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Early Intervention and School Special Interest Section FAQs

These FAQs were developed to help occupational therapy practitioners who work in early intervention and school settings understand and articulate their role and the laws and policies that regulate practice within these settings. Jump to:

Scope of Practice Questions

1. What is the role of an occupational therapy practitioner in school and early intervention settings?

Occupational therapy emphasizes “achieving health, well-being, and participation in life through engagement in occupation” (AOTA, 2014, p. S4), therefore, the role of the occupational therapy practitioner in early intervention and school settings involves supporting engagement in the occupations that comprise the early learning or school experiences of children and youth. While the focus of teachers is on learning, the focus of occupational therapy is on participation. Occupational therapy interventions are designed to help children and youth participate successfully in the daily occupations that occur within their relevant learning environments (e.g., home, daycare, school, community), depending on the age of the child. Services may include working with children with and without disabilities; training school personnel, families, and caregivers; collaborating with teams; and supporting district initiatives such as positive behavior intervention supports (PBIS), response to intervention (RTI), healthy schools, and anti-bullying campaigns.

Occupational therapy practitioners need to be able to clearly and concisely articulate the role of occupational therapy within their setting. The brochures, What is the Role of the School-Based Occupational Therapy Practitioner? Questions and Answers for Parents and What is the Role of School-Based Occupational Therapy Practitioner? Questions and Answers for Administrators were developed to help practitioners communicate their role. The Children and Youth area of AOTA’s website includes a section devoted to school-based practice and early intervention–early childhood that contain a wide variety of resources related to the role of occupational therapy in both settings, including presentations, brochures, and FAQs.

Reference

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1). http://dx.doi.org/10.5014/ajot.2014.682006

2. Can services by other disciplines such as physical therapy be provided in lieu of occupational therapy?

Under the Individuals with Disabilities Education Improvement Act of 2004, a child who is eligible for special education is also eligible to receive related services, which are the supportive services that are required to assist the child to benefit from special education (Sec 300.34)). Occupational therapy and physical therapy are separate and distinct services and are not interchangeable. The unique practice domain, skills, and expertise of each discipline differs and allows for an array of services that may be required to assist the child to benefit from special education. The practices of occupational therapy and physical therapy are regulated in all 50 states, the District of Columbia, Puerto Rico, and Guam. Only an occupational therapist or an occupational therapy assistant under the supervision of an occupational therapist can provide occupational therapy services, and only a physical therapist or physical therapy assistant under the supervision of a physical therapist can provide physical therapy services. State occupational therapy licensure laws prohibit anyone who is not licensed as an occupational therapy practitioner in that state from providing occupational therapy services. In order to help the individualized education program (IEP) or individualized family service plan (IFSP) team determine whether the student needs occupational therapy services, an occupational therapist must be included as a member of the team. Likewise, a physical therapist must be included as a member of the IEP or IFSP team if the team is considering physical therapy services. According to a letter of clarification from the Office of Special Education Programs,

[t]he determination as to whether physical therapy or occupational therapy is a related service that is necessary to assist the child to benefit from special education must be made by the child’s IEP team on a case-by-case basis in light of the child’s unique needs… Related services, including occupational therapy and physical therapy, that the IEP team determines are necessary to assist the child to benefit from special education must be included in the child’s IEP and provided to the child at no cost to the parents. (OSEP, 2004)

It is not appropriate to limit a child’s access to occupational therapy or physical therapy based on the child’s specific disability category or condition, staff availability or building assignments, administrative convenience, or reimbursement funds. For more information about how occupational therapy services are regulated in each state, see AOTA’s State OT Statutes and Regulations webpage.

References

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Office of Special Education Programs. (2004). Letter of clarification to Louis H. Geigerman, November 3, 2004. Retrieved from http://www2.ed.gov/policy/speced/guid/idea/letters/2004-4/geigerman110304fape4q2004.pdf

3. What type of services can an occupational therapy assistant provide in a school or early intervention setting, and what level of supervision is needed?

Occupational therapy assistants (OTAs) deliver occupational therapy services under the supervision of and in partnership with occupational therapists (OTs). OTs and OTAs are equally responsible for developing a collaborative plan for supervision. The OT is ultimately responsible for implementing appropriate supervision, but the OTA also has a responsibility to seek and obtain appropriate supervision to ensure that proper occupational therapy is being provided. Supervision levels are determined in each OT/OTA partnership based on several factors, including the complexity of the child’s needs, caseload size and diversity, knowledge and skill levels of the OT and OTA, type and requirements of the setting, and other regulatory requirements including state licensure laws and regulations. State licensure laws differ on this topic, and some states limit the activities that can be performed by an OTA. To determine your state-specific requirements, refer to the licensure laws for your state. See the State OT Statutes and Regulations page. Additional guidance can be found in the Standards of Practice for Occupational Therapy.

Resources

Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy Services

AOTA Advisory Opinion for the Ethics Commission: OT/OTA Partnerships: Achieving High Ethical Standards in a Challenging Health Care Environment

4. In what ways can paraprofessionals and occupational therapy aides be used to support occupational therapy services, and what supervision is needed?

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) allows paraprofessionals and aides “to assist in the provision of special education and related services” as long as they are “appropriately trained and supervised, in accordance with State law” (Sec 300.156). In some states, paraprofessionals who work with occupational therapy practitioners are considered “occupational therapy aides.” They do not provide skilled occupational therapy services but may be used to provide specifically delegated tasks for which they have been trained and have demonstrated service competency (e.g., clerical activities; workspace or equipment preparation; and predictable, routine activities with the client that do not require judgment, adaptations, or interpretation) (AOTA, 2014). Supervision for paraprofessionals must be provided and documented in accordance with state regulations. Occupational therapy practice is regulated in all 50 states, the District of Columbia, Puerto Rico, and Guam. Occupational therapy practitioners must know and follow their state’s regulations relative to the use of paraprofessionals in the delivery of occupational therapy services. These regulations vary from state to state, and in some states the use of occupational therapy aides is not allowed. See the State OT Statutes and Regulations page for more information on state supervision requirements.

References

American Occupational Therapy Association. (2014). Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 68, S16–S22. http://doi.dx.org/ 10.5014/ajot.2014.686S03

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482. 

5. What special equipment is needed to provide occupational therapy services?

Occupational therapy practitioners working in early intervention and school settings use a wide array of service models, materials, strategies, and accommodations to support a child’s participation and progress. The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) emphasizes the importance of providing services within the natural environment (Part C) and least restrictive environment (Part B). Services that are integrated within these inclusive contexts often use the equipment and materials that exist within that context. Occupational therapy practitioners may offer simple strategies through collaborative consultation with teachers or family members, help design an environment that supports improved processing for learning and performance, and use materials and equipment that exist within the natural context to facilitate greater participation in the learning activity. The individual needs of the young child or student drive this selection and application. The document, Occupational Therapy for Children and Youth Using Sensory Integration Theory and Methods in School-based Practice (AOTA, 2015) discusses options for addressing the sensory needs of children in schools.

References

American Occupational Therapy Association. (2015). Occupational therapy for children and youth using sensory integration theory and methods in school-based practice. American Journal of Occupational Therapy, 69 (Suppl.). http://dx.doi.org/10.5014/ajot.2015.696S04

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

6. What is the role of OT in transition?

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) identifies two major formal transition points for children with disabilities. The first occurs when the child ages out of the early intervention system (Part C) and begins preschool (Part B). Service providers, including occupational therapy practitioners, are expected to assist children with disabilities and their families with the transition out of Part C services. Early intervention and school practitioners can work together and arrange to attend site visits to new programs with families, help parents understand how eligibility and services change when moving from early intervention to preschool, make recommendations to the new program for environmental modifications or assistive technology, and assist the child in developing the skills necessary for the new environment, such as eating snack, putting on and taking off a jacket, or standing in line.

The second major transition occurs when children graduate or age out of public school upon turning 21 (or older, in some states). Planning for this transition must be a part of the student’s individualized education program beginning in the year a student will turn 16, and where appropriate should include independent living skills (34 CFR sec. 300.320). When students begin preparing for the transition to adult life, occupational therapy practitioners can collaborate with school team members or adult service providers to identify potential future environments and the skills necessary to function in them; analyze and subdivide tasks into discrete, teachable components; teach students to master the necessary skills; and suggest accommodations, modifications, and adaptations to tasks and activities. Additionally, occupational therapy practitioners can support students as they transition from one grade level to the next, to and from classes, between activities, from elementary school to middle school to high school, etc.

AOTA’s Transitions section includes links to a wide variety of practice resources. 

Reference

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Resources

Occupational Therapy Practitioners' Roles in Early Childhood Transition

Secrets From the Field: Secondary Transition Resources and Tips

7. What is the role of OT in assistive technology?

Occupational therapy practitioners collaborate with other members of the educational team to evaluate, select, implement, and provide training on assistive technologies that support the individual child’s abilities to access, participate in, and progress in the educational program. Assistive technologies encompass a wide range of devices that include simple, low-tech devices such as pencil grips and seat cushions as well as mid- to high-tech devices such as computer accessibility options, computer software for word prediction, power wheelchairs, and alternative and augmentative communication devices. Occupational therapy practitioners use skills including knowledge of disabilities, occupations, task analysis, environmental considerations, and collaborative problem solving to assess, recommend, and implement appropriate individualized assistive technology devices and services to support student participation.

Resources

Specialized Knowledge and Skills in Technology and Environmental Interventions for Occupational Therapy Practice

Effect of Assistive Technology in a Public School Setting

8. What is the role of occupational therapy in mental health in schools and early intervention?

Using a public health approach, school-based occupational therapy practitioners can address mental health prevention, promotion, and intervention. The mental health for children and youth systematic review (Arbesman, Bazyk, & Nochajski, 2013), Practice Guidelines (Bazyk & Arbesman, 2013) and School Mental Health Toolkit provide information and resources for occupational therapy practitioners interested in this approach. Practitioners working in schools and early intervention can team with other education professionals, such as psychologists, counselors, social workers, speech-language pathologists, special education teachers, or early childhood educators, to support the behavioral and mental health needs of children at both individual and systems levels. For example, at the individual level, an occupational therapy practitioner could foster the parent/child relationship by supporting successful engagement in important family activities and routines. At the systems level, an occupational therapist could help to implement positive behavioral interventions and supports, a behavioral initiative supported by all school staff and a commonly used multi-tiered system of support. AOTA’s children’s mental health section contains a wide variety of resources for occupational therapy practitioners including the Mental Health Toolkit, FAQs, fact sheets, and other practice resources.

References

Arbesman, M., Bazyk, S., & Nochajski, S. M. (2013). Systematic review of occupational therapy and mental health promotion, prevention, and intervention for children and youth. American Journal of Occupational Therapy, 67, e120-e130.

Bazyk, S., & Arbesman, M. (2013). Occupational therapy practice guidelines for mental health promotion, prevention, and intervention for children and youth. Bethesda, MD: AOTA Press.

Resources

Occupational Therapy Services in the Promotion of Psychological and Social Aspects of Mental Health

Positive Behavior Interventions and Supports: A Role for Occupational Therapy in Schools (Scroll to end of issue for CE article)

Incorporating Infant Mental Health Strategies Into Early Intervention Practice

 


Evaluation and Assessment Questions

1. How do I determine whether a student is in need of occupational therapy in a school or early intervention program?

When there is a suspected need for occupational therapy, the occupational therapist evaluates, with parental consent, to provide information that assists the individualized education program (IEP) team or the individualized family service plan (IFSP) team in identifying the presence of a disability and determining whether there is an educational need for occupational therapy services. Evaluation focuses on providing information to the team regarding the student’s disability and how the disability impacts their developmental needs or ability to access, participate in, and make progress in the educational program. Participation in early learning or academic, social, and other school or family routines are considered, as well as needs related to the child’s transition from school to adult life. The need for occupational therapy and other related services is determined collaboratively by the IEP or IFSP team and depends on the child’s program, educational or developmental needs, and the team-identified priorities and goals. Handley-More and Chandler (2007) recommend asking the following questions when determining the need for occupational therapy: (1) Does the child’s learning program include goals or outcomes that are relevant to occupational therapy? (2) Are the skills and expertise of an occupational therapist needed to meet the identified goals or outcomes? (3) What is the purpose of occupational therapy services, and what intervention strategies will best serve that purpose? (4) What services will be needed to support the identified goals using the identified strategies?

Reference

Handley-More, D., & Chandler, B. (2007). The occupational therapy decision-making process. In L. Jackson (Ed.), Occupational therapy services for children and youth under IDEA (3rd ed.). Bethesda, MD: American Occupational Therapy Association.

Resources

Occupational Therapy Services in Early Childhood and School Based Settings (AOTA official document)

Best Practices for Occupational Therapy in Schools, Edited by Gloria Frolek Clark & Barbara Chandler, 2013. Bethesda, MD: AOTA Press.

2. When is it appropriate to discontinue occupational therapy services in school and early intervention programs?

According to the Occupational Therapy Code of Ethics (AOTA, 2015), a collaborative decision regarding discontinuing services should be made when the goals of the services have been met or when ongoing services do not continue to produce measurable changes. In schools and early intervention settings, decisions about the need for occupational therapy should be based on the results of the child’s initial evaluation or reevaluation; his or her academic, developmental, and/or functional needs; progress data; and the goals or outcomes identified by the individualized education program or individualized family service plan team. It is appropriate to discontinue occupational therapy services when the services are no longer relevant to the child’s educational program (i.e., the service does not relate to the program and priorities identified by the team) or when they are no longer necessary (i.e., the absence of the service would not inhibit the child’s ability to participate and make progress in the team-identified program) (Giangreco, 2001). Clearly defining the outcomes for occupational therapy at the initial evaluation and having annual discussions with the teams about how therapy services will evolve as the child ages as well as when it may be appropriate to consider adding or discontinuing services, can help teams determine the on-going need for services. It is important to recognize that adding services, such as occupational therapy, onto a child’s general education program creates an environment that is more restrictive than when the child participates in the general education program without additional services. Thus, continuing to provide services when they are no longer needed may interfere with the child’s ability to receive a free appropriate public education in the least restrictive environment.

References

American Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69, 6913410030p1–6913410030p8 http://dx.doi.org/ 10.5014/ajot.2015.696S03

Giangreco, M. (2001). Guidelines for making decisions about IEP services 2001. Montpelier, VT: Vermont Department of Education. Retrieved from http://www.uvm.edu/~cdci/iepservices/pdfs/decision.pdf 

3. How are determinations made regarding the frequency, intensity, location, and model of service delivery for occupational therapy services? When is consent or a physician’s prescription needed?

According to the Individuals with Disabilities Education Improvement Act of 2004 (IDEA), the individualized education program (IEP) or individualized family service plan (IFSP) team determines the frequency, intensity, location, and service delivery model, based on the individual needs of the student or young child, of occupational therapy services. The team must consider IDEA’s mandate for a natural or least restrictive environment when making decisions about service delivery in order to minimize disruption of the student’s education or early learning program. Some states and districts have guidelines that IEP or IFSP teams may use in making service delivery determinations; however, the team is always the final decision-making entity. Signed consent must be provided by the parents in order for the child to receive occupational therapy and other special education services. Although in most states a physician’s prescription is not necessary for students to receive occupational therapy services in a school or early learning environment, prescription requirements vary from state to state. Practitioners should review their state practice act to determine the requirements for their state. Information on state occupational therapy practice acts and regulations can be found on the State OT Statutes and Regulations page.

Reference

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Resource

Occupation Therapy Services for Children and Youth Under IDEA, 3rd Edition, Edited by Leslie L. Jackson, 2007. Bethesda, MD: AOTA Press

4. What types of documentation are required for occupational therapy in the schools?

Occupational therapy practitioners must follow the standards for documentation established by federal and state laws that regulate early intervention and school programs. Under the Individuals with Disabilities Education Improvement Act of 2004 (IDEA), there are documentation requirements relating to parental notification and consent, evaluation and reevaluation, the individual education program or individual family service plan, regular reporting on student progress, and billing Medicaid for services. Other federal laws such as Medicaid and Section 504 of the Rehabilitation Act of 1973 also include provisions that affect documentation. These federal regulations are interpreted and administered at the state level, and most local education agencies use the state regulations to develop policies and procedures. The occupational therapy practitioner’s role in completing any of these documentation or paperwork requirements will vary depending on state and local policies.

In addition to aspects of the occupational therapy process that coincide with the special education process (e.g., evaluation and progress reporting) occupational therapy documentation should include an occupational therapy–specific intervention plan, service contacts, and data that show progress and therapy outcomes. The components of occupational therapy documentation are described in detail in the Guidelines for Documentation of Occupational Therapy (AOTA, 2013). State regulatory boards may have specific documentation requirements that must be followed by all practitioners working within that state. The Standards of Practice for Occupational Therapy (AOTA, 2010) provide additional guidance. Information on state occupational therapy practice acts and regulations can be found on the State OT Statutes and Regulations page.

References

American Occupational Therapy Association. (2010). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 64, S106–S111. http://dx.doi.org/10.5014/ajot.2010.64S106

American Occupational Therapy Association. (2013). Guidelines for documentation of occupational therapy. American Journal of Occupational Therapy, 67(Suppl.), S32–S38. http://dx.doi.org/10.5014/ajot.2013.67S32

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Rehabilitation Act of 1973, Pub. L. 93-112, 29 U.S.C. §§ 701–796l.


Legislative Questions

1. What are Part B and Part C of the Individuals with Disabilities Education Improvement Act of 2004 (IDEA)? How do the role and function of occupational therapy under Part B and Part C of IDEA differ?

IDEA is a federal mandate that requires that all children with disabilities have access to a free, appropriate public education provided in the least restrictive environment (34 CFR Sect. 300.1). To ensure these rights, IDEA describes the procedure by which children and youth with disabilities receive educational supports and services. Part B of IDEA addresses school-based services for children ages 3 to 21 years. Part C addresses early intervention services for children typically from birth to 3 years, with some variation between states. Under Part C, each eligible child and their family receiving early intervention services is entitled to an individualized family service plan (IFSP), which is a legal document created by the IFSP team that must include the family, the service coordinator, and a person directly involved in conducting the evaluations and assessments (34 CFR 303.348). The IFSP serves as the blueprint for services and includes the family priorities, the service providers that will assist the family in achieving the desired outcomes, and the exact nature of the services that will be provided. Under Part B, the eligible child’s education program is outlined in the individual education program (IEP), which is developed by a team comprised of the child (if older than 16), parents, and school professionals. The IEP includes information about the child’s classification for eligibility for special education services; current level of performance; classroom program and placement for the coming year; goals for achievement in the coming year; the type, duration, and location of the services provided; accommodations for the general and special education environments; and participation in state and district-wide testing.

Under Part C, educational services focus on providing family training within the natural environment of the child. Early intervention services consider the role children with disabilities play as inclusive members of their family and “are designed to meet the developmental needs of an infant or toddler with a disability and the needs of the family to assist appropriately in the infant’s or toddler’s development, as identified by the IFSP Team” [34 CFR Sect. 303.13 (a) (4)]. Services such as occupational therapy are provided in the natural environment where the child is expected to function, such as the home, day care, or community setting. Under Part C of IDEA, occupational therapy is designated as one of several professions that are “qualified” to provide early intervention services [34 CFR 303.13 (c)]. Best practices dictate that services provided support the family’s ability to function as a unit and that goals are all written in terms of the family’s priorities. The transition from early intervention (Part C) to preschool (Part B) is characterized by a change in philosophy, location of services, and expected outcomes for children and families. The primary goal of Part B services is to educate the child. The role of related services, such as occupational therapy, becomes supporting a child’s ability to access all aspects of his or her educational program. These services are typically provided during the school day within naturally occurring school contexts, without the daily involvement of family members.

Reference

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Resources

Part B of IDEA: Services for School-Aged Children

Building the Legacy for Our Youngest Children With Disabilities

Occupation Therapy Services for Children and Youth Under IDEA, 3rd Edition, Edited by Leslie L. Jackson, 2007. Bethesda, MD: AOTA Press

2. What is the difference between related service and specially designed instruction under Part B of the Individuals with Disabilities Education Improvement Act of 2004 (IDEA)?

Specially designed instruction (e.g., special education) is content, methodology, or delivery of instruction that is adapted to meet the unique needs of the eligible child with a disability to ensure access to the general curriculum so the child can meet the educational standards that apply to all children. In general, specially designed instruction refers to the curriculum and the teaching/learning process that is adapted to meet the needs of the child with a disability. Specially designed instruction focuses on learning.

All children, regardless of ability level, are entitled to a free and appropriate public education (FAPE). Related services are supports and services that are required to assist the eligible child with a disability to receive FAPE, make progress in the general curriculum, and benefit from specially designed instruction. These related or supportive services focus on helping the child to access, progress, and participate in the curriculum so he or she can receive FAPE. IDEA identifies occupational therapy as one of many related services.

IDEA specifies that any related service can provide specially designed instruction if the service is considered special education under the state standards (Sec. 300.39(a)(2)(i)). The IDEA 2004 definitions of specially designed instruction and related services are described in Sections 300.39 and 300.34 within IDEA Part B. AOTA’s Collection of OT/PT State Guidelines for School-Based Practice identifies the states that have school-based guidelines.

Reference

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Resource

U.S. Department of Education State Contacts page

3. What if a school-age child is not eligible for special education under the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) but still has needs that could be addressed by occupational therapy?

If the student is not eligible for services under IDEA, school occupational therapy services may still be accessible through various state or locally designed early intervening and instructional support programs. Such programs may include response to intervention (RtI) or other multi-tiered systems of supports (MTSS). Occupational therapists often serve on problem-solving teams within the MTSS framework designed to examine and provide support for a multitude of learning and behavioral needs for students in general education. Occupational therapists also may be available in some school districts to support student participation in school-wide approaches. Finally, school occupational therapy services may be available for a particular student under Section 504 of the Rehabilitation Act of 1973. Section 504 applies when a student has a documented disability and requires accommodations, aids, or services in order to access their education, but who would not otherwise qualify for services under IDEA. Each local school district must have a designated 504 official. Check with this individual in your local school district for additional guidance on how Section 504 is implemented.

There may be times when a child needs occupational therapy services provided outside of the school setting, such as when the child demonstrates a problem that is unrelated to participation in the school environment. If the school occupational therapist identifies such a problem, it is their ethical responsibility to refer the student and family to medically based services. AOTA’s RtI section has additional information on MTSS. 

References

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Rehabilitation Act of 1973, Pub. L. 93-112, 29 U.S.C. §§ 701–796l.

Resource

U.S. Department of Education FAQ: Protecting Students with Disabilities

4. How do the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) mandates regarding the natural environment (Part C) and the least restrictive environment (LRE) (Part B) apply to OT services?

Under IDEA, children with disabilities are educated within the same environments as their typical peers to the maximum extent appropriate. For school-age children and youth with disabilities, those include environments throughout the school such as the regular classroom, playground, cafeteria, and job training site. For infants and toddlers with disabilities, those environments may include the home, daycare, or community.

Part C of IDEA requires services for infants and toddlers to be provided

…to the maximum extent appropriate, in natural environments; and in settings other than the natural environment that are most appropriate, as determined by the parent and the IFSP Team, only when early intervention services cannot be achieved satisfactorily in a natural environment. (34 CFR section 303.126)

Occupational therapy practitioners providing early intervention services should collaborate with the family to identify priorities, address the child’s needs within the family’s everyday routines and activities, and support opportunities for inclusion.

Under Part B, the LRE mandate in IDEA states,

To the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are not disabled and special classes, separate schooling, or other removal of children with disabilities from the regular educational environment 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. (34 CFR sect. 300.114(a)(2)) 

The LRE must be considered for the child’s classroom placement as well as for all supports and services in which the child participates. Working within the LRE mandate requires collaboration with other team members in order to ensure prioritized needs are addressed in naturally occurring contexts.

When determining IEP services for an eligible child, the occupational therapist first considers whether the child’s needs can be met through collaborative consultation and/or services in the classroom and other school environments. Removing the child from the natural contexts of the school program/day should occur only when it has been determined that the needs of the child cannot be met with less restrictive levels of intervention. Occupational therapy intervention should be designed to effect change in school participation based on the individual needs of the child. If services are provided outside of the context of the school program/day (e.g., pullout services), the duration should be only as long as necessary to ensure school participation in the area of concern.

Reference

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

5. How do education reform initiatives impact school-based practice?

As a result of education reform initiatives, occupational therapy practitioners provide services beyond those addressing the needs of students with disabilities as part of an individual education program team, and are impacting the general school population. Current practice includes involvement in whole school initiatives such as Common Core State Standards, multi-tiered systems of supports (MTSS) such as response to intervention (RtI) and positive behavior intervention and supports (PBIS), a focus on literacy achievement, universal design for learning (UDL), health and fitness, anti-bullying campaigns, and a move toward increased accountability. Involvement at this level provides opportunities for occupational therapy practitioners to demonstrate their skills and knowledge in supporting students with and without disabilities. In order to stay relevant in the field of education, occupational therapy practitioners working in schools need to stay up to date on education reforms (Handley-More, Hollenbeck, Orentlicher, & Wall, 2013). For additional information on MTSS and UDL, see the RtI section. AOTA’s School-Based Practice Resources area includes a section related to the Common Core State Standards. See also the Emerging Niche area for information related to addressing bullying and obesity in schools.

Reference

Handley-More, D., Hollenbeck, J., Orentlicher, M. L., & Wall, E. (2013, September). Education reform initiatives and school-based practice. Early Intervention & School Special Interest Section Quarterly, 20(3), 1–4.

Resource

FAQs: What Should the Occupational Therapy Practitioner Know About the Common Core Standards (CCSS)?


School Setting Questions

1. What factors should be considered when determining a reasonable caseload or workload? What is the best way to advocate for a reasonable caseload or workload?

Maintaining work expectations at a manageable level is important for efficiency, effectiveness, and job satisfaction as well as an ethical responsibility. A critical first step is to shift from thinking about services in terms of caseload (number of children served) to thinking about services in terms of workload (activities that need to be done to be effective and meet the requirements of the work setting). To determine a reasonable workload, the occupational therapy department needs to (1) identify the various work activities that practitioners complete as part of their assigned duties; (2) complete a time study to collect data on the time practitioners spend engaged in the various work activities; (3) group the work activities into meaningful categories such as hands-on services, team collaboration, documentation/paperwork, etc.; and (4) analyze the data to determine how occupational therapy time is being used. If some of the expected work activities are not getting done (or they are getting done outside the workday), the data can help identify ways to be more efficient or tasks that could be delegated or eliminated. Sharing the objective time use data with administrators can be a very effective way to advocate for more reasonable workload expectations and to justify hiring new staff. The Caseload to Workload page includes additional resources, including a link to a time study data form.

Resources

Occupational Therapy Code of Ethics (2015)

Best Practices for Occupational Therapy in Schools, Edited by Gloria Frolek Clark & Barbara Chandler, 2013. Bethesda, MD: AOTA Press.

2. What is the purpose of Medicaid billing in schools?

State and local education agencies are responsible for assuming the costs of public education, including the cost of special education and related services. Under the Individuals with Disabilities Education Improvement Act of 2004 (IDEA), students with disabilities are entitled to a free appropriate public education, with special education and related services provided at no cost to themselves or their families. However, when a student’s disability is due, in part, to a medically related condition, IDEA recognizes that schools should not be the sole financier of all of the services the child may require. As a result, IDEA allows states and local districts to use sources of public funding, including Medicaid, to help pay for school-based medical services provided to eligible students by qualified providers. However, Medicaid eligibility cannot influence the service delivery model or the amount of services a child with a disability receives. Likewise, the lack of Medicaid funding should not be a barrier to receiving any and all special education and related services determined necessary by the individual education program or individual family service plan team. See Medicaid-Based Billing FAQs for more information.

3. What is the procedure for performance evaluation of occupational therapists in the schools?

Most states have recently revised or created new laws regarding the evaluation of educational personnel as a result of recent federal initiatives. In some states, school-based occupational therapists are included in the new evaluation procedures. Occupational therapists who work directly for school districts may be evaluated in the same way other teachers and educational personnel are evaluated. Nevertheless, occupational therapy is a distinct profession that is not always understood by school administrators. Occupational therapy practitioners may need to work closely with administrators to help them understand occupational therapy’s distinct role. Also see Guidance for Performance Evaluation of School Occupational Therapists.

4. How can occupational therapy practitioners demonstrate their contribution a to overall student achievement?

Occupational therapy practitioners contribute to overall student achievement in numerous ways, including support of the state’s learning standards and use of universal design for learning (UDL) principles. Occupational therapy services in the schools always support the achievement of academic standards, either directly or indirectly. For example, an occupational therapy practitioner who helps a student access the writing curriculum by using technology is directly supporting the achievement of academic writing standards. An occupational therapist who consults with a teacher to ensure implementation of UDL principles in the general education classroom is indirectly supporting student achievement related to state learning standards. Using evidence-based practice and detailed data collection regarding how services result in increased student participation in the curriculum is essential to demonstrating occupational therapy’s contribution. For example, an occupational therapist who designed movement activities for a preschooler to engage in before small groups may collect initial data regarding the time on task during the small group activity. Increased time on task after engaging in movement activities suggests that the occupational therapist’s intervention supports the student’s participation in classroom activities. Additionally, occupational therapists must be familiar with scientific literature addressing their most commonly used practices.

Resources

Results of a School-Based Evidence-Based Practice Initiative

Providing Effective Occupational Therapy Services: Data-Based Decision Making in School-Based Practice

5. How can occupational therapy practitioners participate in response to intervention (RtI) or other multi-tiered systems of supports (MTSS)?

The extent to which occupational therapy practitioners are involved in MTSS may depend on the policies and procedures of their local and state education agencies. However, the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) allows for up to 15% of special education funds to be used for professional development, evaluations, services and supports to enhance student performance in general education. Under IDEA, occupational therapists can assist with school-wide screening or provide professional development on scientifically based practices that are within the profession’s practice domain such as universal design for learning and differentiated instruction. Practitioners can use co-teaching to model strategies that support motivation and tap into student strengths. In schools that are implementing positive behavior intervention supports, practitioners can help identify school-wide behavior expectations across school environments and provide suggestions for how to teach and implement them. Practitioners can also participate in problem solving teams that review school-wide behavior data, conduct functional behavior analyses, and provide suggestions for behavior interventions to support individual students. The RtI section of the website contains additional resources.

Reference

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Resources

Response to Intervention: Occupational Therapists’ Personal Stories

Positive Behavior Interventions and Supports: A Role for Occupational Therapy in Schools (scroll to CE article)

6. Why is collaboration important?

Occupational therapy practitioners “…collaborate with their clients during evaluation and intervention to develop a plan of services that supports participation” (Handley-More, Wall, Orentlicher, & Hollenbeck, 2013 p. 2). The Individuals with Disabilities Education Improvement Act of 2004 also requires collaboration among team members. Occupational therapy practitioners collaborate with classroom staff, parents, and other team members to identify participation-based needs of the individual child. Collaboration is also necessary to identify and implement strategies and accommodations that support participation. There is a growing body of evidence that supports collaboration as an effective service delivery model (Hanft & Shepherd, 2008; Orentlicher, Handley-More, Ehrenberg, Frenkel, & Markowitz, 2014).

Reference

Handley-More, D., Wall, E., Orentlicher, M., & Hollenbeck, J. (2013, June). Working in early intervention and school settings: Current views of best practice. Early Intervention & School Special Interest Section Quarterly, 20(2), 1–4

Hanft, B., & Shepherd, J. (2008). Collaborating for student success: A guide for school-based occupational therapy. Bethesda, MD: AOTA Press.

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Orentlicher, M. L., Handley-More, D, Ehrenberg, R., Frenkel, M., & Markowitz, L. (2014, June). Interprofessional collaboration in schools: A review of current evidence. Early Intervention and School Special Interest Section Quarterly, 21(2), 1–3. 

7. Is additional certification or training needed to work in school and early intervention settings?

Occupational therapy practitioners graduate from their pre-professional education programs with the foundational knowledge and skills needed to practice in a variety of settings, including early intervention and schools (Swinth, Chandler, Hanft, Jackson, & Shepherd, 2003). Some states require additional state-level certification and/or training to work in these settings.

According to the Occupational Therapy Code of Ethics (AOTA, 2015) practitioners working in any specialized setting (e.g., hospital, school, home health, etc.) have a responsibility to deepen their understanding of legislation, professional practice standards, guidelines, and policies that are relevant to service provision within that setting. For the school or early intervention practitioner, this includes state and federal laws and regulations governing early childhood, general, and special education; education reform initiatives; and how the role of occupational therapy within school and early intervention settings differs from other practice settings. Although not required, AOTA offers board certification in pediatrics and specialty certification in school systems for practitioners who are interested in earning advanced credentials.

References

American Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69, 6913410030p1–6913410030p8. http://dx.doi.org/10.5014/ajot.2015.696S03

Swinth, Y., Chandler, B., Hanft, B., Jackson, L., & Shepherd, J. (2003). Personnel issues in school-based occupational therapy: Supply and demand, preparation, certification and licensure. (COPSSE Document No. IB-1). Gainesville, FL: University of Florida, Center on Personnel Studies in Special Education. Retrieved from: http://copsse.education.ufl.edu//docs/IB-1/1/IB-1.pdf

8. How do I find evidence to support occupational therapy practice in school and early intervention settings?

AOTA has a variety of evidence-based practice resources that can support practitioners who work in schools and early intervention programs, including a collection of relevant links to American Journal of Occupational Therapy articles, Practice Guidelines, and critically appraised topics. The Evidence-Based Practice Resource Directory can be searched by area of practice (e.g., Children and Youth EBP Resources) and provides links to databases, tutorials, and evidence-oriented websites. The Evidence-Based Practice and Research area also has links to Practice Guidelines, a Journal Club Toolkit and other evidence-based practice resources. Practitioners may also have access to searchable databases through their employer, state association, or local university. For example, practitioners who maintain their certification credentials through the National Board for Certification in Occupational Therapy have access to ProQuest, a service that provides a searchable database of publications relevant to medical and allied health professionals. Practitioners looking for supporting evidence can start a journal club using AOTA’s Journal Club Toolkit, write a critically appraised paper on the topic, and submit it to AOTA’s Evidence Exchange.

Best Practices for Occupational Therapy in Schools (Frolek Clark & Chandler, 2013) provides a comprehensive collection of evidence-guided interventions. Strategic and systematic data collection can also provide evidence to support the delivery of occupational therapy services and the effectiveness of therapy interventions.

Reference

Frolek Clark, G., & Chandler B. E. (Eds.). (2013). Best practices for occupational therapy in schools. Bethesda, MD: AOTA Press.

Resource

The Issue Is—Facilitating Evidence-Based Practice: Process, Strategies, and Resources

9. Where can I obtain additional information about providing occupational therapy services in schools and early intervention?

AOTA offers numerous resources for occupational therapy providers working in school and early intervention programs. These can be accessed in the Children and Youth practice area and the Early Intervention & School Special Interest Section page. Books and continuing education products related to schools and early intervention are available at the AOTA store. Practitioners may also access resources, ask questions, and network with other practitioners in the Early Intervention & School Special Interest Section forum on OT Connections (AOTA log in required).

10. How can I promote my role within my school or early intervention setting?

Occupational therapy practitioners working in school and early intervention settings may need to engage in advocacy activities to encourage school administrators to understand and use the full scope of occupational therapy. Here are some tips and strategies to get you started:

  • Know the state and federal laws! The law empowers you.
  • Explore the Children and Youth section and become familiar with the tools and resources available.
  • Share AOTA’s resources (e.g., brochures, presentations, fact sheets, and official documents) with parents, staff, and administrators.
  • Start a dialogue with administrators, using AOTA’s resources.
  • Provide an inservice for your school staff or parent/teacher organization.
  • Stay current with the evidence and best practice and share your approaches and outcomes with administrators and co-workers.
  • Be able to clearly articulate your distinct role and contributions within your setting.
  • Volunteer to serve on school, district, and state-level committees such as curriculum review committees, positive behavioral interventions and supports teams, the local education association council of representatives, or assessment accommodation committees.
  • Get involved in state advocacy activities through your state occupational therapy association, state education association, or state department of education. 
  • Connect with other practitioners and work together to address common issues or concerns.
  • Address the most important things first. Collaborate with other team members to determine what matters most to the student, teacher, and parent.
  • Be able to articulate your advanced knowledge and skills including level of education, credentials, licensure, national exam certification, etc.