Friday, March 11, 2016

Soapbox Moment--Hey, It's Friday

Clinical Reasoning During/After Conducting an Evaluation:

So, let's say I've just completed an evaluation.  That means:
  • I’ve worked with the student 1-1 to assess his school-based fine motor/self help/sensory regulation abilities,
  • Observed him arriving in homeroom and getting ready for the day,
  • Taken note of who he talks to, where he sits during group time, how he attends to his teacher and the other students,
  • Peeked inside his desk and journals, then compared his organization and classwork to peers,
  • Watched him line up for transitions and walk down the hallway,
  • Studied how he reacts to the noise in physical education, lunch, recess and assemblies,
  • Compared his grasp of a spoon or fork to his grasp of a pencil/paintbrush/percussion stick
  • Interviewed his teacher and delved into his family’s concerns,
  • Read reports from his community-based OT…and,
  • now it’s time to analyze the findings.
So, here's my quandry:

When do we “pick up” students for therapy, when do we provide classroom suggestions and when do we end our involvement with the student  after the eval  is completed and shared with the IEP team?
Of course, deciding whether or not OT services are required for the student to access his/her educational setting is a “team” decision.  However, the team relies heavily on the therapist to give a careful opinion on whether or not the student requires our services to be able to access his/her classroom, school building, needed materials, community-based settings and more.

We have about 15 OTs on our staff and, despite having peer review groups to sift through our reasons for recommending/not recommending services, I think we all have different criterion for making our decisions.  When I began working in schools I used a assessment of neurological screening, along with other factors, to determine which students might benefit from OT services.  There I was, asking students to assume quadruped and passively rotating their heads to see if I could elicit an A-TNR.  If they exhibited the reflex then I did yearlong sensorimotor groups to improve their “intrinsic” motor development, so they would write better, cut better and attend more easily to school matters.   This is how I developed my caseload in schools where there were classes (all self-contained in that era) for students with learning and/or emotional disabilities.  I don’t know about you, but I find myself exhibiting an A-TNR when I yawn and stretch my arms or when I pick up a heavy tote full of my OT stash—and I’ve scooted on scooter boards and propped on forearms alongside kids for 35+ years.  You’d think my sensorimotor skills would be perfect by now.

I look for different markers now when I do assessments and most of them relate to what the student needs to do at school.  Can he retrieve what he needs in his pencil box or book bag at the same rate as other students?  If yes, then he’s organized “enough” in class.   Does she know to sit on the edge of the group, next to a peer who is calm and friendly?  That’s a good indication of a young student’s early self-advocacy and emerging interpersonal skills.  Does he write legibly enough that his teachers can read his answers on a worksheet, yet independently use his school-issued laptop for the majority of his other writing?  That counts as being able to appropriately manage writing tasks at school.
What I’m looking for, when it comes to recommending direct OT services, is what does the student need to do that only OT can help him achieve?  Does a 4th grader write legibly, and comfortably, with an immature grasp?  He doesn’t need OT as a related service so he can switch over to a perfect, tripod grasp; it's time away from class that is not critical to his school success.  But, if he can’t sustain a steady grasp on the paintbrush in art because of muscle fatigue then I know how to adapt the paintbrush, the activity, the position of the easel and the knowledge base of the teacher so the student can be independent.  My services are needed.

If we were to assess primitive reflexes, fine motor skills, coordination, sensory-sensitivity and other measurable components that make up a child, many students in special ed and general ed would fall below the average range.  If I had to score within the 1st standard deviation from the norm in all of those areas to pass my employment physical I’d never get the job.
When we consider whether or not a student needs our services to access the school environment, to their highest level of independence, let’s remember that we’re here to provide services that are unique to our professional training and experience.  Although we certainly are useful as intuitive and skilled classroom helpers our mission is not to provide services that are within the scope of other professionals—teachers, instructional assistants, physical education teachers, art teachers and many others.  We deliver the skills and knowledge that we have been educated and trained to provide when it comes to meeting the needs of the student, and then we work ourselves out of a job by training other team members to help that one, specific student, become independent in school.   This may take a semester or much longer, but my goal is independence—on the part of the student and the people he may need for support.

I see my job as figuring out why a student is having difficulties with a critical task at school, trying out and practicing easier or adapted methods for the student to master the skills needed to perform the task and then training the teacher and/or parents on how they can keep the skill moving along.  How do you see your job at school? 


Tonya said...

I agree wholeheartedly.

Christopher Alterio said...

The reason why so many people in our profession struggle with this issue is because we have abandoned our own theory base and in its place we adopt the values of whatever system we are working in. Problematically, those systems often have arbitrary criteria for service provision.

So in the school our colleagues struggle with educational relevance, only to find that educational relevance is actually a relative concept devoid of any real performance standard. In rehab we follow care pathways or FIM cutoff criteria established by an insurance company.

Therapists struggle because they don't have their own theory base that identifies function vs. dysfunction. Now, even if we did, we would still find it at odds with whatever systems we were working in.

It will get worse. Now our professional association wants us to engage in 'value based purchasing' agreements where again some other entity will tell us what constitutes occupational therapy 'value.' We are supposed to embrace a 'triple aim' of healthcare that promotes cost cutting and rationing over patient based need and therapist judgement.

Occupational therapists will solve these problems by decreasing work within these systems and increasing work in more direct roles in private practice. When we do work within those systems we also need to stand up for our own definitions of what constitutes eligibility for services and make those recommendations based on conservative and evidence based decisions.