of IDEA 2004:
Occupational therapy means services provided by a qualified occupational therapist and includes: (a) improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation; (b) improving ability to perform tasks for independent functioning if functions are impaired or lost; and, (c) preventing, through early intervention, initial, or further loss of function. (20 U.S.C. § 1412 [9])
In other words, OTs are qualified professionals who assist and facilitate studentsâ ability to independently function and participate in the school and provide supports that allow a student with a disability to benefit more from special education services.
NCLB 2001 considers occupational therapy practitioners as pupil services personnel:
The term pupil services personnel means . . . other qualified professional personnel involved in providing assessment, diagnosis, counseling, educational, therapeutic, and other necessary services as part of a comprehensive program to meet student needs. (NCLB 2001, section 9101, paragraph 36)
We have listed the legal definition of OT (IDEA, 2004) and pupil services personnel (NCLB, 2001); now, letâs discuss what these mean in practical terms and what you actually will be doing.
Occupational Therapist: From Pull-Out and Caseload to Inclusive, Collaborative Workloads
Occupational therapy practitioners are essential in public schools today. OTs who work in public schools are identified by AOTA as accounting for more than one third of its members, and these professionals are faced with growing caseloads (AOTA, 2006). This increase in school-based occupational therapy practitioners is attributable to many factors. The number has increased primarily because many more students with significant disabilities (e.g., autism spectrum disorders and cognitive disabilities) are included in general education classrooms. In addition, there has been a slow increase in the number of students being identified as having disabilities. Many educators view the consultation and classroom-based support of an OT as crucial for enabling students with disabilities to benefit from special education in the context of general education classrooms.
Consequently, the role of OTs has become more complex as it has moved from a direct, hands-on, pull-out-only service model to classroom-based service. In the past, students with significant disabilities were routinely educated by being âpulled outâ to segregated classrooms with a focus on functional and behavioral skills. Educational goals for these students were essentially limited to life skills and job-related tasks and, as a result, the role of OTs was mainly to support these life skills. AOTA noted,
Pull-out services built around a clinical model of predictable, routine âappointmentsâ have limited support in the educational literature and do not necessarily promote the generalization of skills to the classroom or other appropriate skills . . . [yet] many school districts still use this approach. (2006, p. 1)
Educators in the field have learned that students with disabilities are just as capable of learning as their general education counterparts. Consequently, the goals many students now have in their individualized education programs (IEPs) closely resemble those of their same-age peers. Under federal law, OTs are required to provide related service supports to help students benefit from special education (IDEA, 2004); in doing this, they must work in conjunction with special educators to ensure that students with significant disabilities can function adequately in general education classrooms, and they...