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Chapter 2

Therapy in School

What Is Therapy in the School Setting?

Not all children who attend outpatient or clinic therapy will qualify for therapy in the school setting. It is critical to realize that in order to receive therapy in school, the child’s area of weakness must directly impact function in the educational setting. Furthermore, when a therapist is in a school setting, he/she must write goals which are “educationally relevant.” Therapists in the schools have different roles than those in outpatient clinics. It’s our job to assist students to function in their regular and special education classroom.

There are times in a school setting when the therapist is “consulting” or providing helpful suggestions based on observations and data. The purpose of the consultative model is to identify and collaborate with school staff/resources to provide suggestions and ways to modify the environment/situation for optimal success. The suggestions are meant for improved functional skills in the classroom, during transition times, with center times (for younger students), for planning/organizing, with grip on pencil or scissors, or for visual-perceptual work. The therapist is working with the people who teach the student, the aide or other staff, but not directly with the student when doing consultation. Additionally, when a therapist is working on goals for carry-over, he must ensure the staff working with the student is well-trained.

Another model for providing therapy is by direct service. When a therapist is performing direct services, he/she is working with the student to learn new skills and this usually takes place in the therapy room or quiet area of the classroom. The therapist is using hands-on techniques and focuses solely on the student’s needs and goals. For example, when working on pencil grip, the therapist may be using putty with small objects placed inside to increase hand strength. Next, they practice using the appropriate pre-writing strokes of forming lines. This is not taking place with the other students in the classroom since the student needs to focus and receive the therapist’s individual attention. However, a therapist may have other students in a small group with their targeted student. This is often the case when a speech-language pathologist is working on social skills training.

Some districts use integrated service models. This means that therapists are working hands-on with the student among her peers in her natural environment. The individual student is receiving services to improve functional/ academic skills and achieve goals in the targeted area of weakness. Here’s an example: the OT may be working on cutting with the student while she’s at center time with her peers.

It is important to note whether a therapist is performing consultative or direct services, because she must always take data on the student’s progress to provide necessary information for IEP goal monitoring. Additionally, law mandates that IEPs be reviewed annually and/or at least every three years. The student must receive services in the least restrictive environment. It can be confusing for caregivers to know what may qualify for school therapy services, so please consult your individual therapist or your district or state regulations. They can usually be found on the district’s website, but it’s your right to know these regulations, so ask for a copy.

What Are Some Signs My Student May Need Therapy?

There are many strategies wonderful teachers use with all students or those who may show signs of struggle that are not part of an individualized education plan. They are called “pre-referral interventions.” Schools have been using different approaches to use research-based instruction. Response to Intervention (RTI) is a multi-tiered approach divided into three support levels and the intensity increases with each level. Visit the site: www.rtinetwork.org for information. The site is extremely helpful and explains RTI in clear terms.

Other pre-referral interventions may be done. They may include something such as posting a visual schedule of the school day on the board or copying tests onto only one side of the paper. Often times, after a parent/teacher meeting, the team may agree that some minor changes in school or at homework time will work well. When common strategies have been tried and failed, it may be time for some extra help from a therapist. Please document the things that worked well for your student; did not work well; behaviors the student had when you tried the strategy; or questions you have.

Look for the following signs in different areas where a student may benefit from skilled therapy intervention.

• has more difficulty than other children with self-care activities such as: tying shoes, getting jackets on/off, toileting, set-up or clean-up of lunch;

• avoids or refuses to complete center craft activities;

• exhibits behaviors that are not age appropriate when doing independent work (tantrums, making loud noises with mouth, getting up frequently to sharpen pencil during the time allotted);

• does not initiate speech or social interactions with other students;

• cannot re-tell a story or provide details after reading a passage;

• has difficulty navigating stairs, gym class, and hallways;

• cannot transfer from place to place without falling;

• avoids learning new skills and skills in the classroom;

• has difficulty walking in line or being close to children;

• does not participate in recess and gym activities;

• has difficulty organizing desk and homework materials;

• demonstrates increased difficulty copying work from the board;

• forgets assignments or seems disorganized;

• difficulty with handwriting, using a pen/pencil, forming letters and numbers, forming cursive letters;

• has trouble with the use of tools such as scissors, hole punchers, staplers;

• demonstrates frequent tantrums when tasks are difficult;

• places objects in mouth frequently such as clothing, classroom items, toys;

• has difficulty with following commands or classroom routines;

• does not know left from right;

• avoids getting messy with items such as glue and paint;

• difficulty sitting still and seems in “constant motion”;

• has trouble making friends;

• seems to get lost easily in the school building or when transitioning between activities;

• difficulty playing independently at recess or reckless/impulsive behavior;

• difficulty maintaining upright posture in her chair or during circle time;

• has visual-spatial trouble.

The list above is not exhaustive, but is meant to show examples of what difficulties a student may have. Remember that there are many variations in the time each child acquires skills. For example, if a child has a condition affecting his development, there may be a discrepancy between his actual age and his functional age levels. For example, it is important to note if a particular child is performing academic work well beyond his age expectations, but needs extra help to make friends or remember classroom routines.

Difficulty with activities of daily living (ADLs) are often an indicator of the need for additional therapy. Things such as re-dressing after toileting, blowing nose, opening/closing containers, using toilet, washing hands, opening/closing doors, putting on/taking off jacket, managing backpack, walking, navigating stairs or gym class, setting up lunch and feeding self independently are all activities that a child is required to do independently in school. Remember, these skills may be emerging for pre-k and kindergarten students. Teachers are wonderfully insightful as to whether or not skills are developing appropriately in the classroom.

What Is Occupational Therapy?

Occupational therapists (OTs) are critical members of the team in both medical and school settings. OTs work to ensure the student can perform activities of daily living as independently as possible. There are several areas in school where OTs can make a significant impact. Through a thorough evaluation in areas such as: fine motor, strength, vision and perceptual skills, sensory processing, and more; goals will be developed specifically for your student. Areas that are also considered include: overall transition skills, direction following, organization, attention, and self-care as it relates to education. The time an OT works with a student directly depends on the time that the team determines is necessary to participate in his education with the appropriate accommodations and supports. When parents, teachers, therapists, and students are aware of the tools available to them, it is beneficial to everyone in building the best educational plan. OTs are part of the “related services” category – part b in the Individuals with Disabilities Education Act.

What Are Some Common OT Goals in the School Setting?

In addition to the list of activities in the previous section, many districts are recognizing the importance of SPD (sensory processing disorder) and its impact on a child’s daily routine. Here is an example of an OT goal which would cover SPD relating to a child’s educational needs: By the end of the IEP date, Jacob will demonstrate the ability to regulate his body for quiet work tasks by choosing an appropriate calming down activity 90% of the time. The therapist may teach Jacob how to monitor his level of “alertness” with a program such as How Does Your Engine Run? ® by Shelly Shellenberger and Mary Sue Williams (www.alertprogram.com)⁴. Further, he may then learn which activities in the program are calming to him vs. causing him to become more active when he and his peers are doing quiet work at their desks. I have created a series of activity cards or sensory break cards on my website which are inexpensive and easy to download, print, and laminate. They are colorful and a great visual reminder for students with and without special needs! (www.pocketot.com, under the “shop” tab)

Here are some sample annual goals in an IEP:

• In a one year period, Mary will stabilize the paper with one hand while drawing and writing to compose language arts lessons 75% of the time.

• By the end of the IEP, Victor will be able to isolate a finger to push a button, keyboard, mouse, etc. to type 26 out of 26 lowercase letters 100% of the time in ELA class.

• At the end of the IEP period, Jennifer will demonstrate the ability to hold her writing utensil with a tripod grasp during writing class 75% of the time as evidenced by data collection by OT.

• In one year, Joshua will demonstrate the ability to use proper spacing between words during ELA class when writing 90% of the time.

• Billy will be able to copy math assignments at his desk to record 100% of the assignment during this IEP period.

• Jeremy will complete math tasks regardless of external visual stimulation 70% of the time, by 1/2/16.

• When frustrated during science lessons, Virginia will use relaxation techniques to regulate arousal level 90% of the time, according to data collected by Ms. Jones.

Every goal needs to note who is collecting the data and monitoring the progress. The goals we write need to be measureable and they need to be given a time frame (the annual IEP period for long-term goals). The goals need to be broken down into smaller, more measureable goals. They are called “short-term goals (STG).” They are like steps which show progress toward the long term goal. Here’s an example:

The long-term goal will be: In one year from the date of this IEP, Richard will cut curved lines, including circles accurately within ⅛ inch of the line independently.

• STG 1: Richard will use scissors to cut along the curved line within 1 inch from the line 100% of the time.

• STG 2: Richard will use scissors to cut along the curved line within ½ inch from the line 100% of the time.

• STG 3: Richard will use scissors to cut along the curved line within ¼ inch from the line 100% of the time.

Data is collected on goals in most districts on a quarterly basis, just as progress reports are. The timing is near the school’s quarterly report cards. Therapists, teachers, and those collecting data make notes in the student’s record how she is progressing toward every IEP goal at that time. You may view this data and ask questions about your student.

What Is Language?

What Is a Speech-Language Pathologist?

Language is much more than having the ability to speak. If we think of sign language, there is a beautiful flowing rhythm with facial expressions and body movements. Our verbal language is the same. We use gestures, facial expressions, vocal tones, eye contact, body movements (such as pointing and hand position) to communicate ideas and thoughts. When a child struggles with social communication deficits, language/speech delays, autism, strokes, neurological injuries, and many more; their social skills may suffer. To communicate with each other, we must understand taking turns, the appropriate way to get someone’s attention, body language, conversational turn-taking, facial expressions, sarcasm, idioms, eye contact, and intonation. All of these make up the pragmatics of speech.

There can be delays in either receptive language (understanding), expressive language, or both. To complicate things even more, our language is full of idioms (it’s raining cats and dogs), homophones (hear and here), and sarcasm. Those who are developing typically can become frustrated!

Speech-language pathologists (SLPs) are experts in the area of speech and communication and are vital members of the treatment team. They are part of the “related services” category – part b under the Individuals with Disabilities Education Act. SLPs have additional and specific training and certification in speech and language topics. They work in school settings to help with facilitation of functional communication. Many things are pre-cursers to communication and the SLP knows the steps to take to help students communicate effectively. Even non-verbal students need to have appropriate ways to make their needs known.

The use of deep-breathing techniques, oral-motor training, group therapy, picture communication systems, and gesturing are all used by SLPs. Often times, the IEP may dictate that speech sessions are held in small groups. This is a wonderful way to work on communicating in a real-time functional setting. Bonds often form between students and confidence is built. This can be generalized to the classroom and at home.

SLPs and the treatment team may suggest visual schedules, use of pictures to help the student to communicate, assistive technology (AT) devices (such as DynaVox ® units or communication boards) to help accommodate the student’s needs. Remember, these accommodations should be listed in the IEP or 504 plan and re-evaluated for appropriateness regularly.

Annual and short-term objectives for a student in speech include:

• Katrina will improve her language skills in ELA class as demonstrated by taking turns with a peer 80% of the time.

• Michael will improve text organization through use of graphic organizers to compose narratives in 4/5 opportunities.

• Tanisha will improve written expression for more effective participation in school.

• Max will stay on topic for x amount of turns with a peer.

• Marcie will use pronouns (I, we, his, etc.) in conversation 80% of the time.

• Jennifer will ask for assistance from the teacher when needed in 4/5 opportunities.

• Brant will re-tell a story with three or more details.

• Jason will use strategies for improved reading comprehension as evidenced by his ability to make predictions, answer comprehension questions, and demonstrate appropriate reading phrasing in 5/6 opportunities across three consecutive sessions.

Goals may include idioms, conversational skills, vocabulary, meeting basic needs in the classroom, and identifying emotions. Remember that school speech goals should relate to the school setting.

What Is a Physical Therapist?

Physical therapists are specifically trained in movement, muscles, functional performance, motor development, gross motor (large muscle group) function/ coordination, and positioning, among others. They are part of the “related services” category – part b in the Individuals with Disabilities Education Act.

Sometimes students have difficulty maneuvering in school. They may have disabilities which are physical, such as those causing decreased muscle tone, mitochondrial disease, and many others. Some students require the help of a skilled therapist to modify their environment to transfer (move) from one area to another. The physical therapist can help to adapt the environment for access. Providing safe lifting and positioning are critical for safety and to prevent injury. Additionally, students may need customized equipment or ways to move from the classroom to the lunch area. If there are steps to navigate, the physical therapist can assist with the safe performance of these tasks. Seating and positioning difficulties beyond what can be helped by the special education and school staff are often areas when a skilled therapist is called in for evaluation.

It’s important to remember that the student’s needs must be related to school issues and be provided in the most natural environment.

Goals need to be functional and can include the training of other staff members to assist the student or to modify the environment.

As with other therapists, reassessments and reviews must be done and notes will be taken each time the therapist works with the student or staff. Progress is documented and measured. Goals are written with frequency of services, location, duration, and 1:1 vs. consultative.

Annual and short-term goals for physical therapists may include:

• Mary will sit upright using an adaptive positioning device for 15 minutes 4/5 times during circle time as reported by the teacher.

• Patti will transfer from her chair to circle time independently 5/5 times according to data collected by Ms. Josephs.

• Nancy will navigate the hallway steps safely, without falling 100% of the time during transitions.

What Is a Related Service?

The IDEA states that related services can be any service that is developmental, corrective, and supportive. It includes any of the following: transportation, aides, language and speech, occupational or physical therapy, special strategies used for teaching, audiologists, social work, sign language, any supportive technological device, medical care, psychological assistance, recreation therapy, rehabilitative services/counseling, mobility, orientation services, and others. It is impossible to list every related service because every student is different, any service the student requires to meet her educational goals can be a related service. It is NOT appropriate for the school to state that they do not have funding for related service that the IEP team has deemed necessary.

Upon entering kindergarten, my son required the supervision of a Registered Nurse on a 1:1 basis throughout the school day. He also required a 1:1 aide. As a team, we discussed that it would be ridiculous to have two adults following him around all day. The nurse agreed to receive training on how to cue him appropriately, how to provide transition assistance, and in behavioral techniques. She agreed to perform these duties with consultation and training from various professionals (OTs, special educators, psychologists, and guidance staff). Of course, the school district was happy as they did not have to fund an additional aide!

The section of the IEP which contains the related services includes all of the ways the student’s areas of weakness will be addressed. It should be detailed. Remember, that a goal that states, “Joshua will meet with the reading specialist weekly” is way too general. It’s not measureable and is left open to interpretation of the reader. Here’s an example of a better goal, “Joshua will meet for twenty minutes with the reading specialist two times per week.” This is much better because no one can debate the meaning of the latter goal. Finally, the related services are generally calculated in minutes. An OT will be provided for minutes weekly on a one to one basis in the occupational therapy room.

Chapter 2 Resources

www.alertprogram.com	Alert Program/How Does Your Engine Run?
www.aota.org	American Occupational Therapy Association
www.apta.org	American Physical Therapy Association
www.asha.org	American Speech-Language-Hearing Association
www.rtinetwork.org	Response to Intervention Network
www.pocketot.com	The Pocket Occupational Therapist