School-Based Occupational Therapy

Individuals with Disabilities Education Act (IDEA)

Most children with disabilities receiving occupational therapy in schools obtain services under IDEA, with a smaller number served under Section 504 of the Rehabilitation Act of 1973. IDEA establishes educational programs that ensure two significant rights for children with disabilities—FAPE in the LRE.⁶⁷ Four additional principles guiding the education of children with disabilities were adopted with the original law in 1975 and have remained unchanged, but with subsequent amendments (Box 24-1).

Each of these concepts has significant implications for the public education system, children with disabilities and their families, and occupational therapists. A “free appropriate public education” refers to special education and related services that (1) meet the standards of the state education agency (SEA); (2) are provided at public expense; (3) are under public supervision and direction; (4) include an appropriate education at preschool, elementary, and secondary levels; and (5) are provided in accordance with an individualized education program (IEP). “Free” means at no cost to parents, but of course does not preclude the incidental fees that are normally charged to students without disabilities. The word “appropriate” is more difficult to define because it does not necessarily refer to a grade level or the chronologic age of a child. The IEP, as the centerpiece of IDEA, is used by parents to ensure the development of an “appropriate” special education program to meet their child’s unique needs. This program is based on results of a comprehensive, multidisciplinary assessment. As part of the educational team, occupational therapists have essential roles in these processes.

Least Restrictive Environment

IDEA mandates that students with disabilities be offered special education and related services in the LRE. This means that children with disabilities are educated with children who are not disabled, to the maximum extent appropriate (§300.114). Whatever the disability, the first student placement that should be considered according to IDEA is the general education classroom, with appropriate aids and supports.⁴² This policy is clearly stated in IDEA; the “removal of children with disabilities occurs only when the nature or severity of the disability of a child is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily” (32 C.F.R., §612[5][A]). The overriding rule is that placement decisions must be determined on an individual basis, based on the child’s unique needs and IEP.

The amount of support provided to students integrated in general education varies from a full-time aide to periodic, consultative services by an occupational therapist or special educator. When a child cannot be educated in the regular classroom, an alternative placement is considered. Accordingly, schools are required by law to ensure that a continuum of alternative placements is available to meet the needs of children with disabilities. This continuum includes a range of alternative placements such as instruction in regular classes, special classes, special schools, home instruction, and instruction in hospitals and institutions. Most children with disabilities spend at least a portion of their day in general education classrooms.

Evolution of IDEA

Although the original goal of FAPE in the LRE for children with disabilities has not changed, each reauthorization of IDEA has prompted reflection and a reevaluation of educational services, which, in turn, has brought about important shifts in the delivery of special education and related services.

In 1986, amendments allowed states to provide preschool and early intervention services for children with disabilities from birth to age 5. To reflect current language, the law’s name was changed to the Individuals with Disabilities Education Act in 1990. This amendment authorized additional services (i.e., assistive technology services and devices and transition planning). The reauthorization in 1997 was significant in placing greater emphasis on delivering related services to children with disabilities within the context of the student’s general education curriculum.^59,65 As a result, there has been a gradual shift in service delivery from traditional “pull-out” approaches to the integration of occupational therapy services into the student’s classroom and other relevant school environments (e.g., lunchroom, playground, restroom).⁷⁸ This shift has required occupational therapists to become knowledgeable about the curriculum adopted in specific classrooms and within their school district so that they can better specify how a student’s disability affects functioning within the educational environment and develop relevant intervention strategies. The IDEA Amendments of 1997 also focused on student outcomes by requiring students with disabilities to be included in state and districtwide assessments.

IDEA was most recently reauthorized in 2004 as the Individuals with Disabilities Education Improvement Act. The primary goals of IDEA 2004 are to increase the focus of education on results; prevent problems through early intervening; and improve students’ academic achievement, functional outcomes, and postsecondary success.⁴⁵ By focusing on accountability and improving educational outcomes, Congress intentionally aligned IDEA 2004 with the No Child Left Behind Act (NCLB) of 2002. The long-term goal of special education and related services according to IDEA is to prepare students with disabilities for further education, employment, and independent living.

Section 504 of the Rehabilitation Act and the Americans with Disabilities Act

Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990 (ADA) complement IDEA to ensure nondiscrimination against children with disabilities in public schools.⁸⁷ Section 504 requires schools receiving federal funds to provide qualified students with disabilities access to public education. The ADA ensures that the educational program is accessible to individuals with disabilities and may include providing specific accommodations. The definition of “disability” under Section 504 and ADA includes any student with “a physical or mental impairment that substantially limits one or more major life activities, who has record of such an impairment, or is regarded as having such an impairment” (34 C.F.R. 104.3(j)(2)(i)). Some examples of impairments that may substantially limit major life activities are mental illness, specific learning disabilities, arthritis, cancer, diabetes, and hearing impairment. Major life activities include caring for oneself, education and learning, performing manual tasks, seeing, hearing, speaking, working, walking, and breathing. Because this definition is broader than IDEA’s definition of disability, students who are not IDEA-eligible may be 504-eligible for accommodations to access to the learning environment. “Under Section 504, occupational therapy can be provided alone or in combination with other educations services and may be provided directly to students or as program supports to teachers working with the student” (p. 1).³ Student eligibility for Section 504 services are documented in guidelines developed by each state and local school agency.

Sometimes students with diagnoses such as attention deficit–hyperactivity disorder (ADHD), for example, are not eligible for special education programs. However, these students may struggle to fully participate in classroom activities and often benefit from occupational therapy services. Occupational therapy in the schools can be provided to these students under Section 504. Because the definition of disability is broader in this civil rights act, a child may be eligible for occupational therapy, even when he or she is not eligible for special education services. Although school personnel are not required to develop IEPs for students served under the Rehabilitation Act, a team should develop a written plan that states goals, services, and accommodations needed to meet those goals.⁴⁵

Although additional federal and state funds are not provided for these laws, school districts that do not provide accommodations to students who are eligible through Section 504 and ADA can lose federal funding. Occupational therapy practitioners may assist the school team in determining the most effective and efficient solutions for meeting students’ needs under Section 504 and the ADA.

No Child Left Behind

NCLB, signed into law in 2002 (Public Law 107-110), made major changes to the Elementary and Secondary Education Act of 1965. The original intent of this law was to ensure that all children have an equal opportunity to participate in and receive a good education in school.⁶⁶ This law, which is considered a key component in the education reform movement, covers all public schools in all states.

NCLB is mainly understood to be a general education law emphasizing increased accountability for results. Under this law, states are working to close the achievement gap by establishing high achievement standards for all students, especially those who are disadvantaged because of poverty or disability.⁸¹ Based on yearly testing, annual state and district report cards indicate whether the state, district, and schools are making adequate yearly progress (AYP) toward proficiency (i.e., achieving grade level). Parents whose children are attending Title I (low-income) schools that do not make AYP for several years are given the option to transfer their child to a better performing school or obtain free tutoring.⁸² In addition to proficiency testing, NCLB raised the requirements for public school teachers in all states to meet the standards of “highly qualified”—holding at least a bachelor’s degree and having passed a state test of subject knowledge.

This synthesis of legislation provides the foundation for understanding the evolving role of occupational therapy practitioners working in schools. In the following sections, occupational therapy’s traditional role serving children with disabilities is presented, followed by a discussion of emerging roles in general education and school mental health based on current legislation. For example, changes brought about by the reauthorization of IDEA and the enactment of NCLB have been instrumental in providing opportunities for expanding occupational therapy’s role to serving all children attending school.⁴⁵

Occupational Therapy Domain in School-Based Practice

Education is identified as one of the key performance areas in the Occupational Therapy Practice Framework: Domain and Process, 2nd edition (Framework-II) (2008) and refers to the “activities needed for being a student and participating in the learning environment” (p. 620).¹ The occupation of education includes academic (math, reading, writing), nonacademic (recess, lunch, self-help skills), extracurricular (sports, band, cheerleading, clubs), and prevocational and vocational activities.⁴⁹ Consequently, in addressing a student’s education, attention to a broad range of occupational performance areas is often required to help children succeed in their student role including play, leisure, social participation, activities of daily living, and work.

Occupational therapists working in schools must skillfully combine their professional knowledge and skills with the definition of occupational therapy in federal and state education legislation. School districts are mandated to provide related services, including occupational therapy, when a student who receives special education requires such services to benefit from special education. “Related services” means “transportation, and such developmental, corrective, and other supportive services (including speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, social work services, school nurse services… counseling services, including rehabilitation counseling, orientation and mobility services, and medical services, except that such medical services shall be for diagnostic and evaluation purposes only as may be required to assist a child with a disability to benefit from special education, and includes the early identification and assessment of disabling conditions in children” (§300.320(a)(4)). Special education and related services may be provided in a number of settings including schools, homes, hospitals, juvenile justice centers, and alternative education settings.²

Occupational therapy services must be educationally relevant, by contributing to the development, or improvement, of the child’s academic and functional school performance. The regulations of IDEA define occupational therapy broadly as “(A) improving, developing or restoring functions impaired or lost through illness, injury or deprivation, (B) improving ability to perform tasks for independent functioning when functions are impaired or lost, and (C) preventing, through early intervention, initial or further impairment or loss of function” [§300.34(c)(6)]. Occupational therapy services can promote self-help skills (e.g., eating, dressing); positioning (e.g., sitting appropriately in class); sensory-motor processing; fine motor performance; psychosocial function; and life skills training.⁶⁴ Services must be provided by a qualified occupational therapist or service provider under the direction or supervision of a qualified occupational therapist. Although regulations focus on what constitutes “highly qualified” teachers, requirements beyond adhering to state licensure laws have not been created for occupational therapy.⁴⁴

Occupational Therapy Process in School-Based Practice

The reauthorization of IDEA (2004) increased the focus of special education and related services on results—including academic achievement, functional outcomes, and postsecondary success. Expected outcomes for students with disabilities leaving high school include higher education, employment, and independent living (§602(d)). In collaboration with other members of the education team, occupational therapists contribute to the referral, evaluation, intervention, and outcome processes. With these important outcomes in mind, a key question guiding the special education process should be: “What does the child need or want to do to be successful as a student now and to prepare for future roles?”⁷⁹ The special education process is depicted in Figure 24-2. This section describes the occupational therapy processes of referral, evaluation, and intervention.

Referral

Each local education agency (LEA) has a “Child Find” system that locates, identifies, and evaluates all children who have disabilities and need special education.⁶⁹ A referral of a child suspected as having a disability may be made by any source, including parents, teachers, or other individuals. An occupational therapist evaluation may be requested at the time of initial referral if the team perceives that information provided by an occupational therapist will contribute to the evaluation process. This suggests how critical it is for school administrators and other team members to have an accurate understanding of the domain and scope of occupational therapy practice—that occupational therapists address the education, activities of daily living, play, leisure, work, and social participation areas of function related to the student’s academic and nonacademic expectations. If team members have a narrow understanding of the scope of occupational therapy practice (e.g., occupational therapists address handwriting issues), then it is likely that the role of occupational therapy in that setting will be narrow as well.⁴⁸ Effort spent in informing principals, teachers, school psychologists, and other personnel about the role of occupational therapy in regular and general education ensures that students who may benefit from occupational therapy services are identified.

Evaluation

“Evaluation means procedures used in accordance with §§300.304–300.311 to determine whether a child has a disability and the nature and extent of the special education and related services that the child needs” (§300.15).

After obtaining parental consent, a full and individual evaluation is completed by a multidisciplinary team to determine whether the child is eligible for special education and, if so, it identifies educational and related service needs (§300.301). This multidisciplinary evaluation is needed even when the child has an obvious disability (e.g., cerebral palsy, Down syndrome) and has received therapeutic services in the past (e.g., in an early intervention program). In addition, this team determines the nature and scope of the full and individual evaluations for each child and decides if related services evaluations, including occupational therapy, are needed. The role of the occupational therapist in the evaluation process depends on how well he or she has explained the role and the team’s understanding of the domain and scope of occupational therapy.

IDEA and the OTPF define evaluation and assessment consistently.¹ Evaluation refers to the process of gathering and interpreting information about the student’s strengths and educational needs. Assessments refer to the tests or measures used to obtain data about specific areas of function. IDEA specifies that school personnel evaluate referred or eligible students in all areas of suspected disability. Furthermore, a variety of assessment tools or evaluation strategies must be used to obtain relevant academic, functional, and developmental information about the student (§300.304(b)(1)). The evaluation must be completed within 60 days of initial parent consent, unless the state specifies otherwise.

Top-down or occupation-based approach. Although one of the main purposes of evaluation according to IDEA is to determine eligibility, which is based on qualifying as a child with a disability, the law has placed greater emphasis on assessing the child’s participation needs in relevant school contexts. This thinking is in agreement with current social views regarding the evaluation of children and those adopted within the profession of occupational therapy. A top-down approach to evaluation is believed to more accurately reflect the true nature of occupational therapy and has been referred to as occupation-based evaluation.⁶⁹ A top-down approach to evaluation begins with gathering information about what the person needs and wants to do across a variety of occupational performance areas and settings (Figure 24-3).^18,30 Box 24-2 provides a description of the School Function Assessment¹⁹ representing a top-down strategy used to initiate the evaluation process. Performance component function is assessed to the extent that it is thought to limit participation in occupation. An occupational therapist’s ability to implement this approach is dependent on using appropriate evaluation strategies and assessment tools, developing the knowledge and skills needed to implement these strategies, and then actually using them in practice.

International social views of children’s health also focus on participation in context. The World Health Organization (WHO), for example, recently published the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), in 2007.⁸⁶ This document emphasizes that the health of children is dependent upon their participation in context—both within their stage of development and in relevant environments. Similar to IDEA and OTPF, this model focuses on how multiple factors (i.e., individual abilities, activity, and context) influence the child’s function.⁶⁹

Individualized Education Program

The IEP represents both the formal planning process and the resulting legal document that establishes the services and programs that will enable the student to participate in school activities and receive an “appropriate education.” According to IDEA (34 C.F.R. §§300.320–300.324), the IEP is a written statement for each child with a disability that outlines the student’s educational and functional needs and the supports and services required to meet those needs. It is developed, reviewed, and revised in a meeting in accordance with the guidelines of the IDEA.

The IEP team is made up at minimum of the child’s parents; one regular education teacher of the child; one special education teacher of the child; one special education provider, when appropriate; a representative of the public agency who had knowledge and qualifications; an individual who can interpret the instructional implications of the evaluation results (may be one of the other members); other individuals who have knowledge or special expertise regarding the child (e.g., related services personnel) as appropriate, and the child with a disability when appropriate (34 C.F.R. §300.321(a) and (b)(1)). Although related services personnel are generally considered “discretionary” team members (§300.321(a)(6)), if an occupational therapist formally identified as a member of a particular IEP team or if occupational therapy is being discussed at the meeting, it is fitting and desirable that the therapist attend the meeting.⁴⁵

The collaborative planning procedure that guides the process of developing an IEP involves many components. The school-based occupational therapist contributes to many of those components when participating as a member of a student’s IEP team. Although the exact components may vary from state to state, depending on the special education policies and procedures adopted by the state, the following items represent at least the minimum for all states because they are mandated as general requirements by IDEA (34 C.F.R. §300.320(a))(Table 24-3).

The first steps involve interpretation of the most recent evaluation of the child, consideration of the child’s performance on any general state or districtwide assessment programs, and identification of the student’s strengths and needs. It also involves discussion with the parents, educational team, and sometimes the student regarding priorities and goals. During this initial phase, it is important to “create a team ‘vision’ about who the student is and what a student needs to succeed in school” (p. 1).⁴⁹ This information is documented on the IEP as the present levels of academic achievement and functional performance and the description of how the student’s disability affects participation in general education. For a preschool student, consideration is given to whether the disability affects participation in any activity appropriate for a preschooler. Typically, all team members participate in developing this statement, which includes a summary of all evaluation results, thus giving a total picture of the student’s academic and functional performance. Occupational therapists should be ready to share evaluation results, which are included in the student’s present levels of performance. Therapists should specify how the student’s performance influences participation in the general education curriculum, including functional activities. For example, sharing the student’s time delay before initiating work, percentage of time engaged in off-task behavior, or how writing speed relates to educationally relevant performance in written expression. In the case of a preschool student, the therapist should document whether the performance results suggest problems that will affect the student’s access to typical preschool activities. Table 24-4 provides examples of educationally relevant present levels of performance and statements of need.

The next step involves the development of measurable annual goals (both academic and functional) designed to enable the student to have access to and make progress in the general education curriculum and meet the child’s other educational needs that result from the child’s disability (34 C.F.R. §300.320(a)(2)(i)(B)). The goals are statements of measurable and attainable behaviors a student is expected to demonstrate within 1 year. Many states are linking goals to their state curriculum content standards.⁴⁴ This ensures that the goals are related directly to the learning objectives mandated by the SEA for all students. IDEA 2004 eliminated the requirement of writing short-term objectives (benchmarks) in the IEP except for children with disabilities who take alternate assessments aligned to alternate achievement standards (§300.320(a)(2)(ii). Congress opted to eliminate short-term objectives as a way to reduce paperwork and also because parents are informed of short-term progress through the use of quarterly and other periodic reports. Although short-term objectives are not required for all students receiving special education, a plan for measuring progress must be documented, specifying how the child is meeting IEP goals and when periodic progress reports will be provided (such as through the use of quarterly reports concurrent with the issuance of report cards) (34 C.F.R. §300.320(a)(2)). It should be noted that the frequency of reporting progress must be at least as often as the progress reports received by the parents of nondisabled students. The actual progress attained toward the goals must be included. Occupational therapists are responsible for measuring progress toward annual goals and objectives when they are one of the services listed to support that student’s goal. Often, several members of the IEP team share data keeping for a student’s progress toward general education goals.

Goal writing is a collaborative process and is completed at the IEP meeting with the input of all team members including the parents, and in some cases the student. Goal writing in most districts is facilitated by an online process that enables the IEP to be developed on a shared website. Student needs are prioritized and academic and functional goals are selected based on identifying skills that are needed to progress in the general educational environment. Team members, including occupational therapists, must relate their activities and recommendations to the general education curriculum and extracurricular activities. Therefore, all team members must be knowledgeable about the classroom curriculum and behavioral expectations and the state educational standards. Target behaviors are those actions and skills that students typically do or need to develop, such as participating in physical education, writing an essay, eating lunch independently, playing with friends during recess, and participating in after-school clubs.⁴⁹ Although occupational therapists may identify limitations in discrete performance skills that negatively impact school participation, such separate clinical goals should not be suggested to the IEP team. Goals need to address academic achievement and functional performance. Furthermore, the occupational therapist may feel that a particular skill is a priority for a child. However, when viewing the whole child, the team may not concur. If this is the case, some negotiation among IEP team members may be needed to select the priorities for the child so that appropriate goals and objectives can be developed for the student. A description of how to develop goals is provided in Box 24-3.

Once the IEP goals have been developed, the team determines the special education, related services, supplemental aids and services, modifications, and supports to be provided by the school. These pertain to the student’s advancement toward the annual goals and access to the general education curriculum, and participation in nonacademic and extracurricular activities. The IEP team determines if related services are “required to assist a child with a disability to benefit from special education” (34 C.F.R. §300.34(a)). “One of the most important clarifications that teams should understand is that students with disabilities do not attend school to receive related services; they receive services so they can attend and participate in school” (p. 6).³⁴ Therefore, the role of the school-based occupational therapist is not to provide a full rehabilitation program but to support the child’s efforts within the academic environment and only if necessary.³² In general, occupational therapy services under IDEA are not provided when a student has a temporary impairment (e.g., a fractured bone) or when an impairment does not interfere with the student’s performance in school. For example, a bright first grader had mild left hemiparesis cerebral palsy. This student participated in all aspects of the educational program, including physical education, with few adaptations. The disability did not interfere with the student’s educational program. Therefore, she was not eligible for occupational therapy in school, despite the fact that she did not have the full use of her left hand (Figure 24-6).

It is important, however, for the occupational therapist to effectively communicate the domain and scope of occupational therapy services to the entire IEP team so that an informed decision will be made regarding service provision. On the basis of evaluation findings, the occupational therapist articulates to the IEP team recommendations regarding the need for occupational therapy services to enable the child to benefit from his or her education. The IEP team makes the decision based on the student’s educational program and unique needs. “Occupational therapy services are appropriate when the unique skills and expertise of the occupational therapist are needed to support the priorities identified by the team” (p. 78).⁴⁰

If the occupational therapist is to provide services to the student, it must be noted specifically in this section of the IEP along with the projected date for initiating services and anticipated frequency, location, and duration of the services. Documentation of the type of occupational therapy service delivery should ensure that a range of service approaches be available to the student—both direct (to the child) and indirect (on behalf of the child) services. Based on the individualized needs of the student, direct intervention may be necessary during one week, whereas indirect consultation provided to the teacher on the student’s behalf may be useful during the next week. In addition, flexibility in documenting time and frequency is also recommended (i.e., 2 hours per month or 1 hour per grading period), rather than specifying set weekly visits. “For example, a high school student may need 3 hours the first month to set up a prevocational program and to train the instructional team. Much smaller periods of time, such as 1 hour per month, may be needed when the OT returns in subsequent weeks to evaluate the effectiveness of the program and revise as needed” (p. 3).⁶⁸ Recommendations for duration of services, generally written as beginning and ending dates, and location of services (e.g., cafeteria, classroom, playground, hallways) must also be specified.

The occupational therapist may also participate in suggesting appropriate modifications and support based on the assessment results. As an example, the occupational therapist may suggest limiting the amount of information on the student’s worksheets because of a student’s poor visual figure-ground processing. If the team were to agree to the recommendation, it would be documented on the IEP. Similarly, a statement of any individual appropriate accommodations that are necessary to measure the academic achievement and functional performance of the child on state and districtwide assessments consistent with §612(a)(16) of the IDEA, must also be determined by the IEP team.⁶³ In addition, if the IEP team determines that the child must take an alternate assessment instead of the regular state or districtwide assessment of student achievement, a statement of why the child cannot participate in the regular assessment and why the alternate assessment is appropriate for the child must be documented. The occupational therapist may contribute in the team discussion about appropriate testing modification. For example, the occupational therapist may suggest testing a student with sensory sensitivities in a separate room. For a student with motor limitations and difficulty with handwriting, the occupational therapist may suggest using an electronic text format of the test that would allow the student to use a keyboard. Each state determines the allowable modifications.

Once the IEP team has determined what the child needs in terms of special education services, the team can determine where the services should be provided. Placement decisions are made annually based on where the IEP team has determined that the student’s IEP goals can be met.⁸⁸ In accordance with LRE as defined in the IDEA, children with disabilities are required to be educated with their nondisabled peers to the maximum extent appropriate (34 C.F.R. §300.114(A)(2)(i)). This means instruction must be available in a continuum of placement options ranging from regular education classrooms to specialized classrooms, residential facilities, and home-based programs. Removal to separate classes is permissible only “if the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily” (34 C.F.R. §300.114(A(2)(ii)). On the basis of student’s IEP goals, the team should consider whether supplementary aids and services provided within a general education classroom would allow the student to receive an appropriate education or whether such a placement would impede her or his learning and/or the learning of other students. If a child will not be participating fully with children without disabilities in a regular classroom, in nonacademic and extracurricular activities, there must be an explanation on the IEP as to the extent the child will not be participating.

Finally, once the child turns 16, or before that if determined appropriate by the IEP team, the IEP must include a written transition plan. Transition is the process of beginning to plan for the student’s completion of education and postgraduation life. This plan is based on age-appropriate transition assessments related to training, education, employment, and, when appropriate, independent living skills. The transition plan should include a statement of the services needed and should clearly connect the student’s goals for after-school life and a planned course of studies in high school. The transition services (including courses of study) needed to assist the child in reaching those goals may include vocational training, supported employment, independent living, work experience, community participation, or planning appropriate high school classes in preparation for college. When the student reaches age 16, a statement of interagency responsibility is also included in the IEP. Occupational therapists may be involved in this process by providing input on the student’s functional capabilities related to vocational planning and community living.

The development of IEPs can be a daunting task because of the changing legal requirements with each reauthorization of IDEA and the changing face of each IEP team. Occupational therapists need to develop the skills to work effectively with a multitude of parents and professionals. Although IEP teams have characteristics that make them like other types of working teams, there are also unique characteristics to IEP teams that need to be considered by the various members. It has been suggested that IEP teams differ from other teams in the following ways²⁰:

As a result of these differences, development of the IEP involves high levels of collaboration and, at times, negotiation among and consensus building by all team members. The written IEP document is developed in a formal meeting, so the contents reflect the consensus of the team. Parents and other team members, including occupational therapists, contribute equally to the process. The team members discuss the student’s strengths and needs and then develop goals, outcome statements, and plans through a collaborative process. By developing the student’s IEP using a team process that includes the family, the team assures the family that the IEP belongs to the student and is unique to that student’s educational needs.

Occupational Therapy Services

Once the IEP team agrees that occupational therapy services are necessary to support the student’s goal achievement, the occupational therapist can propose how to provide services. IDEA 2004 recognizes that services and supports need to be delivered in different ways for children with disabilities to benefit from education. The nature of occupational therapy practice in schools is complex because of the considerable variability in service provision including the target of services (who), types of services and how these are delivered (what and how), scheduling of services (when), and place of delivery (where).

Although the primary “client” is the child, intervention may also target general and special education teachers, other related service providers (e.g., music therapists), administrators (e.g., principals), and paraprofessionals involved in supporting the child’s IEP.^14,41 Intervention with a variety of “clients” occurs as a direct result of employing a range of service delivery options. Traditionally, services in schools were provided directly to the child in an isolated therapy setting similar to clinical practice. This type of service delivery involves primarily one “client” —the child. However, IDEA does not mandate any one service model and allows for a range of services including those provided directly to the child (direct), on behalf of the child (indirect), and as program supports or modifications for teachers and other staff working with the child (indirect) (§614(d)(IV). Services provided on behalf of the child or to provide program supports, require the therapist to work directly with a range of other “clients” including regular and special educators, parents, or paraprofessionals. For instance, a therapist may consult with the classroom teacher to help modify instructional materials and methods for a student with physical or organizational needs requiring close interaction with the teacher. Decisions about how occupational therapy services are made based on the child’s needs, the educational program, and expected outcomes.^14,67 Examples of the range of services provided by an occupational therapy practitioner are working individually with children, consulting with the teacher about a student, co-leading a small group in the classroom, providing an in-service training program for educational personnel, and/or working on a curriculum or other school-level committee.⁷⁷ For example, an occupational therapist may co-lead groups with a special education teacher as discussed in Box 24-4 (Figure 24-7).

In addition to determining the most effective range of services for a child, therapists are also encouraged to provide services in a flexible manner depending on the student’s stage in the therapy process and particular needs. For example, the occupational therapist may choose to work directly with a student for several weeks to teach the student how to implement the ALERT Program of Self-Regulation,⁸⁵ followed by consultation with the teacher or paraprofessional to ensure generalization of the strategies in the classroom.

Another factor influencing occupational therapy service provision is a consideration of the different approaches to intervention—to promote health, prevent disability, restore function, adapt/modify task, or maintain function. Traditionally, occupational therapy’s role in the schools has focused on restoring function and adapting the task or environment to promote participation for children with disabilities. However, the reauthorization of IDEA and NCLB has created new opportunities for occupational therapy to contribute to health promotion and prevention in all children. The shift to preventive models of service delivery will likely broaden the definition of “client” for occupational therapists to include all children in general education.

Given the variability, provision based on the unique needs of each child given the who, what, when, where, and why determining needed services, occupational therapists must enter school practice aware of this complexity and the personal and interpersonal skills required to succeed in such an environment. For example, therapists need good organization and time management to develop and maintain their work schedules given the variability of school settings and types of service needs of their particular caseload. Therapists must be as effective and efficient as possible in meeting the complex demands of their job. Providing group interventions to children with and without disabilities, for example, offers an opportunity to serve several children at once and allows the therapist to assess and promote social participation among the group members at the same time.

In addition to the required documentation for the IEP and follow-up progress reports, routine documentation of service provision is not mandated by IDEA. The occupational therapist should develop a method of documentation of services to record the student’s progress toward goals, response to interventions, other changes in performance, and strategies that were promising or ineffective.¹⁴

Annual Review and Reevaluation

The student’s IEP must be reviewed by the IEP team at least once a year, or more often if the parents or school requests a review. Outcomes are measured by student achievement of the IEP goals, including participation on state and districtwide assessments.² At the time of review, it is important to keep in mind one of the primary goals of IDEA 2004—to improve student academic achievement and functional outcomes in addition to postsecondary success. The long-term goal is for students with disabilities to leave high school prepared to work, attend higher education, and live independently.

Termination of related services may be decided at any annual review if the team determines that the related service is not necessary for the student to benefit from her or his IEP. The occupational therapist may recommend termination when the student has acquired the needed skills and uses them during school, when needed adaptations and supports are in place, or when services have failed to produce the desired outcomes despite numerous approaches and lengthy attempts.⁶⁸ At least every 3 years, the child must be reevaluated to determine if he or she continues to be a “child with a disability” as defined by IDEA and then to redefine the child’s educational needs.

Prevention-Based Multitiered Services

The reauthorization of IDEA in 1997 ended a long period during which special education and general education were viewed as separate programs serving separate populations.⁷⁵ IDEA 1997 placed greater emphasis on the inclusion of students with disabilities in general education by embedding special education and related services in the classroom and extracurricular activities when possible. General and special education practices have further aligned as a result of IDEA 2004 and NCLB, providing school personnel including occupational therapists with increasing opportunities to expand their role in schools, particularly in the area of prevention.¹³

These shifting roles can be visualized as a movement from a two-tiered to multitiered model of service delivery (Figure 24-10). The traditional two-tiered system represents students falling into one of two categories—children with disabilities who meet eligibility criteria as outlined in IDEA or Section 504 and receive services or students in general education who do not receive services. A concern with this system is that some children in general education with learning or behavioral difficulties do not qualify for services under IDEA. In such instances, children may experience frustration and failure before becoming eligible for special education and related services.¹³ In contrast, a multitiered model of supports and services commits to the success of all students by providing early identification and intervening services.

To address increasing concerns among parents, teachers, and policymakers that some students have not received needed help in a timely manner, two provisions in IDEA 2004 enable schools to help students struggling with learning or behavior before they are referred to special education.⁶³ These are early intervening services (EIS) and response to intervention (RtI).

Comprehensive EIS are designed to help students in general education who are not eligible for special education but who need additional academic and behavioral supports to succeed in school (34 CFR §300.226). Schools are allowed to spend up to 15% of special education funds for EIS, including professional development for teachers and other staff and to fund direct services, such as small group instruction, behavioral evaluations and supports, or information on the use of adaptive and instructional software. Related services are specifically included in IDEA 2004 (§300.208) as possible EIS. In addition, under NCLB, occupational therapists may function as pupil services personnel (professionals who provide services to students) in providing EIS.

The second provision in IDEA 2004 developed to prevent school failure is the response-to-intervention (RtI) process. Federal regulations (34 C.F.R. §§300.307–309) require that states adopt criteria for determining that a child has a specific learning disability.⁸³ RtI is a research-based model of schoolwide support services that focuses on providing high-quality instruction and intervention matched to student needs followed by systematically looking at their response to education/intervention.^61,73 Although originally explored as an approach assisting students with specific learning disabilities, evidence has supported its effectiveness for any student with academic or behavioral problems.^5,52

The overall purpose of RtI is one of prevention and early intervention—to identify and address student problems early to reduce the need for more intensive services later. Typical practices underpinning an RtI model include (1) high-quality general education instruction based on scientific evidence, (2) continuous progress monitoring of student performance, (3) universal screening of academics and behavior, and (4) the use of multiple tiers of instruction that are progressively more intense based on the student’s response to intervention.⁸³ Most states and local districts use a multitiered model of interventions and supports made up of three levels—Tier 1 (universal or core instruction); Tier 2 (targeted intervention); and Tier 3 (intensive intervention). In a three-tiered model, the first tier provides school- or classroom-wide interventions made up of high quality instructional, behavioral, and social supports for all students.⁷³ Whole-class screening is used to assess whether academic and behavioral performance is appropriate for the student’s age and grade. For the group of struggling students, Tier 2–targeted interventions may be developed by student support teams (SSTs) to address specific needs. Interventions and supports at this level may include small group interventions or more intensive instruction such as tutoring. At this level, interventions reflect more intensive 1:1 services and supports provided within general education or special education.

With the growing movement to a three-tiered system of service provision, it is important for occupational therapists to envision, articulate, and advocate for their role within each of the tiers. For example, occupational therapists should educate student-support teams on how their services can meet the academic and behavioral needs of students in general education.⁴⁵ At Tier 1 (schoolwide services), occupational therapists can assist the general education team in helping students access and participate in the curriculum by paying careful attention to areas of function within our scope of practice—education, social participation, play/leisure, activities of daily living, and work. For instance, the occupational therapist may participate in universal screening of handwriting to identify students who are struggling (depending on whether the state allows screening).³ This might be followed by providing a teacher in-service training presentation on multisensory strategies for teaching handwriting and joining a curriculum committee to assist in identifying an appropriate handwriting curriculum. To help foster student attendance and positive behavior, the occupational therapist might assist educators in implementing the ALERT Program in their classroom.⁸⁵ In addition, the occupational therapist might join a school team working on a student conduct and behavior management program to become aware of issues in this area and offer strategies from an occupational therapy perspective.

At Tier 2 (targeted interventions for those at risk), the occupational therapist might develop a social skills group for students struggling with behavior management and social interaction with peers. Tier 3 interventions call for more individualized interventions for those not responding to Tier 2 interventions. At this level, students may receive such services as a part of RtI or may be referred for special education.

With opportunities to expand occupational therapy’s role in general education, therapists might be questioning how they can create time to provide prevention and early intervening services. Traditionally, an occupational therapist’s job expectations have been based on a caseload model of counting the number of children receiving direct intervention as a part of their IEP.⁴ This model often neglects to account for essential indirect services including collaborative consultation, team meetings, and in-service trainings.⁷⁶ In contrast, the concept of workload encompasses all of the direct and indirect services performed to benefit students making a workload approach helpful for conceptualizing work patterns that optimize effectiveness and impact.⁴ Occupational therapists must have the flexibility of organizing their work patterns to serve students in their LRE, collaborate with teachers and other school personnel, attend meetings, supervise and train occupational therapy assistants, plan interventions, and collect data. Careful documentation of workload using a time study may help state regulatory boards become knowledgeable about the range of occupational therapy services and encourage them to adopt a workload versus caseload system of documenting service provision. Kentucky, for example, has adopted a workload model, defining workload as “the amount of minutes per day, week, or month a therapist needs to work to adequately perform his/her duties” (p. 43).⁷⁵

The School Mental Health Movement

Although mental health services for children have historically been provided in hospitals and community mental health centers, the EHA of 1975 was the first federal initiative that required schools to meet the mental health needs of students with emotional disturbance, playing a key role in blurring the lines of responsibility for where such services should be provided.^7,53 Because IDEA focuses solely on students with identifiable disabilities that interfere with educational achievement, only a small percentage of children needing mental health services actually receive such care in school. Nonetheless, most children receiving mental health services obtain care in schools, making schools the “de facto mental health system for children in this country” (p. 62) (see Figure 24-1).⁵³

A national movement to develop and expand school mental health (SMH) services has grown during the past 2 decades as a result of the high prevalence of mental health conditions among youth and the awareness that more youth can be reached in schools.^54,84 Approximately one in five children ages 9 to 17 have a diagnosable emotional or behavioral disorder, with the most common being anxiety, depression, conduct disorders, and attention-deficit/hyperactive disorder (ADHD) (see Chapter 13).⁵¹ Prominent federal initiatives (Surgeon General’s Report on Children’s Mental Health, 1999, and President’s New Freedom Commission on Mental Health, 2003) have identified fragmented services and gaps in care, forcing federal, state, and local child-serving agencies to address the mental health needs of children attending school.⁸⁴ As a result of federal support, two national technical assistance centers were developed in 1995 to promote mental health in schools—the Center for Mental Health in Schools at the University of California at Los Angeles (UCLA) and the Center for School Mental Health Analysis and Action (CSMA) at the University of Maryland. Despite the recent emphasis on SMH, the field can be viewed as underdeveloped and emerging—far too many children continue to be underidentified and underserved in schools.⁵¹ Schools must be active partners in the mental health of children because it is currently accepted that a major barrier to learning is immature or limited social-emotional skills and not necessarily cognitive impairment.⁵⁰

Multitiered Public Health Model of School Mental Health

Although the mental health field has traditionally been viewed as the domain of mental health specialists, it is now acknowledged that addressing mental health issues is far too complex to relegate to a few professionals. Experts are calling for a paradigm shift to better prepare all school personnel (teachers, administrators, psychologists, social workers, and related service providers) to proactively address the mental health needs of all students.⁵⁰ Teachers and other front line personnel, including occupational therapists, play a crucial role in the development of children from both an academic and personal, social, and emotional perspectives.

The failure to adequately provide mental health services for children has been viewed as a major public health concern, causing leaders in the field to propose a public health model of service delivery to address the needs of all children.^23,50 A public health model supports a systemwide shift from an individual, deficit-driven model of intervention to a schoolwide strength-based model focusing on prevention, early intervention, and integration of services for all children. Similar to RtI, three major tiers of service are promoted—universal or schoolwide intervention, selective/targeted interventions, and intensive individualized interventions (Figure 24-11).

The Role of Occupational Therapy

With occupational therapy’s rich history of addressing mental health in all areas of practice, along with the call for all school personnel to proactively address children’s mental health, the role of occupational therapy in SMH seems clear.⁷ Occupational therapy practitioners have specialized knowledge and skills in addressing psychosocial and mental health needs of individuals and thus are well positioned to contribute to all three levels of prevention and intervention. A continuum of occupational therapy early intervening services (EIS) aimed at social emotional and mental health promotion, prevention of problem behaviors, early detection through screening, and intensive intervention is recommended. Depending on state guidelines, these services could involve occupational therapy practitioners working directly with students, providing professional development for school personnel, or working collaboratively with teachers and parents.

Occupational therapists can use a number of traditional approaches to guide service provision within a public health model including meaningful occupations and sensory strategies. The findings of a recent evidence-based literature review, for example, indicate that activity-based interventions help improve children’s peer interactions, task-focused behaviors, and conformity to social norms.⁴⁶ An example of an activity-based approach to foster successful completion is analyzing and modifying homework requirements for a child experiencing anxiety. Other traditional occupational therapy approaches used to evaluate and address the psychosocial needs of children include sensory-based interventions and social learning theory.

In addition to traditional occupational therapy intervention approaches, other approaches developed in the fields of psychology and education are often used by occupational therapists—social-emotional learning (SEL) and positive behavior supports (PBSs).

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