two page paper

566 September/October 2003, Volume 57, Number 5

Occupational therapists who work inearly childhood education provide interventions that support the program- ming for students with developmental delays. Currently approximately 50% of therapists in the school systems use a direct service model including a combination of individual and group intervention (Davies & Gavin, 1994). In addition to direct ser- vice, other models of intervention include indirect (also known as monitoring) and consultation.

An increasing number of therapists in the schools are using consultation for vari- ous reasons (Dudgeon & Greenberg, 1998). Some therapists choose consultation because they feel that support in the class- room will benefit the child more than direct service once a week. Sometimes this model of service is not chosen by the therapist, or determined in response to the Individual Education Plan (IEP), but is dictated by special service administrators in the hope of

increasing caseloads of the occupational therapists. However, consultation is a com- plex process and can take as much or more time as direct service (Hanft & Place, 1996). Further, when the consultation model is used, it is important to emphasize that students who need hands-on therapy must still receive direct services from an occupational therapist (Hanft & Place).

Even though some authors have sug- gested that models of service delivery may be differentially responsive to different types of goals (Davies & Gavin, 1994; Dunn, 1988; Kemmis & Dunn, 1996), recent research has found no statistically significant differences between the results of direct, indirect, and consultative models of intervention for preschoolers with motor delays (Davies & Gavin; Dunn, 1988; Kemmis & Dunn, 1996). Dunn compared the three models and demon- strated, with three students ages 6, 9, and 17 years, that all models can be effective

BRIEF REPORT

A Comparison of Consultative Model and Direct–Indirect Intervention With Preschoolers

Diann S. Dreiling, Anita C. Bundy

KEY WORDS • evidence-based practice • Goal Attainment Scaling • motor delays

Diann S. Dreiling, MS, OTR, is School Therapist, Douglas County School District, Castle Rock, Colorado. At the time of the study, she was Graduate Student, Occupational Therapy Program, Colorado State University, Fort Collins, Colorado. Mailing address: 1478 S. Moline, Aurora, Colorado 80012; [email protected]

Anita C. Bundy, ScD, OTR, is Professor and Chair, School of Occupation and Leisure Sciences, University of Sydney, Sydney, Australia. At the time the study was completed, she was Professor, Department of Occupational Therapy, Colorado State University, Fort Collins, Colorado.

OBJECTIVE. The purpose of this study was to compare the effectiveness of a consultative model of inter- vention with that of direct–indirect intervention for meeting goals of preschool students with mild motor delays.

METHOD. Two occupational therapists provided consultation to teams working with 11 children 1 day a week for all 40 weeks of the school year. A different occupational therapist provided direct–indirect treatment to another 9 children for a full week every 3 weeks for the 40 weeks of the school year. Data for both groups used in this study were kept for the last 4 months at the end of the school year or as the children appeared to be nearing completion of their goals of the study. All therapists met with their teams twice a month to plan and review progress. All parents carried out activities with their children at home. Goal Attainment Scaling was used to examine progress.

RESULTS. No statistically significant differences were found between the two types of intervention (t = .359; df = 18; p = .724).

CONCLUSION. The study suggests that a consultative model and a direct–indirect model are equally effec- tive in meeting objectives for preschoolers with relatively mild motor impairments.

Dreiling, D. S., & Bundy, A. C. (2003). Brief report—A comparison of consultative model and direct–indirect intervention with preschoolers. American Journal of Occupational Therapy, 57, 566–569.

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The American Journal of Occupational Therapy 567

for accomplishing goals. Davies and Gavin compared progress in two groups of 10 preschoolers’ ages 3 to 5 years using con- sultation with one group and direct inter- vention with the other. Dunn and Davies and Gavin have all suggested that further study should be done to define use of con- sultation in schools.

The purpose of this study was to com- pare outcomes for students with motor delays who were served through either direct–indirect intervention or consultation to parents and preschool staff.

Method Design

A between group design was used for this study. One group of children received a consultative model of intervention, and the second group received direct–indirect inter- vention.

Participants

Participants were children who were evalu- ated through a county child assessment pro- gram. The children were assigned to one of 23 integrated preschool classrooms within the county based on the results of their developmental assessment. Each classroom had 10 typically developing students and five or six students with special needs.

Twenty-two boys and girls from 12 classrooms, who met the following criteria, participated: (a) were between 3 and 5 years of age; (b) had gross or fine motor–visual motor delays defined as scores at least one standard deviation below their age norms on one standardized measure of motor skill (i.e., Peabody Developmental Motor Scales [Folio & Fewell, 1983], Learning Accom-

plishment Profile [LAP-D] [Nehring, Nehring, Bruni, & Randolph, 1992], Developmental Test of Visual-Motor Integration [VMI] [Beery, 1997]); (c) had a current IEP requiring occupational therapy; and (d) were not receiving private occupa- tional therapy or physical therapy during the time of the study. The participants did not have a medical diagnosis (e.g., attention deficit disorder, muscular dystrophy, cere- bral palsy) recorded in their school records or by parent report, and were not taking medication on a regular basis. They did not have significant cognitive or emotional delays, but some of the participants did have speech or language delays.

The children were assigned to one of two groups for the study, consultation or direct–indirect, depending on the model already in place in their classrooms. Students in the consultation group (n = 11; 7 males, 4 females; mage = 4.5 years) were selected from 6 of 8 classrooms in the dis- trict using the consultative model for occu- pational therapy. These classrooms were selected for this study because the staff was the most experienced and the occupational therapist demonstrated the greatest under- standing and use of consultation. Although these specialists all had worked for at least 3 years in Douglas County, the team mem- bers had not previously worked together (see Figure 1).

Students in the direct–indirect inter- vention group (n = 9; 5 males, 4 females; mage = 4.7) were selected from 3 classrooms (3 morning classes and 3 afternoon classes) being served by one special education team. The classes were also chosen for the experi- ence of the special education team includ- ing the occupational therapist, who had

been part of this team previous to the study (see Figure 1).

The parents were an integral part of the therapy teams in both groups. They agreed to participate during the entire study, including implementing all home programs, although, no measure of com- pliance was used for the parents in the study.

Instrumentation

Goal Attainment Scaling (GAS) (Carr, 1979) was used to determine the efficacy of each model of intervention. Using GAS, we measured the degree to which goals were achieved regardless of the intervention. The goals used as outcome measures for this study were drawn from the IEP of each stu- dent.

Procedure

Before beginning the study, parents signed informed consent forms for both their child’s and their own participation. In addi- tion, the two therapists (one in each group) who provided intervention participated in one training session with the first author to record the intervention data and prioritize goals.

We followed eight steps described by Ottenbacher and Cusick (1990) for Goal Attainment Scaling. The first author and two occupational therapists from a county assessment program (different from the therapists providing the intervention) com- pleted the initial evaluation of all the chil- dren prior to their placement in preschool. The therapists providing intervention eval- uated students who had been in the preschool program for a year. Following testing, the therapists set goals to address

Figure 1. Schematic representation of therapists, preschools, classes, and children.

Consultation

Occupational Therapists Preschool Classes* Children Frequency Duration

1 I 2 I

1 day/week 40 weeks3 ∀ 4 ∀

Direct-Indirect Service

1 I 2 I

~1 1/2 hours/week 40 weeks

3 I every 3 weeks

*Note. ∀ denotes one class within a preschool.

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568 September/October 2003, Volume 57, Number 5

the specific motor needs of each student tai- lored to the preschool environment and educational expectations.

The two primary therapists, who pro- vided consultative intervention (including the first author, who was the only therapist to take part in both initial evaluation and intervention) and the one primary therapist who provided direct–indirect intervention, determined the expected levels of perfor- mance as well as the weights for each goal. Input from parents, teachers, and special educators was considered when setting the expected levels and weights (Ottenbacher & Cusick, 1990).

Data were recorded for a total of 39 goals (M = 3.55; range = 2 to 6) for students receiving intervention through a consulta- tion model and 56 goals (M = 6.22; range = 2 to 10) for students receiving services through direct–indirect intervention. The number of goals for each student varied based upon his or her needs, parents’ input, and the determinations of the team assign- ing the goals. The results for this study are based on completion of goals. For both models of service, the special education team collected data regarding goal attain- ment weekly on all students as per the pro- tocol for the district. Data for both groups used in this study were kept for final 4 months of the study. The occupational therapists reviewed the data weekly and dis- cussed the success of the strategies with staff or parents or both. If the strategies were not effective, they were modified.

Intervention

Two occupational therapists provided con- sultation services (see Figure 1). Each ther- apist consulted to one different pre-school team. They spent 1 full day a week during the 40-week school year in the each of their assigned classrooms observing the students during various activities and consulting with the staff regarding therapeutic strate- gies used for the students’ needs in gross motor, fine motor, or visual-motor skills and student progress; they also met with the full preschool team for 1 half day twice a month during the school year. In addition, the occupational therapists met with par- ents on an as needed basis for consultation and to review home activities. At the begin- ning of the year, the consulting occupation-

al therapists spent additional time in the schools to build rapport with team mem- bers, set and review role expectations, edu- cate, and collaborate on strategies. Toward the end of the study, their time was spent primarily on evaluating and modifying ongoing treatment strategies.

One occupational therapist worked on a transdisciplinary team and provided the direct–indirect model of intervention to another 9 children for a full week every 3 weeks for the 40-week school year (see Figure 1). The occupational therapist pro- vided direct services daily in the classroom during her week’s rotation; each child received an average of an hour and a half of service per week to address the students’ needs in gross motor, fine motor, or visual- motor skills. The occupational therapist instructed the team in how to implement the intervention in her absence. She also participated in a half-day planning session weekly with the team.

Data Analysis

At the completion of the intervention peri- od, T scores were computed on the goal- related data for each student using the for- mula for GAS (Kiresuk & Sherman, 1968). The formula is:

where Wi represents the weighting for a particular goal and Xi represents the out- come score for each behavior (i.e., a value from -2 to +2). The r value in the formula reflects the estimated average intercorrela- tion for the outcome scores. An r value of .30 was suggested as a constant by Kiresuk and Sherman (1968) and Maloney, Mirrett, Brooks, and Johannes (1978); the latter felt that the r value yielded a standard deviation of 10 units around 50. The T value is a standardized score with a mean of 50 and standard deviation of 10.

Results Both models of intervention were found to help students meet their goals (Mconsult = 48.25; Mdir.svc = 49.69) at approximately the rate expected (Mexpected = 50; SD = 10). Students in the consultation group met or exceeded expectations (levels 0 to +2) on 22

of their 39 (56%) goals, whereas students in the direct–indirect intervention group met or exceeded expectations on 28 of the 56 (50%) goals. A t test for independent sam- ples revealed no significant difference between the outcomes for students receiv- ing intervention in consultative model and those receiving direct intervention (t = .359; df = 18; p = .724). The small difference between groups was supported by a small effect size (d = .16).

Discussion The results of this study indicate that a con- sultative model of intervention and a direct intervention model were equally effective for addressing goals related to improved motor performance for preschoolers in this study. This finding supports recent research that found no statistically significant differ- ence in outcomes for different types of ser- vice delivery (Davies & Gavin, 1994; Kem- mis & Dunn, 1996). These results also support the beliefs of many (e.g., Donald- son & Christiansen, 1990; Kemmis & Dunn, 1996) regarding the efficacy of consultation.

Because many of the goals in this study were similar for students regardless of the type of service they received, these results challenge theorists’ suggestions that some kinds of goals are better met with a specific type of intervention (Bundy, 1993; Dunn, 1988; Hanft & Place, 1996). Given that the goals were primarily to improve motor skill, it might have been logical to assume that direct–indirect service would be the best service approach because the occupa- tional therapist is the best trained to observe a child’s performance and alter the nature of a therapeutic task to ensure success. In indi- rect service, the occupational therapist would teach a caregiver to do particular activities with the child, thus providing the child with many opportunities for practice. However, the consulting therapists in this study were able to help other caregivers insert motor activities into their routines in particularly clever ways. Many preschool teachers use preacademic activities when transitioning from one activity to another (e.g., “children with red shirts, go line up”) whereas preschool teachers in the present study paired that with a movement activity (e.g., “children with red shirts, hop like a

(10∑WiXi)T = 50 + √ (1-r)∑Wi2 + r (∑Wi)2

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The American Journal of Occupational Therapy 569

bunny to line up”). With these preschool age children who had relatively minor dis- abilities, consultation provided opportuni- ties for repetition of motor skills in the nat- ural context of the preschool classroom or at home. This may explain some of the rea- son for the success of this model.

Another reason for the success of both models of intervention could be that the preschool teams met regularly and agreed to work collaboratively to establish and carry out suggested strategies. That is, the fit of each model to the beliefs and skills of each of the teams was particularly good. Adequate time for consultative teams to meet regularly has been considered by many authors to be necessary to the success of consultation (e.g., Kemmis & Dunn, 1996). In fact, Kemmis and Dunn (1996) indicated that remedial and compensatory interventions were equally successful within a consultative framework when the thera- pist and teacher met 1 hour weekly to col- laborate. Although administrators often see the consultative model as a way of increas- ing therapists’ caseloads, the results of this study suggest that the required time for consultation is initially just as much or more than direct intervention, but as the year progresses the amount of time required decreases. This pattern occurs because ini- tially the consultant is spending more time building rapport with, educating, and planning strategies with the teams and observing the students. As the year pro- gresses, the team typically becomes more effective at solving their own problems (i.e., determining which strategies work in their classrooms and carrying out those strate- gies) and need less time for education. Future studies could evaluate the exact amount of time that is spent in consulting versus direct intervention to give a more accurate assessment of the difference in time spent and, thus, shed light on the rel- ative cost effectiveness of each model.

Interestingly, the therapist in this study who administered direct–indirect service created significantly more objectives (M = 6.2; SD = 1.3) for the children on her caseload than the therapists who utilized consultation (M = 3.7; SD = 2.8; p equal vari- ances not assumed = .03). The reason for this is unclear. Perhaps when therapists collabo- rate with colleagues to create plans that will

be carried out by the others, they consider very carefully the number of objectives that seems reasonable. Each objective requires the insertion of one or more strategies into the school day. This can be very time-con- suming with 5 or 6 children with special needs in each classroom. Thus, more objec- tives actually may mean less success at meeting them and, consequently, less progress for each child.

A small sample size and the use of one geographic region limit the ability to gener- alize the results of this study beyond the sample. Variability of special needs among the participants may have influenced the intervention outcomes. Although all stu- dents had delays in motor skills and no diagnosable condition, other areas of devel- opment (i.e., cognitive or behavioral) were not well controlled. For future studies, par- ticipants could be only children with delays in motor skills with all other developmental areas within the limits of typical develop- ment. The extent to which parents imple- mented home programs also was a variable that was not specifically examined. As a member of a county assessment team pro- viding the initial assessments as well as part of one of the preschool teams, the first author both evaluated and provided inter- vention for four of the children receiving consultation, a factor that may have influ- enced the results. Finally, differential amounts of experience working together among the various teams also may have affected the success of their interventions.

Conclusion Eleven students who received a consulta- tion model of intervention achieved 22 of 39 (56%) goals addressing improved motor performance, while the nine students in the direct intervention model met or exceeded expectations on 28 of their 56 (50%) goals. The results of this study support the con- clusion that consultation is a viable model of intervention in preschool settings and is just as effective as direct–indirect interven- tions. ▲

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