two page paper

Models of Occupational Therapy Service Provision in the School System

Winnie Dunn

Key Words: intervention process, occupational therapy. public schools

Occupational therapy is a related service when pro- vided within the public schools, which means that services must enhance or support educational goals. Three service provision models have been described for school therapists: direct service, monitoring, and consultation. Direct service addresses individual- ized needs that require specialized intervention strategies which can safely be performed only by the occupational therapist. Monitoring, which is some- times referred to as integrated programming, uses therapeutic expertise within functional tasks to maximize opportunities for practice and general- ization. Consultation addresses problems by en- abling others to work more effectively on the educa- tional goals they have set for the students. Evidence is accumulating to demonstrate that each model is effective when chosen and applied appropriately. This paper reviews each model, provides examples of studies that have been conducted, and suggests directionsfor future research.

Winnie Dunn, PhD, OTR, FAOTA, is Chair, Occupational Therapy Curricula, University of Kansas, Medical Center, Kansas City, Kansas. (Mailing address: 4013 Hinch Hall, KUMC, 39th and Rainbow Boulevards, Kansas City, Kansas 66103.)

This article was accepted for publication June 11, 1988.

T he passage of Public Law 94-142 in 1975 (the Education for All Handicapped Children Act), in which occupational therapy was identified as

one of several related services for school-age chil- dren, introduced both a new role and a new practice environment to the occupational therapist. The law's mandates challenged pediatric occupational thera- pists to focus their role on proViding only those thera- peutic approaches that would enhance a student's ed- ucational experience. In other words, occupational therapy intervention in schools must enhance or sup- port the student's educational goals. The interven- tions and goals are written in the student's individual- ized education program (IEP), a document that coor- dinates the goals of all professionals involved with the student.

Models of Service Provision The American Occupational Therapy Association (AOTA) has long recognized the need for specialized skills to effectively proVide occupational therapy ser- vices in the public schools. In 1980 AOTA proVided in every state training programs that addressed the unique skills of public school service provision. These programs are set forth in Training: Occupa- tional Therapy Educational Management in the Schools (TOTEMS) (Gilfoyle, 1980). More recently, a special task force was formed to review TOTEMS ma- terials, compile materials from several states, collect comments from identified nationwide experts, and summarize the results of survey data to design com- prehensive guidelines for occupational therapy ser- vices in the public schools. The task force defined the specific models of school-based occupational therapy service provision that will be referred to here (AOTA, 1987).

Each service provision model (direct service, monitoring, and consultation) is viable within the public schools. As was discussed in the article by Coutinho (see pp. 706-712 of this issue), the members of the interdisciplinary team must carefully identify the student's needs within the context of that student'S educational placement, and choose service models for both special education and related ser- vices accordingly. The intent of Pu blic Law 94 -14 2 is that the type and amount of service provision may not be determined by parental wishes or district resource limitations such as space or personnel shortages, but rather by the student's needs alone. A broader under- standing of the various service provision models will facilitate application of the appropriate service.

Direct Service Direct service is the most familiar model of service proVision. In this model, occupational therapy practi- tioners use specific techniques and approaches with one student or a small group of students, and gener-

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ally have frequent contact with them (e.g., once or twice a week) (AOTA, 1987).

The most critical feature in choosing direct ser- vice is the identification of an educational need that can be met only by direct interaction between the student and the occupational therapist. The interven- tion chosen might include treatment techniques that depend on an in-depth knowledge of the neuromu- scular system or the integrative functions of sensory, perceptual, and motor performance. A key factor might be the necessity for ongoing clinical judgments to adjust the activities to best meet the student's on- going needs. In all cases, the intervention must have a direct relationship to the educational needs of the student.

A number of researchers have demonstrated the effectiveness of the direct service model on students' performance. Kuharski, Rues, Cook, and Guess (1985) found that vibration, inversion, and rotation techniques were effective sensory procedures for im- proving head and trunk control for classroom activi- ties in three preschoolers with severe disabilities. Ot- tenbacher (1982) conducted a meta-analysis of stud- ies that compared the outcome performance of direct service intervention using sensory integrative ap- proaches with the performance of a control group and found that direct service intervention produced better outcomes more than 78% of the time. Ottenbacher, Short, and Watson (1981) investigated direct services with children who had severe disabilities by compar- ing a treatment and a control group on motor develop- ment and postural control. The children who received direct services made significantly greater gains than those who did not. Children with severe disabilities also made significant improvements in a study con- ducted by Sobsey and Orelove (1984). They used a reversal design to demonstrate that direct occupa- tional therapy services produced better lip closure and less spilling from the mouth than routine classroom techniques.

However, some researchers have tested the limits of the direct service model. Jenkins et al. (1982) stud- ied two intensities of direct service (once a week and three times a week for 15 weeks) with developmen- tally disabled children. They found that direct ser- vices produced improved gross motor skills in these children when they were compared with a control group, but that the two intensities of service did not differ from each other in the results they produced. The authors concluded that multiple sessions may not be necessary to produce developmental outcomes. More studies such as these are needed to determine the most efficient pattern of service provision.

Monitoring

The monitoring model of service provision requires diagnostic skills to identify student needs, program

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planning skills to design appropriate interventions, and teaching and supervisory skills to assist others in the immediate environment to carry out the proce- dures with the student. Regular contact (a minimum of twice a month) is needed to determine whether adjustments in the intervention procedures are neces- sary (AOTA, 1987). The occupational therapist con- tinues to be responsible for outcomes, but entrusts another person with the regular implementation of the program plan. The most critical feature of moni- toring is the identification of an educational need that will be best served by routine and consistent proce- dures needing ongoing gUidance and practice. Activi- ties of daily liVing, positioning and handling, reach and grasp, fine motor skill development, or coordina- tion needs might be best served through monitoring. Three questions are asked to determine whether monitoring is a safe choice for a student: (a) Is the student's health and safety protected when the pro- gram is conducted by a person other than the occupa- tional therapist? (b) Can the person being trained correctly demonstrate the activities without assis- tance? (c) Can the person being trained indepen- dently describe restrictions and signals of failure that would warrant discontinuation and making contact with the supervising therapist? (AOTA, 1987). If one cannot answer "yes" to all three questions, then monitoring is not the service model of choice, be- cause a negative answer to any question would mean that monitoring would introduce a measure of risk into the service provision process.

Monitoring seems to be an effective means for service provision, perhaps because it proVides an intu- itive measure of validity and the possibility of good reliability through observation. Furthermore, empiri- cal data on the effects of monitoring have demon- strated its value. Several authors have investigated in- tegrated programming techniques, which incorporate the principles of monitoring discussed above (Camp- bell, 1987; Campbell, McInerney, & Cooper, 1984; Giangreco, 1986; Rainforth & York, 1987). For exam- ple, Giangreco (1986) found that when therapy tech- niques were incorporated into microswitch activation, the student performed at higher levels than when iso- lated direct services were proVided prior to micro- switch classroom activities. Campbell, McInerney, and Cooper (1984) incorporated neuromotor proce- dures into all reaching tasks performed dUring the school day by a preschooler with moderate disabili- ties, with therapists monitoring both correct applica- tion of the techniques and data collection. The child attained 65% competence in all activities, and attained 100% competence in more motivating activities, such as in activities carried out in a large group. They con- cluded that a combination of therapeutic and educa- tional strategies may be the most effective approach to

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achieve student goals. Further research is needed to identify other successful integrative approaches that use occupational therapy expertise to facilitate func- tional skill development for learning.

Consultation

This service model is the least familiar to occupa- tional therapists. As applied to occupational therapy in the schools, consultation is a service model in which specialized expertise is used to facilitate the workings of the educational system. Consultation in the educational environment is oriented toward the needs of (a) the student, (b) professionals, or (c) the system; in practice, these forms often occur together. Case consultation addresses the student's needs, fo- cusing on developing the most effective educational environment for a specific student. Colleague consul- tation addresses the needs of other professionals to improve their skills and knowledge. System consulta- tion improves the effectiveness of the agency or dis- trict by addressing the needs of generic groups within the system (AOTA, 1987).

The most critical factor in choosing consultation is the identification of an educational need that is most effectively met through a supportive environ- ment. Designing proper seating, preparing an adap- tive device for classroom use, suggesting alternate means for presenting or prodUcing classroom work, or assisting with IEP goal development can all be considered examples of consultation. Consultation can be an effective means to create an environment that supports student learning, and offers the opportu- nity for the student to generalize his or her skills to different environments (Dunn, 1985).

Much of the writing on consultation comes from the medical literature, or from the literature on men- tal health, school psychology, and organizational de- velopment (Dunn, 1985; Idol & West, 1987; West & Idol, 1987). West and Idol (1987) reported on a com- posite definition of consultation from these bodies of literature that was originally designed by Meyers, Par- sons, and Martin (1979). Several characteristics emerge: (a) Two persons interact, with one haVing the direct responsibility for a third person; (b) inter- actions are voluntary; (c) interactions are a shared problem-solVing process; (d) the immediate goal is to solve a current problem of the person seeking con- sultation; and, (e) the long-range goal is to enable the person seeking consultation to handle future situa- tions more skillfully. These characteristics clearly un- derline the importance of adult communication in prodUcing successful outcomes from consultation.

West and Idol (1987) divided research on con- sultation in special education and related professions into three major areas: input, process, and output vari-

abies. Input variables include personal characteristics of the professionals and the problem to be addressed; process variables refer to the techniques used in the consultation process; and output variables are those observable results that emerge from the consultation. Methodological limitations and inadequate opera- tional definitions were cited as the major reasons overall results have been inconsistent thus far.

Input variables have been given a small amount of attention in research (West & Idol, 1987). These, the most inwardly focused variables, are the most dif- ficult to assess validly. For instance, the variable "years of teacher experience" yields inconsistent re- sults when investigators look at frequency of consul- tation requests (Gutkin, 1980; Pryzwansky & White, 1983; West & Idol, 1987). Readiness for the consulta- tion experience may be a factor related to the effec- tiveness of outcomes; this variable can include the expertise of the consultant as well as awareness, on the part of the person seeking consultation, of how the consultation process works. The consultant's per- sonality and work traits, including fleXibility, warmth and efficiency, are also important (Pryzwansky & White, 1983; West & Idol, 1987). More research is needed to clarify the role that input variables play in the success of consultation.

Only a few studies have investigated process vari- ables. Even when teachers and administrators have been exposed to various consultation models, they overwhelmingly prefer the collaborative style of con- sultation (Babcock & Pryzwansky, 1983; West, 1984). Collaborative approaches use an equal partnership between the two individuals involved to identify, plan, and carry out recommendations. Both partners are then responsible for and committed to positive outcomes (Dunn, 1985). Effective collaboration can be time consuming, but may lead to more goals being met because of the commitment made by both parties.

Most research on consultation is being done on output variables. This research focuses on the changes, both in persons seeking consultation and in students, that are a direct result of consultation. Teachers receiving consultation have reported posi- tive feelings about those experiences (Gutkin, 1980; West & Idol, 1987). Furthermore, teachers who re- ceived in-service training on consultation were there- after observed to use consultation more often than a control group who did not receive this training (West & Idol, 1987). Peck and Killen (1987) found that preschool teachers proVided their students with more opportunities to practice skills and got better out- come behaviors after consultation that focused on IEP treatment goals.

Consultation is a viable service provision alterna- tive in the public schools because it proVides a mech-

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anism through which students have opportunities to practice skills and generalize what they have learned to different situations. Occupational therapy knowl- edge is used efficiently when it is applied through consultation approaches to adapt environments and alter teaching and learning strategies to facilitate bet- ter outcomes for the student. Occupational therapy research is needed to identify successful consultation methods and clarify what conditions must be present in order for consultation to be the service mode! of choice for specific situations.

Use of Service Provision Models

The art of service provision in the public schools is in choosing the model that would be the most appro- priate to meet a student's educational needs. The American Occupational Therapy Association (AOTA, 1987) identified 10 parameters that help the therapist choose the best service model (see list below). These parameters are used to determine how important it is for the occupational therapist to be directly involved with the student, the teachers, and the environment. For example, if the teachers are experienced and knowledgeable about feeding and positioning, Pa- rameter 7 would be ranked lower, suggesting that the occupational therapist might be better employed pro- viding consultation or monitoring for classroom im- plementation. Parameter 6 (age of the student) is re- lated to chronological age expectations; a student who is successfully meeting age expectations might reqUire less direct intervention than one who fails at age-appropriate tasks. For example, a student may be coping with upper elementary school expectations with the help of adaptations, but may reqUire direct intervention as he or she prepares for vocational training and placement. The assessment of all param- eters leads to an impression of the entire Situation, which in turn can assist the therapist in choosing an appropriate service model.

Parameters for Setting Priorities

1.� Health and safety of the student 2.� Necessity for external communication 3.� Necessity for environmental modifications 4.� Role of sensory, perceptual, and motor func-

tions in the student'S educational perfor- mance

5.� Potential for functional improvement 6.� Age of the student 7.� Expertise of other persons in the student's

environment to assist in the educational pro- cess

8.� Availability of other persons in the student'S environment to assist in the educational pro- cess

The Americanjournal a/Occupational Therapy

9.� Level of interference of the handicapping condition

10.� Availability of space, time, and equipment in the local education agency (AOTA, 1987, pp. 9-1-9-2)

Each model has benefits and limitations. Direct service is time consuming and therefore costly, but can address very complex problems and be qUickly adapted to meet the student's changing needs. Moni- toring is more time efficient, since others carry out the programs, but the student's health and safety must be considered. Consultation is an effective mechanism for proViding ongoing environmental support, but reo quires special skills to be administered properly. A few brief examples will illustrate the use of each model.

Case Number 1: Use of Direct Service and Consultation

Tommy is a 9-year-old boy with an educational diag- nosis of learning disability. His psychoeducational testing revealed above average intelligence, but he is performing poorly in school. He has a difficult time completing his work in the regular classroom, even though his classroom teacher is giving him work that is at his tested reading and math levels. The occupa- tional therapy assessment revealed that Tommy was having difficulty understanding information from touch, position, and movement receptors, and had poor ability to organize body and hand movements. During testing and later classroom observation, the occupational therapist noted poor attention to task and difficulty in carrying out verbal directions, even though he could repeat directions. The therapist con- cluded that Tommy's related service needs might best be served through a combination of direct service and consultation. Direct service would address the poor sensory processing and difficulty with planning motor acts that seemed to be contributing to his poor organi- zation of work, inattention to classroom tasks, and poor ability to carry out school tasks. Direct service seemed necessary because of Tommy's specialized sensory-motor needs. Consultation would be used to adapt his regular classroom, to help the teacher un- derstand the reasons Tommy's problems were affect- ing his classroom performance, and to assist her with strategies to increase his performance capabilities in the classroom.

These recommendations were discussed at the IEP team meeting, and the team agreed that both di- rect service and consultation were appropriate ap- proaches. They also recommended that the physical education teacher receive occupational therapy con- sultation, since Tommy had trouble performing physi- cal acts and frequently became angry because of

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this frustration. This component was then added to the IEP.

Case Number 2: Use ofMonitoring

Cassie is a 6-year-old girl with an educational diag- nosis of educable mental retardation and a medical diagnosis of Down syndrome. An assessment revealed strengths in cooperation, social skills, and some matching skills (e.g., colors, shapes), and concerns in motor skills postural control, muscle tone, and daily living skills. After reviewing the records and conduct- ing an occupational therapy assessment, the therapist examined Cassie's educational environment (a self- contained classroom), which was staffed with an ex- perienced special educator and teacher's aide and had a roUtine curriculum focus of developmental and daily living skill development. The occupational ther- apist determined from all the information available that Cassie's related service needs would best be served through a monitored program with the teacher and teacher's aide. At the IEP team meeting, this rec- ommendation was discussed, and the team agreed that the teachers and the occupational therapist would meet bimonthly to review the motor development and daily living skills programs designed by the thera- pist to determine whether changes needed to be made and to discuss activities for the next time period.

Case Number 3: Use of Consultation

Kurt is a 17-year-old student whose physical perfor- mance is slow as a result of cerebral palsy. He has received special education and related services for various learning needs throughout his school career. He has been in a vocational readiness program in conjunction with his high school program, and he is now ready to be placed in a work environment. The educational team is concerned that without some preplacement preparation and environmental adapta- tions, Kurt will have a difficult time succeeding in his work placement even though he has demonstrated the necessary skills to do so in the educational setting. The occupational therapist set up consultation with the prospective employer to prepare both the workers and the environment for Kurt's arrival. After Kurt begins work, the supervisor, Kurt, and the therapist will meet once a week for the first month and then once a month for the rest of the school year to solve new problems that might arise.

The above examples depict only some of the combinations of service prOVision that might be nec- essary to meet a student's needs. The lEP team is responsible for the final decisions regarding program- ming, although the team must rely heavily on recom- mendations from the group members in order to

make those decisions. All team members must be able to step back from their discipline's perspective to see the overall needs of the student when planning the most appropriate program, keeping educational goals in mind.

Conclusion

The AOTA 1985 manpower study revealed that in 1982, one third of employed occupational therapists worked in pediatrics, with many of these holding jobs in public schools. With the recent passage of Public Law 99-457 (the Education of the Handicapped Act Amendments of 1986), infants, preschoolers, and their families will also be eligible for occupational therapy services. To meet these demands, occupa- tional therapy will need to devise successful strategies for implementing all of the service provision models discussed here. Under the auspices of AOTA, Hen- derson et al. (1987) have collected data to compare the type of educational and fieldwork experiences available to occupational therapists with those com- petencies that practicing clinicians deem necessary for successful service provision in public schools. The results of this study will be used to further delineate the characteristics of successful occupational therapy service provision in schools and appropriate preser- vice experiences for school-based occupational therapists.

References

American Occupational Therapy Association. (985). Occupational therapy manpower: A plan for progress. Rockville, MD: Author.

American Occupational Therapy Association. (987). Guidelines for occupational therapy services in school sys- tems. Rockville, MD: Author.

Babcock, N. L., & Pryzwansky, W. B. (983). Models of consultation preferences of educational professionals at five stages of service. School Psychology, 21, 359-366.

Campbell, P. (1987). The integrated programming team: An approach for coordinating professionals of various disciplines in programs for students with severe and multi- ple handicaps. journal of the Association for Persons with Severe Handicaps, 12, 107-116.

Campbell, P. H., McInerney, W. F., & Cooper, M. A. (984). Therapeutic programming for students with severe handicaps. Americanjournal ofOccupational Therapy, 38, 594-602.

Coutinho, M.J., & Hunter, D. L. (988). Special educa- tion and occupational therapy: Making the relationship work. American journal of Occupational Therapy, 42, 706-712

Dunn, W. 0985, March). Therapists as consultants to educators. Sensory Integration Special Interest Section Newsletter, pp. 1-4.

Education for All Handicapped Children Act of 1975 (Public Law 94-142),20 U.S.C. §1401.

Education of the Handicapped Act Amendments of 1986 (Public Law 99-457),20 U.S.C. §1400.

Giangreco, M. F. (986). Effects of integrated therapy:

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A pilot study, journal of the Association for Persons with Severe Handicaps, 11, 205-208,

Gilfoyle, E, (Ed,) (1980), Training: Occupational therapy educational management in the schools (Vol. 3), Rockville, MD: American Occupational Therapy Associa- tion,

Gutkin, T, B, (1980), Teacher perceptions of consulta- tion services proVided by schoOl psychologists, Professional Psychology, 11,637-642,

Henderson, A" Pressler-Hoover, S" Dunn, W" Pen- hoski, C" Murray, E" Koomar, J" Black, T" & Exner, C, (1987), [Pediatric survey for the American Occupational Therapy Association Commission on Education], Unpub- lished raw data,

Idol, L" & West, J. F, (1987), Consultation in special education (part II): Training and practice.journal ofLearn- ing Disabilities, 20,474-494,

Jenkins, J. R" Sells, C. j., Brady, D" Down, j., Moore, B" Carman, P" & Holm, R, (1982), Effects of developmental therapy on motor impaired children, Physical & Occupa- tional Therapy in Pediatrics, 2(4), 19-28

Kuharski, T" Rues, j" Cook, D" & Guess, D, (1985) Effects of vestibular stimulation on sitting behaviors among preschoolers with severe handicaps, journal of the Associa- tionfor Persons with Severe Handicaps, 10, 137-145,

Meyers, j" Parsons, D" & Martin, R, (1979). Mental health consultation in the schools, San Francisco: jossey- Bass,

Ottenbacher, K, (1982), Occupational therapy and spe- cial education: Some issues and concerns related to public

law 94 -14 2, American journal of Occupational Therapy, 36, 81-84,

Ottenbacher, K" Short, M, A" & Watson, P, J. (1981), The effects of a clinically applied program of vestibular stimulation on the neuromotor performance of children with severe developmental disability, Physical & Occupa- tional Therapy in Pediatrics, 1(3),1-11.

Peck, C. A" & Killen, C, C, (1987, November), In- creasing implementation of language instruction in regu- lar classroom routines: Effects of teacher facilitation. Paper presented at the meeting of the American Speech and Hear- ing Association, New Orleans,

Pryzwansky, W, B, & White, G, W, (1983). The influ- ence of consultee characteristics on preferences for consul- tation approaches, Professional Psychology Research and Practices, 14,457-461.

Rainforth, B" & York, J. (1987), Integrating related services in community instruction, journal of the Associa- tionfor Persons with Severe Handicaps, 12, 190-198,

Sobsey, R" & Orelove, F, P (1984), Neurophysiologi- cal facilitation of eating skills in children with severe handi- caps, journal of the Association for Persons with Severe Handicaps,9,98-110,

West, J. F" & Idol, L. (1987), School consultation (part I): An interdisciplinary perspective on theory, models, and research, journal of Learning Disabilities, 20,388-408,

West, W, L. (1984), A reaffirmed philosophy and prac- tice of occupational therapy for the 1980s, American jour- nal of Occupational Therapy, 38, 15-23

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