Client-centered practice in pediatrics

For the month of September, the Handwriting is Fun! Blog will be sharing insights about the role of Occupational Therapy in the classroom.  In recent years, the role of OT, in general, has been changing with the waves of healthcare and education reforms.  Despite a certain amount of turmoil and confusion where those changes may have thrown us a curve ball, most often they have provided us with an opportunity to make a difference in an area in which we’ve longed to see an improvement.  Client involvement is an excellent example of a concept that can turn the tide in school-based and pediatric practice.   Although this concept is relatively new in pediatrics, it remains an important one to embrace as we enter this new generation of healthcare and education perspectives.  In that light, this week’s article focuses upon the concepts that define a client-centered therapeutic approach and the implications for its use in all facets of occupational therapy, including pediatrics and in the schools.

 

Inclusion geralt pixabay

 

 

Client-centered practice in pediatrics.

by Katherine J. Collmer, M.Ed., OTR/L

 

 

 

 

 

 

The rehabilitation process and client-centered practice:  Defined

The rehabilitation process can be defined as a “reiterative, active, educational, problem solving process focused on a patient’s behavior (disability)” that uses assessment, goal setting, intervention, and evaluation tools to achieve its objectives.  The objective of the rehabilitation process includes maximizing the client’s participation in his or her environment and to minimize the effects of pain and distress on the client and client families. (1)  In recent years, the approach to rehabilitation has moved from a “predominantly medical one to one in which psychological and sociocultural aspects are equally important.”  This has resulted in transforming the rehabilitation process into a client-centered practice where the personal perspectives and backgrounds of the client are becoming increasingly important.

The process of rehabilitation is complex (1) and works within a structure that demands the collaboration of a multi-disciplinary team who works toward client-specific goals and encourages involvement of the individual and his or her family.  (2)  In the past, this group included professionals from the medial, therapeutic, and ancillary staff of the hospital, school, clinic, or facility where the client was receiving services.  Family members and caregivers in the adult environment were invited to participate in team meetings, training, and decision making events along with the client.  The client’s level of participation in the process rested on his or her capacity for understanding the choices and for making decisions.   A child-centered rehabilitation process, however, typically includes the professionals on the team and the family members responsible for the child’s wellbeing.  The child most often serves in an “invisible role” on the team appearing for the assessment and therapeutic interventions but rarely for events that would determine his or her goals for therapy.  The move toward a client-centered practice has not completely turned the corner into pediatrics.

 

 

children omarmedinard pixabayThe rehabilitation process in the pediatric practice remains the same regardless of the arena within which it is carried out.  The provision of therapy in the clinic or hospital, the home or the school, begins and ends with the same tools as it seeks to achieve the highest level of independence for the clients.  Our clients are young, ranging from birth to around 18 years of age, and present with a wide range of strengths and needs.  They are all individuals and deserve strategies for care that respect them as such.

In that light, the process of their care in any environment should include them in what has been described as a “working alliance.” This relationship “is formed as individuals collaborate with one another to develop common goals and as they develop a sense of shared responsibility for working on tasks that are involved in achieving those goals.” (Bordin, E.S., 1979, qtd. in 4) The development and maintenance of rapport, mutual respect, and collaboration between therapists and their clients have been linked to the therapeutic relationship that standards of practice OT2fosters client participation in their own rehabilitation.  (4) Client participation has been considered a focal point in occupational therapy and is reflected in the professional standards established by the American Occupational Therapy Association.  They clearly state that occupational therapists will collaborate with the client in the assessment of his or her skills and during the development and implementation of the intervention plan. (5)

However, results of a 1995 study of the participation of adult patients in their rehabilitation process conducted by Northen et al. (5, quoted in 6) determined that the “maximum potential of client-centered practice was not realized throughout the treatment process.” This was linked primarily to inconsistencies in the use of structured methods for encouraging client participation in the initial process as well as during the ongoing rehabilitation process.  Given the lack of data available that tracks client involvement in the pediatric practice, it is of value to discuss the implications of client-centered rehabilitation with children.

 

Client-centered therapy and its implications for pediatric outcomes.

Client-centered therapy implies that the person for whom the services are designed will actively and willingly participate in the rehabilitation process and includes both a “behavioral” and a “motivational” component on his part.   In the case of student “involvement,” this translates to the “amount of physical and psychological energy” that he devotes to the learning experience.  This involvement can be measured in both quantitative and qualitative terms using testing and the observation of functional use of skills. The student achieves both functional and personal development through his participation in this working alliance.  And the effectiveness of that alliance rests upon “the capacity of (the practitioner) to increase student involvement. (8)

 

Success of a client-centered occupational therapy practice depends upon two principal components, as outlined by Maitra and Erway, in their article “Perception of Client-Centered Practice in Occupational Therapists and Their Clients:”

 

  1. The desire and ability of the clients to take part in the decision-making process, and
  2. The desire and ability of the occupational therapists to include clients in the decision-making process. (6)

 

These two components rely upon the development and implementation of a team-based strategy that is designed to enhance both client and therapist involvement in the client-centered process.  This type of strategy is based upon three factors for success:  rapport, a working reliance, and a stable relationship.

Client Centered Process

 

The development of rapport, a working alliance, and a stable working relationship requires “an ongoing communication process that involves the exchange of information.” (4)*

 

Rapport.  Children rely on trust within each of their daily interactions with teachers, therapists, and school personnel.  Trust in a therapeutic partnership begins with the gathering and sharing of information about the client and the therapist, the demonstration of “cooperative intent” during the initial stages of the alliance, and the regulation of the student’s involvement in decision-making events.  Trust is built during informal discussions about activities that each enjoys, challenges they have faced, and goals for the future.  It continues to develop when each understands that the other can be flexible and accept changes in plans or challenges that push comfortable boundaries.  And, most importantly, trust is built when the therapist recognizes the student’s need to have less distraction or increased interaction in order to be successful.

 

Working Alliance.  As the rapport continues to develop, the therapist and client begin to focus on the goals and tasks that will define the student’s therapy.  Eleanor Cawley, MS., OTR/L, in her book, The Student Interview, stresses that the use of effective communication techniques can produce benefits that improve diagnosis and outcomes, treatment adherence, (and) patient satisfaction….” (9)  She refers to communication strategies that build a working alliance as avenues of exchange that can help students to build “a sense of self and of personal identity.” While her information partnership geralt pixabaytargets the adolescent population, students of any age will experience a sense of belonging and importance when the therapy plan is shared with them and decision making involves them at an age-appropriate level.

Perhaps one of the most significant facets of the development of rapport and a working alliance is the therapist’s and the student’s combined response to the success or failure of a therapy technique.  Tickle-Degnen, in her AJOT article, “Client-Centered Practice, Therapeutic Relationship, and the Use of Research Evidence,” (4) suggests the use of a recording tool** that documents the goals of the treatment and whether or not the task or strategy is accomplishing them.  In addition, in an effort to enhance the working relationship, she suggests that “occupational therapists should incorporate client satisfaction and frustration ratings” into this recording tool.  Children can easily express their feelings of frustration with a task, as well as their sense that it is beneficial.  The working alliance is a “living relationship” that continues to expand and contract as it becomes a stable working relationship.

 

Stable Relationship.  This phase of the client-centered therapeutic process has been described as the place where the “hard work of therapy begins” and one where the challenges and changes that provide opportunities for growth and skill in therapy can also “enhance the probability of ‘errors’ during interaction (and) threaten the continuation of the relationship.” (4) Communication and student engagement become an even more significant set of tools during this phase as these changes and challenges will require intrinsic motivation on the part of the student.  While student engagement is considered to be among the better predictors of learning and personal development, (12 qtd. in 10) with positive links to critical thinking and grades, (11) it has also been identified as an important tool that allows our young clients to express their priorities, goals, and impressions of therapy.  A stable relationship that fosters rapport and a working alliance relies upon the therapist’s ability to work alongside students in an effort to maintain an “authoritative” position that “gains control through interaction with the student and incorporates the student’s opinions and ideas” into the rehabilitation process.  Ultimately, this results in a “Student-Therapist Partnership.”  (9)

 

Barriers to implementing a client-centered practice.  Research has unveiled 4 significant barriers to implementing a client-centered practice that can be reflected in every therapeutic environment:

Barriers to Client Centered Process

We, as the service provider have control over our knowledge base and our feelings of comfort or insecurity that surround the implementation of a client-centered approach to therapy.  We can influence a student’s intrinsic motivation by attending to the development of rapport, a working alliance, and a stable working relationship and by adapting the process to meet his particular learning, cognitive, and physical needs.  We can influence the environment with the demonstration of success within our personal practice of client-centered therapy and with discussions about the benefits for increasing a client’s sense of worth and self-efficacy.

 

Conclusions.

A client-centered approach to therapy is not a new concept.  The term was coined by Carl Rogers, an American humanistic psychologist, in his 1939 book, The clinical treatment of the problem child.  In it he stresses the importance of “individuality, holism, sense of self, the influence of the environment, values development, actualization, and goal-directed behavior” in both the individual’s overall development and the development of the client-therapist relationship.  (15, qtd. in 14) The Philosophical Base of Occupational Therapy (16) defines “participation in a meaningful occupation (as) a determinant of health.”  It stresses the same concepts of therapy as Rogers, describing the environment, intrinsic individual factors, occupational contexts, and inherent characteristics of the activity as significant factors to consider as we develop a focus and outcome expectations to encourage and enhance our clients’ engagement in meaningful occupations.  Children, our students and clients, deserve the opportunity to use “occupation” as a change agent, as well as an individual means to achieve their goals, and to experience a client-centered therapeutic approach as a means for active participation in their service plan.

 

Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine

Katherine J. Collmer, M.Ed., OTR/L, is a pediatric occupational therapist who specializes in the assessment and remediation of handwriting skills and understands the link between handwriting skills and writing.  She can be contacted via her website, Handwriting With Katherine.
  Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
 Photos are the property of the contributors of Pixabay and their use should include the link provided to the photographer’s source.
*The information in this section was adapted from Reference No. 4.
**Student Self-Assessments have been identified as tools that facilitate the collection of information relative to a student’s perception of his skill strengths and needs, his participation in therapy, and the value of the therapeutic interventions included in his rehabilitation plan.  Each self-assessment instrument should be reviewed prior to administration to measure its benefits and limitations for the audience for whom it is intended.   (13, 14)

References:

  1. Wade, D. T., and B. A. DeJong. “Recent Advances: Recent Advances in Rehabilitation.” Bmj7246 (2000): 1385-388. Web. 15 Sept. 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118051/pdf/1385.pdf>.
  2. Wressle, Ewa. Client Participation in the Rehabilitation Process. Diss. Linköpings Universitet, 2002. Linköping: UniTryck, 2002. Print.
  3. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260.
  4. Tickle-Degnen, L. “Client-Centered Practice, Therapeutic Relationship, and the Use of Research Evidence.” American Journal of Occupational Therapy4 (2002): 470-74. Web. 15 Sept. 2015.
  5. “Standards of Practice for Occupational Therapy.” The American Journal of Occupational Therapy6 (2010): S106-111. Web. 5 Aug. 2015. Prepared by The Commission on Practice and presented as a Supplement to the American Journal of Occupational Therapy
  6. Maitra, K. K., and F. Erway. “Perception of Client-Centered Practice in Occupational Therapists and Their Clients.” American Journal of Occupational Therapy3 (2006): 298-310. Web. 15 Sept. 2015.
  7. Northen, J. G., Rust, D. M., Nelson, C. E, & Watts, J. H. (1995). Involvement of adult rehabilitation patients in set- ting occupational therapy goals. American Journal of Occupational Therapy, 49, 214–220.
  8. Astin, Alexander W. “Student Involvement: A Developmental Theory for Higher Education.” Journal of College Student Development Sept/Oct 40.No. 5 (1999): 518-29. Web. 16 Sept. 2015.
  9. Cawley, Eleanor, MS, OTR/L. The Student Interview. 2013. Print.
  10. Gan, C., K. A. Campbell, A. Snider, S. Cohen, and J. Hubbard. “Giving Youth a Voice (GYV): A Measure of Youths’ Perceptions of the Client-Centredness of Rehabilitation Services.” Canadian Journal of Occupational Therapy2 (2008): 96-104. Web. 16 Sept. 2015.
  11. Carini, Robert M., George D. Kuh, and Stephen P. Klein. “Student Engagement and Student Learning: Testing the Linkages*.” Research in Higher Education Res High Educ1 (2006): 1-32. Web. 16 Sept. 2015.
  12. Engel-Yeger, B., L. Nagauker-Yanuv, and S. Rosenblum. “Handwriting Performance, Self-Reports, and Perceived Self-Efficacy Among Children With Dysgraphia.” American Journal of Occupational Therapy2 (2009): 182-92. Web. 8 Sept. 2015.
  13. Fredricks, Jennifer A., and Wendy McColskey. “The Measurement of Student Engagement: A Comparative Analysis of Various Methods and Student Self-report Instruments.” Handbook of Research on Student Engagement. New York: Springer, 2012. 763-82. Print.
  14. Corring, D., and J. Cook. “Client-Centred Care Means That I Am a Valued Human Being.” Canadian Journal of Occupational Therapy2 (1999): 71-82. Web. 16 Sept. 2015.
  15. Rogers, C.R. (1939). The clinical treatment of the problem child. Boston, MA.: Houghton Mifflin.
  16. “The Philosophical Base of Occupational Therapy.” American Journal of Occupational Therapy6_Supplement (2011): n. pag. Web. 16 Sept. 2015. Authored by The Commission on Education

 

Behavior and Transitions in School Settings

For the month of September, the Handwriting is Fun! Blog will be sharing insights about the role of Occupational Therapy in the classroom.  In recent years, the role of OT, in general, has been changing with the waves of healthcare and education reforms.  Despite a certain amount of turmoil and confusion where those changes may have thrown us a curve ball, most often they have provided us with an opportunity to make a difference in an area in which we’ve longed to see an improvement.  Occupational Therapists have recently received an increasing number of referrals to consult with teachers and staff about the behavioral needs exhibited by their clients, as well as those displayed by other students in the school. In that light, this week’s article focuses upon techniques for becoming a “behavior detective” to guide us in uncovering the underlying causes for students’ behaviors in school and to offer tried-and-true strategies for helping them to manage their feelings and stresses.

No child wants to fail!Behavior and Transitions in School Settings

By:  Cara Koscinski MOT, OTR/L 

No child wants to misbehave.  Rules exist in homes, schools, and communities in attempt to maintain a peaceful and calm environment.  It’s important that children with and without special needs learn to follow the rules of the classroom setting.  As students grow into adulthood, their success is dependent on their own ability to adhere to rules while controlling impulsivity and behavior.

Children often exhibit behaviors when they are overwhelmed, confused, or asked to complete a non-preferred task.  The creation of rules is critical to helping students know exactly what to expect.  Therefore, rules should be consistent throughout all settings and consequences delivered.  It’s critical to remember that children with special needs often experience co-morbid conditions.  Examples include:  reflux and other gastro-intestinal disorders, sleep disturbances, and processing delays.  School settings themselves can be quite overwhelming for students with sensory processing disorders.  There’s so much to consider when working with children who exhibit difficult behaviors.

What’s our responsibility in the school setting?  As clinicians, we need to determine the root cause of the behavior. As a veteran clinician and parentOT Behavior Detective to two sons with autism and behavioral challenges, I consider myself to be a ‘behavior detective.’  Let’s look some critical steps therapists can take to help figure out the problem.  In my book, The Special Needs SCHOOL Survival Guide, there is an entire chapter about behavior in school.  It offers a plethora of helpful techniques I’ve figure out over the years.  Here are five of the most important:

1)  Be objective.  Don’t form opinions of a child based on a specific diagnosis or from a written report.  There’s a saying I use often, “If you’ve seen one child with autism, you’ve seen ONE child with autism.”  It’s true for all children with special needs!  They are people first.

2) Consider the skill level of the child.  If a skill has not been learned and rehearsed, then the child will have difficulty generalizing the skill.  Perhaps, bad habits were formed in earlier years or grade levels.  Re-evaluate what’s already been done and rehearse again.  Remember that no child wants to fail.

3) Evaluate for receptive and/or expressive language delays.  Many children simply need more time to process a directive.  This is especially true in a busy classroom setting.  Ensure the instruction giver has the child’s full attention prior to giving a command.

4) Consider time of day. Often, my new OT students forget that everyone has a different time of day in which they function best.  We all experience different body rhythms in sleep/wake cycles, hunger/thirst/digestion, etc.  I’m a late morning person.  I am simply not at my best first thing in the morning.  No one can change that as it’s my body’s physiological condition (interoception).

5) How has the task been presented?  This is the ‘before’ or antecedent.  Antecedent information includes the tone of voice of the direction giver, visual vs. auditory command, child’s sensory arousal/state prior to the command, child’s attention to command and child’s underlying ability to actually follow commands.  Not many people consider the BEFORE…..in fact, it’s more common in the school setting to consider the RESULTING behavior.  It’s a veteran behavior detective who can form non-biased conclusions as to the events that occur prior to the child’s tantrum.

Success

BONUS tip…Does or has the child been given attention for the behavior?  Is he perhaps seeking a reaction from the teacher, clinician, or students?  If this is the case, keep an even tone when giving directions and choose your battles.  For example, I was called in to observe a third grader with lower-functioning autism.  She consistently threw her paper onto the floor when the teacher gave a writing assignment.  Upon observation, the teacher instructed her to ‘pick it up’ each time.  The teacher and other students were consistently distracted and frustrated.  I suggested the teacher simply ignore the behavior.  The student threw everything from her desk onto the floor and no one looked or responded.  After a week without attention, she stopped tossing paper onto the floor.  Yes, this is a simple example, but it’s applicable to many other situations.

I’d like to offer some advice to help children transition smoothly.  Review rules and consequences BEFORE a tantrum and when the child is quietly listening.  Remember that fight or flight reactions are CHEMICALLY driven and once the hormone (adrenaline) is released, it takes time for a child to calm and organize.  Please don’t attempt to teach a child who is in a tantrum.  I’d bet you do not want to learn a new skill or receive a lecture when you are upset and need to re-group.

Finally, utilize visual strategies for transitions.  Adults rely on the use of calendars, timers, and electronic devices for transitions and reminders.  In the school, provide a written or picture schedule of transition times.  Give verbal warnings or countdowns prior to changing activities.  It’s best to provide consistency and use the same strategies consistently throughout the day.  If the student prefers to learn visually, allow the use of a visual timer or schedule for transitions.  For others, provide verbal warnings at various intervals of time beginning at least ten minutes prior to transition time.

The most important takeaway from my post today is to remember that there is ALWAYS a reason for everyone’s behavior and it’s our job to investigate.  Being a behavior detective is not easy, but the rewards are well worth your effort.  Your students will thank you for it!

CaraKoscinskiHeadshot1Cara Koscinski, MOT, OTR/L, is passionate and excited about providing quality treatment to children with special needs.  As a homeschooling mother to her own children born with autism, Cara co-founded Aspire Pediatric Therapy, LLC, to provide quality therapy for autism and Sensory Processing Disorder at schools, in homes, and in centers around the Pittsburg area.  Cara is the author of The Pocket Occupational Therapist, winner of the 2015 Family Choice Award and recommended in the Autism Spectrum Quarterly as a “Great Resource for Families and Professionals.”  In addition, she has authored her latest publication, The Special Needs SCHOOL Survival Guide, and The Weighted Blanket Sensation (coming in Winter 2015).  Cara has served as an adjunct clinical instructor for the Duquesne University Occupational Therapy program and was the recipient of the Duquesne University’s Innovative Practice Entrepreneur Award.  For more information about Cara, or to contact her directly, please visit her website, The Pocket OT.

Photos are the property of Cara Koscinski and are not to be used in any fashion except as links to this blog post or the Pocket OT website without the expressed, written permission of the author.

 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
 
 

An OT Advocate for Change: Handwriting gets the help it deserves.

For the month of September, the Handwriting is Fun! Blog will be sharing insights about the role of Occupational Therapy in the classroom.  In recent years, the role of OT, in general, has been changing with the waves of healthcare and education reforms.  Despite a certain amount of turmoil and confusion where those changes may have thrown us a curve ball, most often they have provided us with an opportunity to make a difference in an area in which we’ve longed to see an improvement.  For me, that has been handwriting mastery.  For others, it has been the role of OT in the educational system as a whole.  This second article in our “OT in the Classroom” series addresses the role of OT as an vehicle for guiding teachers, educational staff, and administrative leaders in striving for and achieving handwriting mastery for their students.  Marie Toole, OTR/L, shares the amazing work that she and the OT staff in her district are doing to Advocate for Change.

An Advocate for Change

by Marie Toole, OTR/L

time for change door geralt pixabayMany years ago, as a new school-based occupational therapist, I was ready to conquer the world. That first year was a blur of referrals and therapy and meetings and learning. The OT staff sat down at the end of that first school year and — after counting up how many referrals we got for handwriting — decided to do something different.

We had to figure out how to handle all these referrals and distinguish between those students who really needed occupational therapy intervention and those who would benefit from good instruction in handwriting from the teacher.  We needed to be agents of change or we were going to be burned out.

Over the last 20 years we have seen a significant drop in our referrals for strictly handwriting.  The referrals we get now are for a myriad of reasons and almost all of them end up with us servicing the child for direct OT interventions.  How did we cut our referrals in half, meet the concerns of the classroom teachers and yet still make sure students have legible handwriting?  Over the years we have employed a number of strategies.  Let me share them with you.

coaching geralt pixabayEducation/Inservices:

Teachers told us they either did not feel comfortable teaching handwriting in the classroom or felt like they were not doing a good job. So we helped.

  • We gave workshops to teachers, paraprofessionals, and parents about hand skills, handwriting, and posture. Building on our handwriting curriculum, we wrote out each letter description, which showed them how to form the letters and gave them the language and developmental order in which to teach letters. Everybody is now using the same language to teach in a consistent manner.
  • Partnering with the physical therapist, we gave an inservice to local preschools on the typical development of the 2- to 6-year old. This helped those teachers to have realistic expectations for hand skill development.
  • With our physical education teachers we developed Classroom Rechargers. These are 20 movement-based activities per grade level that teachers can perform right in their classroom with little-to-no equipment or space.  We put together handwriting warm-ups, exercises, and activities to be done just prior to teaching letter instruction.
  • We showed kindergarten teachers the importance of building the base of hand skills before adding on the challenge of handwriting.
  • We continually give workshops once or twice per year on various topics.  Information, tips, or skills teachers can use the next day in their classroom are the most valuable to them.  We generally have a large audience.
  • When new teachers join our buildings or teachers switch grades, we always make sure to touch base with them and help them navigate the teaching of the handwriting process. Checking in periodically to see how letter instruction is going is always helpful, too.

5 Reasons Why Handwriting Needs a Good SeatErgonomics

Seating and posture were important areas where teachers needed assistance.

  • At the beginning of each school year, we go in and check the desk and chair height for every student on our caseload.  We make sure students fit their work space.
  • We send an email to remind staff how to check for proper desk and chair height and will help any teachers struggling with this. The custodian is our friend, helping us find the right furniture or to adjust desk height.
  • We have also advocated for stand up desks and several of our classrooms now sport at least one stand up desk.  We add sensory equipment — seat cushions, bicycle tubing around the chair legs, and hand tools — for those students who move and fidget.  When students are comfortable and in a good place for learning, it makes handwriting instruction so much easier.     

Pre-referral process

We use a pre-referral process to keep track of teacher requests and to address needs in a timely manner.  

  • Teachers must fill out a basic form telling us their concerns and what they have tried already.
  • The pre-referral forms help us fine tune our classroom observations to an area in which the student may be having challenges, such as math, writing, or organization.
  • We then tailor our classroom observation to those specific areas.  

planning dates condesign pixabayIn the classroom

Planning and coordination are important first steps.

  • At the beginning of each school year we discuss with the classroom teacher and special educator the most convenient time when writing is being taught and we plan our schedules around it. Most of our teachers have been with us long enough to understand the limitations in our schedule and will cooperate to make this work. When we show up for our therapy time, the teachers welcome the extra pair of hands to help with letter instruction, the writing process, typing on Google Docs, or writing poetry.
  • We know the curriculum.  The students do not get pulled from instruction and we get to work in the moment with the students on meaningful work.  We also get to put our eyes on all the students in that classroom and may help other struggling writers as well.
  • We co-teach cursive letter instruction in most of our third grade classrooms as part of our third-graders’ therapy time.  It gives us in-class time and we get to work with the whole class by showing them some multisensory ways to learn letters using sand, chalkboards, or kin-tac cards.
  • We are lucky that we are district employees and have the luxury of having an occasional block of time to observe students in class, on the playground, or in the gym.  We also use our therapy time to work in the classrooms with students on their OT goals.

Early Intervention and Response to Intervention (RtI):

In our district we are lucky to have an administration that support us.  

  • This allows us to go into each kindergarten classroom under regular education for one half hour per week to “SPOT” children who might need help with hand skills.
  • SPOT stands for Speech and OT.  Our “SPOT” time is available to assist the teacher with activities that may be challenging for 5- and 6-year olds. In our OT sessions we might be working on scissor skills, gluing, coloring, and eventually, after months of hand skills training, handwriting.
  • As the year progresses we generally have a small group of students that  we focus on during SPOT.  We do the same activity that the whole class is doing but those students may need more assistance.  These students become our “watch” students in first grade and then we have our entry into the first grade classrooms under RtI.
  •   This took many years of “selling” to our principal. We argued that we could ward off some referrals by giving a little help early rather than a lot of help later. The administration agreed to a trial. After seeing the results, the program stuck.
  • One way we have cemented that progress in our administrators’ minds is to have them conduct their yearly observations of us when we work in the classrooms.  We love to have them come observe us working with a group in the fall, again in January, and later in May.  To see that transformation is like gold in the bank.

Winning over skeptics

Patience and respect guide us in the classroom.

  • It is not always easy and there are some teachers who do not appreciate us coming into their classrooms. In those cases, we take it slow and become a guest in that teacher’s classroom. When they see the intrinsic value that we bring to the table as occupational therapists, most teachers come around.
  • Generally we have found that teachers can’t wait for us to work in their classroom and are bummed when they do not have students who receive OT in their classroom that year. It takes time, sometimes lots of years of trying. But working together as a team shows the student that everyone is on the same page and you have the same expectations for him or her.


teamwork zipnon pixabayTeamwork

Having a strong special education team is helpful as well.  

  • Working with the classroom teacher, special educator, and the rest of the special education team has helped us to fine tune our occupational therapy process.  
  • Often it is the special education teacher who brings concerns or referrals to the occupational therapy staff.

Advocating at the administrative level

Becoming visible is essential.

  • We knew we needed to get good at this or we would continue to struggle year after year.  Our principal, assistant principal, and even the superintendent know who we are.
  • We consistently advocate for what is right for children.  In our 20 plus years, there have been many principals and superintendents at the helm.  We had to get to know them, their goals, and how they liked to work.
  • We asked for OT be represented on the curriculum committee for language arts when administrators revised it many years ago.  We ended up putting a handwriting strand into the curriculum with expectations developmentally appropriate for kindergarten through fourth grade.
  • When the district was thinking of cutting out cursive instruction, we took this on as our mission to research it and make informed decisions.  We took our time, and over the course of three years, we read many research articles and spoke with many other local districts to see what they were doing.  We ultimately decided to keep cursive instruction as an integral part of our third grade curriculum.  
  • When advocating for the SPOT time in kindergarten, we came armed with data to show that it was beneficial.  We constantly print out articles about teaching handwriting and give them to our principal.
  • Being relentless in the pursuit of continually advocating for what is right for children can be tiring.  It is not something that happens overnight.  Looking ahead and looking towards the big picture has helped us to maintain our vision.  Continually putting it in front of administrators keeps it fresh and does not allow stagnation or somebody to forget how important handwriting is in the curriculum.

important note clkerfreevectorimages pixabayOur role

An important point to remember:

  • We cannot become the “handwriting teacher.”  That’s the job of the classroom teacher. We are occupational therapists who look at functional skills and participation in the school curriculum and environment.
  • By empowering teachers to actually teach handwriting before they expect children to write, we advocate for what our students need. Ongoing support and advocacy will encourage teachers to keep teaching proper letter formation. This in turn will allow our OT interventions to remain focused on the functional skills students need to navigate the complex world of school.

Marie Toole, MS, OTR/L Marie L. Toole, MS, OTR/ L, is a pediatric occupational therapist with over 28 years experience in NICU, Early Intervention, and private practice with the last 21 years spent working in public schools. She is NBCOT and SIPT certified as well as a member of AOTA and NHOTA.  Follow her on Twitter @MarieTooleOTNH, on Pinterest marietooleNHOT, and on School Tools for Pediatric Occupational Therapists  where she tweets, pins, and posts about OT, education, autism, and sensory integration, as well as other school related topics.

 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
 
Photos are the property of Handwriting With Katherine and are not to be used in any fashion except as links to the appropriate blog or the Handwriting With Katherine website without the expressed, written permission of Katherine Collmer.

OT and Handwriting Programs: What is our role?

 

For the month of September, the Handwriting is Fun! Blog will be sharing insights about the role of Occupational Therapy in the classroom.  In recent years, the role of OT, in general, has been changing with the waves of healthcare and education reforms.  Despite a certain amount of turmoil and confusion where those changes may have thrown us a curve ball, most often they have provided us with an opportunity to make a difference in an area in which we’ve longed to see an improvement.  For me, that has been handwriting mastery.  For others, it has been the role of OT in the educational system as a whole.  This first article in our “OT in the Classroom” series addresses the first of these interests – the role of OT in handwriting mastery –  and brings up points that I hope will generate discussion and help us all to learn and grow within our profession.

 

Handwriting PracticeOT and Handwriting Programs: What is our role?

by Katherine J. Collmer, M.Ed., OTR/L

 

 

 

 

I have been asked often to reveal my “favorite choice” for a handwriting program. The question inevitably arises, “Which handwriting program do you use for instruction in your specialized OT practice?” And the answer is always the same, “I have none.” I’ve actually never considered the selection of one program over another, nor have I recommended one as my “preferred,” feeling that in my practice it is not my role to do that.  My business goals are to assess and remediate children’s handwriting development skills.  My first priority is to identify and target the underlying problems that are revealed in the student’s handwriting struggles.  My next step is to evaluate the capability of the classroom’s handwriting program to facilitate the student’s success with remediation.  If I feel it cannot, then I will speak with the teacher and parents about addressing the student’s needs with a different program.  For the older students, this is commonly not an issue, as they are not receiving handwriting instruction in class.  In both of these cases, I will address the student’s individual needs with a handwriting program that blends with his learning styles and remediation goals.  Handwriting “instruction,” per se, is not the mission of my particular business.

 

Of course, Occupational Therapy has certainly made a presence in the handwriting program environment. And rightly so, as we understand the underlying developmental skills that build handwriting mastery and our interventions in both instruction and remediation have been effective in advancing students in their handwriting mastery.  (1)  Occupational Therapists have designed effective handwriting programs based upon developmental principles, worked with a handwriting program publisher,* and most certainly have used handwriting programs in their therapy sessions.  But, what IS our role with handwriting programs?  Where does the value of our expertise and the validity of our responsibility fit into the provision of handwriting instruction?  These questions are legitimate and warrant a discussion in search for answers.

 

1.  What are handwriting programs designed to do?

 

First, let’s make the distinction between the two types of handwriting programs, the curriculum program and the published handwriting program, and the facets that define each as beneficial.

 

curriculum-wokandapix-pixabay-614155_1280

A curriculum handwriting program is one that is designed to provide

  • structured, consistent, and guided instruction in the development of letter formations, letter alignment, and spacing, both during copying and independent writing tasks;
  • instruction that provides handwriters with the tools to edit and correct their own work;

and

  • handwriting tasks across the subject areas                                                      that will promote the functional use of that skill.

 

A published handwriting program is designed to provide:

  • teachers with a structured program that will assist them in providing their students with consistent and guided instruction in the development of letter formations, letter alignment, and spacing, both during copying and independent writing tasks;

cursive-blackboard-kyasarin-pixabay-209152_1280

  • tools that assist the teachers in their instruction, as well as the students in their learning; and
  • a network of professionals who can guide teachers in their use of the handwriting program.

 

Published handwriting programs are a facet of a curriculum’s handwriting program. It is ultimately the role of the school to assess different published programs and select the one that fits their students’ and teachers’ needs.

 

What makes a good handwriting program?

There are a few basic characteristics that are included in the development of an effective curriculum and published handwriting program. Each must be:

 

  • Structured: The instruction is delivered in a format or plan that allows a developmental progression of skill development.
  • Consistent: The instruction is provided in a format that allows students to practice the skills sufficiently to enhance learning.
  • Guided: The instruction provides tools to assist teachers in their instruction and offers students one-to-one assistance and additional learning strategies during classroom instruction.

 

These tenets are integral to the development and mastery of handwriting skills. The development of a published handwriting program is a task as complex as the mastery of the skill itself and, therefore, research and experience play a vital role in the development of a good handwriting program. Occupational therapists, educators, and literacy experts have spent a great deal of time, energy, and finances toward building effective and valuable handwriting programs that address the diverse needs of our young learners.   Some published programs offer online teacher assistance, free downloads for creating worksheets, in-class technology to enhance visual and kinesthetic learning, or inexpensive teaching materials to help with school budgets. Some schools have included handwriting instruction as an integral part of their elementary school curriculum, while others are streamlining their instruction to meet overall educational requirements.  But, when it’s all said and done, an effective handwriting program – both a curriculum or a published program – is one that is “structured, consistent, and guided.”

 

2.  What makes a good fit for an OT-Handwriting Program Relationship?

As a school-based, private practice, or clinic-based occupational therapist, we do not assess or select the handwriting programs that our clients will be mastering in their classrooms…unless, of course, we are on the curriculum selection committee, where we would indeed be an asset.  However, although studies indicate that “having preschool classroom teachers implement an occupational therapy-based curriculum to teach handwriting readiness skills reflects a more inclusive service model that benefits all students,” (1) at present the selection of a handwriting program most often remains in the hands of the school system.  Therefore, at the elementary school level, it isn’t our role to select another program to use in our therapy sessions that we might feel provides a better instructional format.  This gets confusing and does not provide the “structured, consistent, and guided” instruction that builds mastery.  Our role as OT’s is to assess and remediate handwriting development skills….which are the same skills he will need for handwriting mastery no matter which program is being taught in the classroom.  Our expertise guides us in the creation of instructional adaptations that can enhance a student’s learning, as well as cognitive, sensory, and physical suggestions to promote success in the classroom and at home.  This also allows us to consider the student’s individual needs to determine if he would benefit from a different program and if the discussion of a program change is warranted.   In the end, our role as OT’s continues to be the assessment and remediation of handwriting development skills….no matter which program the student is working with in the classroom.

We have a much broader role when we are working with older students (fifth grade and beyond), however, one that allows room for us to introduce a new handwriting program.  Their struggles may result from the lack of a structured, consistent, and guided program in elementary school; or they may have needed the assistance of an OT at that level but had not been provided with those services.  At this point, there would be many choices for us to consider that would meet their needs.

So, I pose the question that, instead of looking for a “good fit for an OT-Handwriting Program Relationship,” wouldn’t the more appropriate question here be

 

3.  What makes a good fit for an OT-Handwriting Relationship?

April is OT Month!
OT’s build independence by providing information! We are “information stations!”

 

Building an OT-Handwriting Relationship in the classroom begins with prevention.

One of our primary services has always been to inform our clients about choices and information relative to their needs.  For instance, in the adult community, we are a valuable link between those who are experiencing the results of a traumatic brain injury and the durable equipment options to increase independence in activities of daily living.  In the older community, we can share vital home safety tips about inexpensive modifications that can help clients and their caregivers extend a person’s ability to age in place.  We provide ergonomic and backpack safety information to office workers and students, as well as pain management techniques and tools for those suffering from osteoarthritis.  Moms welcome our early intervention skills as we share information about sensory needs and developmental milestone stages.  We ARE the “information station!”

This integral part of our practice also weaves its thread through our relationship with handwriting development skills.  Prevention is our first step in helping students with their handwriting needs and for building a recognized and valued OT-handwriting relationship.  We are the frontline source for fine- and visual-motor information for teachers and parents and the best member of the community to guide them toward building healthy habits for handwriting success.   In light of our position as “information stations,” we must take time to

 

  • share information with teachers and parents about pre-handwriting skill development and the appropriate ages for working on grasping patterns and for introducing a pencil;
  • help teachers and parents understand the positive benefits of movement and play in the development of body awareness, physical strength, and sensory skills;
  • become involved in the assessment and acquisition of a developmentally sound handwriting program; and

And we need to do these things BEFORE children are referred to us for occupational therapy to address their handwriting development needs. Prevention first!

information station logo property of handwriting with katherine

 

 

 

Building an OT-Handwriting Relationship in the classroom thrives through student success. 

The benefits of any practice are validated only by their visible successes.  Handwriting development skills are most often “invisible,” with the only evidence of their need for service being a poor handwriting style.  Hence, a functional penmanship style becomes the visible success.  In some instances, the teacher and parent won’t ever become aware of the myriad of underlying skills that we have addressed in our therapy sessions to bring about that result. Most often, however, our work with a student’s handwriting development skills will enhance his successes in other subject areas, validating even further the benefits of addressing handwriting needs.  There are times, of course, when an evaluation of the student’s skills will reveal that his struggles would benefit simply from the provision of a more structured and guided method of instruction, rendering the need for direct services as unnecessary.  The “ounce of prevention” tips offered above can help prevent those students from being referred for services as we assist teachers in assessing their needs and adapting their teaching style to meet them.  But, when a student does arrive at our doorstep with underlying handwriting development needs, it is important for us to have the skills to assess and remediate those needs…no matter which program the student is using in the classroom.  And no matter whether or not he is receiving any handwriting instruction at all.  It is our responsibility to seek continuing education instruction and practice guidance that will add these skills to our tool boxes. Handwriting assessment and remediation is an OT-related service.  And our students’ successes will pave the way for enhanced recognition of the role we play in handwriting mastery.

 

Handwriting programs are important, for sure.  But as OT’s in general, our primary concern is, and always should be, the development of the underlying skills that form the foundation for handwriting success.

 

Please join us next week for an article by a guest blogger that will showcase the significant impact that a school-based OT can have in handwriting success!

 

 

(1)Lust, C. A., and D. K. Donica. “Effectiveness of a Handwriting Readiness Program in Head Start: A Two-Group Controlled Trial.” American Journal of Occupational Therapy 65.5 (2011): 560-68. Web. 18 Aug. 2015.

 

* I was honored when Universal Publishing valued occupational therapy and my work by including “Katherine’s OT Tips” in the Teachers’ Editions of their latest edition of their Universal Handwriting Program.  It was a positive way to build a relationship between occupational therapy and a handwriting program publisher.

 

Katherine J. Collmer, M.Ed., OTR/LKatherine J. Collmer, M.Ed., OTR/L, is a pediatric occupational therapist who specializes in the assessment and remediation of handwriting skills and author of the book, “Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists.”  She can be contacted via her website, Handwriting With Katherine.
 
 
 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
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