PHYSICAL & OCCUPATIONAL THERAPY

SCHOOL BASED SERVICES

…Ensure all children with disabilities have available to them a free appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living (Sec 300.1)

…Meet the child’s needs that result from the child’s disability to enable the child to be involved and progress in the general curriculum; and

Meet each of the child’s other educational needs that results from the child’s disability

(Sec. 300.320(a)(2)(A-B)

Purpose of IDEA

Related services means transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education, and includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, ….

(Sec. 300.34[a]) http://idea.ed.gov/explore/home

Related Services

All students with an IEP are ELIGIBLE for PT & OT

Student with documented disabilities may be ELIGIBLE for PT & OT

NOT ALL STUDENTS WITH IEP NEED PT & OT

Students without an IEP??

Who is ELIGIBILE for PT & OT?

Deliver services to improve ability to perform tasks for independent function◦ Includes accommodating a disability

Promote access to special education programming. ◦ Does not necessarily mean maximizing motor skills

Conduct context-based assessments to evaluate access, participation in educational activities and environments◦ Emphasis on function within performance environment

Enhance participation/performance in school with specific, skilled interventions focused on attainment of educational outcomes.

WHAT DO PT’s & OT’s DO?

Gross Motor ◦ Functional mobility for changing positions,

negotiating the classroom and campus alongside peers

◦ Postural stability for attention and focus on educational tasks

◦ Transportation, Carrying Items/materials, using the bathroom, participating at recess or in PE

◦ Assist in incorporating movement activities into instruction

◦ Motor Planning◦ Body Awareness

AREAS PT’s & OT’s ADDRESS

Fine Motor◦ Pre-writing and Handwriting difficulties related to

disability and that limit access/participation◦ Self Help Skills – fasteners for clothing

management◦ Scissor skills ◦ Visual motor skills – tracking, copying from

blackboard, scanning, etc.

AREAS PT’s & OT’s ADDRESS

Support ◦ Support early intervening services/RtI model◦ Reduce environmental barriers that limit student

participation◦ Use assistive technology to support student

success◦ Sensory integration strategies/supports ◦ Maintain Health, Prevent Contractures/Deformities ◦ Staff education – body mechanics, classroom

adaptation, reduce risk for injury◦ Suggest adaptive equipment ◦ Team Meetings◦ Parent Contact◦ Student Advocate!

AREAS PT’s & OT’s ADDRESS

Safely navigate environment?

YESSafe navigation

indicates that within their individual

classroom they have functional gross

motor skills to access and functionally

perform the tasks required of them

within their classroom.

NO This may look like the student who steps on other

students when finding their spot on the

carpet or trips over classroom obstacles.

This may be an indication of a gross

motor concern.

Safely Access All Areas of School?

YES Remember that all

students may not be the most active kid on the playground. Our goal is that they are able to access all the equipment and

are able to participate in games/activities with their peers.

NOThis may be the

student who can’t climb the stairs to the slide or auditorium,

the student who avoids certain

equipment due to fear, or the student

who consistently spills food off their

tray. This may be an indication of a gross

motor concern.

Concern: Functional Mobility

Falling significantly more

than peers?

YESFalling significantly

more than peers can indicate a gross

motor concern. Fall risk can also increase with increased fatigue

when walking. It is also important to take

into account the student’s

attention/hyperactivity levels.

NOStudent falls are a common event in

elementary schools. Young students are more likely to fall

than older students. Students who have decreased attention are also more apt to tripping and falling.

Injuries due to Falls?

YESMost typical falls do

not result in significant injuries to students. This can

indicate a gross motor concern with balance or safety responses. Please

also consider consultation with the nurse if the student breaks bones easily.

NOMost student falls do

not result in significant injury.

Scrapes and bruises are common,

especially in young students..

Concern: Functional Mobility

Balance Coordination Strength Endurance Body Awareness Attention

Skills for Functional Mobility

The ability to maintain the line of gravity within the base of support with minimal postural sway.

Able to compile/organize information from◦ vision ◦ vestibular◦ kinesthesia/proprioception ◦ muscle tone

Balance challenged by◦ changing base of support (feet together)◦ Limiting/changing sensory input (uneven

surfaces) ◦ Static/dynamic movements (speed of movement)

Concern: Balance/Postural Stability

Coordination is when movements of several limbs or body parts combined in a well-trained, smooth and efficient way to complete a task.

Coordination difficulties typically stem from cerebellum – may appear clumsy, frustrated, and difficulty learning new skills

Ataxia: lack of coordination seen with existing diagnosis (i.e. MD, CP, MS)

Dyspraxia: altered or decreased coordination

Concern: Coordination/Praxis

Poor Timing Poor Balance

Difficulty sequencing Proprioception difficulties

Ambidextrous Sensory processing difficulties

Low muscle tone Fatigue

Conscious force created through muscle contraction

Stable “core” = solid base of support◦ Solid base of support = more precision/control

NOT muscle tone◦ Tone is unconscious response to a stretch on the

muscle◦ Can be low (hypotonia) – decreased response

Slower reaction time, increased fatigue Associated with Down Syndrome, Autism (?), SMA

◦ Can be high (hypertonia) – increased response Rigid, difficult to move Associated with cerebral palsy, TBI

Concerns: Strength

Understanding what position one’s body is in, where & how one’s body is moving through space & in relation to other objects◦ Processing information from various sensory systems

to build a “body map” Vestibular Difficulties: movement intolerance Tactile Difficulties: Need more/less touch to learn Proprioception Difficulties: Falls frequently; falls out of

chair Poor body awareness may impact

◦ Motor planning◦ Crossing midline◦ Fine motor skills, including handwriting

Concerns: Body Awareness

Student that has difficulty blocking out environmental stimuli to focus on a task.

May appear “wiggly” ◦ If movement is not interfering with academic

progress, allowing movement may assist with learning.

◦ Ergonomic considerations – position/posture in seat, position in classroom

Concerns: Attention

Concern: Handwriting

Explicit Instruction in Handwriting?

YES: Letter formation requires memory, eye-hand coordination, fine

motor muscle coordination, visual

perceptual skills, postural stability

stability, and visual tracking skills.

NO: Students MUST receive explicit

handwriting instruction to

develop efficient legible handwriting. Students must also be provided with opportunities for

repetition and practice.

Knows All Letters – Upper & Lower

Case?

YES: Letter formation requires memory, hand eye coordination, fine

motor muscle coordination, visual

perceptual skills, postural stability,

and visual tracking.

NO: To be an effective writer,

students’ must have knowledge of letters

and their corresponding

forms. Drill and practice to help fill in this educational

gap is appropriate.

Concern: Handwriting

Writing better copying than free writing?

YES: Continue exploring motor skills that may influence the

student’s writing.

NO: A student who is able to copy

legibly, but unable to free-write

legibly likely does NOT have a motor

impairment. Observations to

see which component(s) of

the written language process is failing may be

required.

Student passed vision screening?

YES: Continue exploring motor skills that may influence the

student’s writing.

NO: Consult with family regarding vision concerns

and seeking vision assessment.

Provide accommodations in meantime.

Concern: Handwriting

Concerns with Grasp?

YES: Implement strategies to

assist, i.e. pencil grasp, short

pencils, mechanical pencil

or soft lead pencils. OT may

consult to provide additional

strategies.

NO: A functional but atypical grasp does not require intervention or

alteration.

Spacing, Orientation, Posture Limiting Legibility?

YES: Implement strategies to

assist, i.e. finger spacing or

highlighted lines, change chair

height.

NO: Motor skills are likely not impacting the

student’s handwriting.

Continue to offer opportunities for instruction and

practice.

Posture Grasp Pre-Writing Skills Visual Motor Skills

Skills Required for Handwriting

Good posture allows for more precise control of hand & fingers for handwriting

90-90-90 Posture is Best◦ Elbows, hips and knees at 90 Degrees◦ Feet flat on floor or foot rest◦ Raise or lower desk heights as needed◦ Computer screen at eye level

Concern: Posture

Concern: Pencil GraspDoes the student have any of these grasp/grip concerns?

Pushes Too Hard/Soft Complains of Hand Grasp Concerns Moves Whole Arm Switches Hands Fatigue or Pain

YESYES YES YES

Initial interventions to try: mechanical pencil, felt or fabric

under paper, or softer lead pencils.

For more suggestions, please consult with OT for Tier II Strategies.

Initial interventions to try: a pencil grip, encourage

play with putty or Playdoh. Consult

with OT regarding additional

suggestions for preventing hand

fatigue.

Initial interventions to try: “The Pencil Grip”, use of golf pencil or broken crayons. Consult with OT regarding

pencil grasp strategies.

This is often seen with younger

students. Encourage them

to keep their forearm on table

and allow opportunities to work on vertical

surfaces.

This is often seen with younger

students. Continue to encourage them to

utilize only one hand. If they have not

developed a preference for one hand, this could

indicate a need for Motor Therapist

Consult.

YES

Concern: Pencil GraspWhat Grasp is Your Student Using?

Dynamic Tripod (Functional)

Dynamic Quadropod (Functional)

Adapted Tripod (Functional)

Five Fingertip (Functional)

Thumb Wrap (Functional)

Fisted/Palmer (NON-Functional)

Difficulty imitating block building patterns Difficulty matching shapes/puzzles Difficulty identifying simple directional

concepts Difficulty tracing a line Difficulty imitating after demonstration Difficulty copying/drawing simple shapes

◦ (i.e. circle, vertical line, horizontal line, cross) Inappropriate pencil pressure

◦ Too light◦ Too Dark

Concern: Pre-Writing

Illegible handwriting Letter reversals Inaccurate letter formation

Concern: Letter Formation

Letters too close together Letters too far apart Letters written over or under the writing line Letters too small Letters too large

Concern: Spacing & Alignment

Visual Spatial Perception◦ Too much/not enough pressure◦ Spacing ◦ Messy/disorganized work

Tracking◦ Difficulty reading and writing across page/pages◦ Turning head while reading◦ Skipping letters/words when copying ◦ Squinting/closing one eye

Shifting Focus◦ i.e. Copying from Black (white) board

Concern: Visual Motor

Difficulty holding or using scissors ◦ OVER THE AGE of FOUR (4) YEARS

Difficulty opening and closing scissors Chopping paper

Concern: Cutting

Difficulty opening and closing fasteners Difficulty dressing Difficulty sequencing steps Difficulty with self feeding

◦ Using utensils, opening/closing containers◦ NOT chewing & swallowing

Difficulty toileting ◦ NOT POTTY TRAINING

Concern: Self-Help

Consult with therapist◦ Describe student and concerns ◦ Describe perceived impact ◦ Describe any attempted strategies

Determine with therapist which strategies may address concerns ◦ Classroom strategies?◦ RtI Plan?

If concerns appear to indicate a motor concern, determine with therapist if assessment is appropriate.

Consult versus Evaluation

Identification of School-

Based Issues

Observe & Document Concerns

Prioritize Concerns

Pre-Referral Strategies

Implementation of

Strategies

Evaluating the Results

Goals

NOT Met

REFER for Evaluation

If strategies NOT working, develop new strategies.

If strategies ARE working, continue 4-6 weeks.

Goals

MET

Pre-Referral for OT & PT

Tier I: Universal Level Support: ◦ Instruction, curriculum, screenings to meet needs

of majority of students in general classroom setting

◦ OT & PT role is to promote universal design for learning, provide minimal input to benefit all students i.e. ergonomics, developmental sequence,

handwriting acquisition, movement breaks for improved learning

◦ NO ROLE AT INDIVIDUAL STUDENT LEVEL

OT & PT in RtI

Tier II: Targeted Level Support◦ Student’s needs not met at universal level. ◦ Consult with team to problem solve specific areas

of concern related to PT & OT◦ Assist teacher in differentiating instruction for

individual student

OT & PT IN RtI

Tier III: Intensive Level ◦ Includes general and special education◦ Instruction is intensive, in small groups or

individual◦ Provide consultative services, work directly with

teachers to provide interventions or embed therapeutic activities into academic activities

◦ Defined, problem-focused, short duration

OT & PT IN RtI

Focus of Intervention

Pre-K & Kindergarten Elementary School

Intense remediation and intervention to promote skills or prevent functional impairments

Early identification of task and environmental adaptations to increase participation

Continued remediation and intervention for skill development or preventing loss of function in early years

Increasing consideration for adaptations

Motor skill acquisition is SLOWING

Focus of Intervention

Intermediate/Middle High School

Increased focus on task and environmental adaptations

New motor skill achievement slows/plateaus

Remediation/accommodations may be necessary considering life skills programs/prevocational programs

Focus is mostly on task and environmental adaptations

Accommodations for impairments may be required in consideration of prevocational programs/life skills.

Service needs may change depending upon post-high school plans.

TYPICALLY SERVICES PROGRESS FROM DIRECT

TO MORE CONSULTATIVE/INTEGRATIV

E METHODS

Direct –◦ Therapist works with student on IEP objectives◦ Therapy may be in group or individual sessions◦ Therapy may be in classroom, lunchroom, PE

class, or “therapy room” (pulled out individually with therapist)

◦ Student needs specialized instruction that ONLY a therapist can provide

◦ Establish/teach a NEW skill that student may use in various other environments and activities

DIRECT VS. CONSULT

CONSULT◦ Therapist works with other professionals -

teachers, EA’s, etc (NOT the student)◦ Provide adaptations, accommodations and

supports to help student meet the IEP objectives ◦ Ensure the student has multiple opportunities

within the school day to practice a particular skill

DIRECT vs. CONSULT

CONSULT (Cont’d)◦ May include observation of and interaction with

student◦ Not treatment or intervention ◦ Does not mean LESS services – often is at least as

time consuming as direct services ◦ Therapist AND others collect data/information to

determine needs and evaluate results of implemented accommodations/adaptations

DIRECT vs. CONSULT

QUESTIONS????