What’s the difference between School Based or Private Pediatric OT?

People are often confused about why a child would qualify in one setting but not the other, or why therapy looks so different in the two settings. Although occupational therapists are trained to help “people participate in the things they want and need to do through therapeutic use of everyday activities (occupations)” the goal or mission of the school or clinic setting is different, thus different models are used to deliver services. Private clinics use a Medical Model where the primary goal is to address medical conditions and to help a child realize their full potential.  Schools use an Educational Model where the primary goal is to support engagement and participation in the curriculum and school setting. 

In both settings a child must have a recognized disability or disorder that affects their performance.  Both require initial evaluation to determine the need for service and continuous monitoring of the intervention plan once service is started.  The intervention plan must document a student’s strengths as well as the limitations along with setting goals to help improve performance. 

In the Medical Model, the interventions will address skills needed for tasks across a variety of settings: home, community and school. The overall goal is to help the child function to the best of their potential in all environments.  

• A doctor’s referral for services is required here in Illinois, while it is not always needed in the school setting.

• A doctor can refer because of a specific disability or because of an apparent delay in development that needs to be addressed.

• Children with mild, moderate and severe disabilities may benefit.

• Therapy can address movement and regulation quality as well as function.

• Therapy is usually delivered in a one to one setting.

• Activities can address underlying deficits in order to improve higher skill ability.

• Insurance may or may not pay for therapy services depending on the individual insurance policy.

• Therapy often looks like play, as a therapist scaffolds difficulty in games and tasks to allow for development and progress toward the goals.

In the Educational Model, the interventions address skills needed in the school environment.  The focus is on independence and functionality.  The goal for services is that a child achieve within the average range of performance as same age peers or has functional alternatives rather than fulfill their best potential.

• Direct Occupational Therapy services in the school are a related service, meaning the student must qualify for special education services due to academic concerns; a student can not qualify for direct OT services without an accompanying academic delay.

• Schools often need to prove a percentage of delay from expected age norms, meaning the performance is below the average range, not necessarily just below the median or 50th %tile.

• In other words, a child who does not perform to what may be his/her full potential but functions adequately, would not qualify for school based services.

• An occupational therapist may consult with a team for a child who has a 504 plan, or a medical condition which does not affect academic performance but limits a students access to the building or curriculum. Consultation would include accommodations needed in the classroom, environmental changes that would allow for greater access, and strategies for staff to use.

• Consultation with teachers and teams may also be provided during the Multi-tiered System of Support (MTSS) to help keep a student within the average range of functioning so that special education services are not needed.

• Therapy is often delivered in a group, within the natural context of the classroom.

• Therapy services are provided by the school district.

• Goals are directly related to the functional activities/skills that are targeted for intervention, underlying foundational skills are not the focus of therapy sessions.

Often times children qualify and receive therapy in both settings.  A child may have delays at school and need occupational therapy to enhance their participation in the approved curriculum, as well as have delays in daily functioning within the family and community. Often school therapists will work on handwriting and fine motor skills development, while the clinical therapist will work on social skills, regulation and many of the underlying foundational skills.  In these situations it is best when the therapists from each setting can talk with each other, sharing insights about the child as well as what the goals are and how the child is progressing toward accomplishing those goals.

There are many reasons why a child would need clinical OT services even though they are receiving it at school. The foundational skills needed for holding a pencil to write are the same foundational skills needed to hold and use eating utensils or a paintbrush or sidewalk chalk.  Visual scanning is necessary for reading as well as scanning a room to locate a specific toy or a second sock while getting dressed.  A child may have attention/regulation issues in school that interfere with learning, while in the home parents need strategies to get through the morning routine and out the door in time for school. There also may be times a child has room for improvement in fine and visual motor skill development necessary for handwriting, cutting and reading; but not qualify for services in the school.  In all of these instances, private clinic based services can help a child reach their fullest potential. 

Having worked in both settings, I fully understand the limitations of the Educational Model – therapy in that setting is for a different purpose than providing private occupational therapy.  Therapy in the school setting is not meant to be a replacement for clinical therapy. Students who need therapy in the school setting often have disorders that affect life outside the school as well, and private therapy is there in a more expansive manner to help a child navigate all aspects of life. 

The Impact of Reflexes on Sensory Regulation

So many times children are referred to occupational therapy because they are having problems with self-regulation. Some people are OVER responsive to information – becoming easily overwhelmed leading to emotional meltdowns.  Others are UNDER responsive, needing so much more information to just notice it – they seem bored, spaced out and aren’t available to take in new information.  And yet others need so much more information that they will do anything to seek it out, and the seeking interferes with accessing what’s happening around them in that moment. The difficulty with self-regulation is it is one of those murky problems that has such a wide variety of symptoms and related behaviors; progress often feels like one step forward and two steps back.  In all instances the person is not able to remain available for comfortable interaction with the materials, items and people in the environment around them. 

Having studied and worked with kiddos that have “regulation difficulties” over the years I’ve used a variety of tools.  Some of those are what we call top down strategies, they require cognitive problem solving to use different strategies to change their own state of regulation.  The Alert Program and Zones of Regulation are examples of these top down strategies.  Sensory Integration theory utilizes a bottom up or body based strategy that allows input through the body to influence the nervous system and change a person’s state of regulation.  By filling up the body’s needs or changing the environment to reduce the impact of environmental sensations we allow the nervous system to regulate. 

In recent years I’ve found that all of the above tools have some effect, but they aren’t treating the underlying cause of sensory regulation problems– they are treating the symptoms.  The behaviors that we observe are symptoms of a nervous system which is not effectively dealing with perceived threats from the environment. 

Individuals who have difficulty regulating their arousal level are often described as being in a fight or flight response.  This is a physiological response to a perceived threat or harmful event.  This response is triggered by the Moro Reflex.  If our Moro Reflex does not become fully integrated, we easily move into that fight or flight response at what seems to be very slight threats.  An individual might become very angry and have an over reaction, or they may engage in avoidant behaviors, trying to get away from the situation. 

A similar response would be to freeze – to not engage, or respond.  These individuals often look like they have low arousal; they aren’t paying attention to what’s going on around them.  In reality, their nervous system is feeling threatened and going into a different physiological state brought on by the Fear Paralysis Reflex.  This reflex protects us by having us stop, almost like a opossum playing dead, until the threat is gone.  It should integrate by the 3rd year of life, and when it doesn’t our nervous system will rely on this inadequate response as a coping strategy.

More and more I find that the “on the go”, hyperactive individual keeps moving because they don’t have core stability – the Spinal Galant Reflex and/or the Spinal Perez Reflex aren’t integrated properly.  These spinal reflexes are responsible for the development of our proprioceptive system, coordination of our legs and body core, postural control and attention.  When they are interfering our body stays in motion to compensate for the lack of coordinated stability. 

All of these reflexes are processed in the Brainstem or Diencepholon, meaning our brain processes all of the sensory information and forms a physiologic response before the information even reaches the Cerebral Cortex where we can “think” about the threat level of the information.  By normalizing the responses of these reflexes, we are teaching the nervous system to respond to input in an ordinary way; allowing the nervous system to remain in a relaxed/ready state instead of a hyper alert state.  This is the beauty of working with reflexes; we are effecting lasting change in the nervous system that translates into improved regulation.  We are no longer just addressing the symptoms; we are getting at the cause of the problem. 

What’s the value in an evaluation?

Many times parents ask if they really need a full evaluation.  Evaluations are expensive and time consuming.  They may have one from the school or their child had been in therapy before.  They just want to get down to the therapy, to get to the fix. 

Over the years I’ve come to value this important step in the therapeutic process more and more. In the schools we formally re-evaluate every three years and there are years I can’t wait for that re-eval year to come up again. Even though I work with a student weekly, the process of formal evaluation brings me so much information I can’t get in weekly sessions.  I often go back and re-read evaluations after months of working with an individual.  It keeps me centered on the presenting problems, allows me to see where growth is taking place and areas to focus on next.  That’s why it’s important to do a thorough evaluation in the beginning.    

So what makes an evaluation valuable? 

Let’s look at the components of the evaluation.  There are the formal assessments, the clinical observations of behavior and movement, the interpretation or analysis of all that information and finally the recommendations and treatment plan that comes out of it.  Formal assessments  are the standardized tests and rating scales which allow us to compare skill performance to same age typically functioning peers.  Some of the assessments help to narrow down exactly what pieces aren’t working as well, and where a child’s strengths lay.  Scores can be compared over time to demonstrate growth.  The limitations of standardized tests are that they demonstrate what a child can do, but they do not indicate how a child does it.  What does it take to get that result?  How is the child moving, holding themselves, reacting behaviorally?  That’s where clinical observations play an important role.  Observations give the depth and background that help inform who the child is.  Clinical observations are sometimes formal, specific activities/actions that are done to see how a child carries out the action.  Other times they are the informal observations regarding how a child reacts.  All of this observational information is important in describing the individual, what’s working and what’s not working.  The standardized tests will give us numbers, the observations will give us context. 

Both the formal assessments and the observations produce information.  It’s then my turn to look at all the information and ask Why?  Why is this individual not functioning at optimal?  What pieces are holding this child or person back?  What pieces can we use to build on to strengthen skills and perceptions? My education and training as an occupational therapist allows me to analyze the information in relation to the roles that person holds such as family member, student, team mate, worker, musician, community member etc.  How is this person and their family affected by the deficits that were identified? 

That leads right into the last and most important part of an evaluation – the recommendations and treatment plan.  Now that we know all of this, what do we do about it?  I always start with education – what does this family need to know that will make the therapy process successful?  Do they need information about how the body processes information?  Do they need to know how to adapt activities or the home to increases success and decrease stress?  Will they understand the importance of the home activities and be able to implement them?  Do they need a referral to other professionals that can also help?  This is the starting place – the learning phase.  Which is just as important as the actual therapy.  When the education base is in place, the therapy has maximum benefit. 

Finally there is the plan.  What are we going to focus on right now and set as goals? Hopefully by this point the parents have shared their goals and desired outcomes, which are incorporated into the treatment plan.  The goals are broken down into achievable and measurable objectives. Different methods are identified to achieve those goals.  And most therapists agree that a key to making progress on those goals are the incorporation of a home program, which is outlined here as well.  It’s the blueprint or working document for coming therapy. 

Here is where a full evaluation becomes so valuable – once those objectives are met, we go back o the evaluation and decide have we met the goals or are there other goals to work on.  A good evaluation will outline the next phase of treatment.   A long the way we re-evaluate using the same tools to help measure progress.  The value of the evaluation is that it provides the frame for progress to take place.  Because in the end we all want progress for a better outcome.

Why Occupational Therapy?

As I sat during Occupational Therapy Month in April, I contemplated what called me to the profession over 20 years ago.  I had a position in a profession I loved – teaching special education in a district where I was supported and knew I was making a difference.  In fact the last day of that job I cried wondering if I could ever find satisfaction in another job.   I had known I wanted to be a teacher since the age of 7, and knew I wanted to specialize and work with students that had cognitive delays since the age of 12.  Yet, the more I taught the more I felt I wasn’t making the difference I needed to make.  I could break tasks down to teach in steps, I could implement specialized curriculums, I could set up real life experiences for optimal learning opportunities.  But I couldn’t teach my students how to use their bodies to complete simple things like pushing in a knob while turning it, holding all the coins for the vending machine in their hand while placing one coin in at a time, how to calm when overexcited, or visually scan a room and find what they were looking for.  These seemingly small experiences of daily living were standing in the way of independence.

I was learning so much from the occupational therapists I worked with, but I felt it wasn’t enough.  I wanted the OT with my class as much as possible, to be there when these break downs happened so my students could learn alternatives or better yet, improve in the micro skills that were not allowing for the smooth movement, the smooth transition and the easy ability to take in information through the senses.  So I decided to go back to school and get a degree in occupational therapy, all the while thinking I would return to the classroom a much better teacher. 

Then I entered the world of occupational therapy.  It expanded everything I thought about education, about learning, about the role of the teacher in the process.  The foundation in anatomy and neurology finally helped me make sense of what was going wrong for my students.  The ability to assess deeply and locate specific avenues that can be improved for better function.  The ability to look at the environment and re-arrange it to improve the process.  Creating new ways for an individual to complete simple or complex tasks.  I was being called to a new profession – similar but so much more effective.  I eventually returned to the classroom as a therapist.  However, I still consider myself a teacher – but now I’m not just teaching a student a skill.  I’m teaching parents, teachers, paraprofessionals and administrators about the how and why of improving students skill abilities.  By bringing a more holistic view to the table occupational therapy allows for growth in emotional, social and skill development areas.  I was called to this profession, and am proud to be an occupational therapist.