Occupational and Physical Therapy in the Classroom

1. Occupational and Physical Therapy in the Classroom Kim Hartranft OTR/L Kerri Braun, OTR/L Carol Mulligan, PT

2. What is the difference between PT and OT?

3. PT versus OT: Physical Therapy Gross Motor Skills Functional Mobility Occupational Therapy Fine Motor Skills Functional Handwriting V-P skills

4. PT and OT according to IDEA • Defined as a related service ( included with transportation!) • “supportive services… as are required to assist a child with a disability to benefit from special education.” • PT and OT may be delivered for students who do not receive special education, but have a medical diagnosis under Section 504 of the Rehabilitation Act

5. Does every child that has a disability qualify for special ed?

6. Does every child that gets special ed qualify for OT and PT services?

7. Can we fix the diagnosis? (Cerebral palsy, Downs, Muscular dystrophy, Autism)

8. What do PT and OT do in the educational setting?? • Assist children and adolescents in “achieving the educational goals…and accessing and participating in the educational environment.” • Not related to “rehab” • Needs to be integrated, not isolated • Services used to be determined based on the “Disability Model” and now we look at what the desired outcome is…….

9. Where do we fit into the IEP? We contribute to: -current level of performance -how the child’s disability affects involvement and progress in education -school and transitional related functional goal(s) “Discipline-free” --

10. Who’s goals are they? Goals need to be meaningful to the student! What does the child need to work towards to participate in their educational setting? What does the child need to work towards goals after high school

11. The team should develop goals as a team, not on a service by service basis. • Best way to do this is to discuss during team meetings or during IEP’s what goals are best for student and then writing IEP based on team decision. • (Based on Pattan’s First Annual PT/OT in the Educational setting conference 7/07 and Providing PT services under Parts B and C of IDEAby Irene McEwen, PT, PhD, Editor)

12. IDEA is pushing more towards an “Integrated Model” for delivery of service • The entire team participate in developing the students goals • Experts indicate that goals and objectives belong to the student and all team members are responsible for contributing information and skills for maximum success of that student

13. Must the amount of OT and PT service be be documented on the IEP? • Yes, and each district/team needs to define and educate the parents on how and where the services will be delivered • Pattan is promoting integrated related services.

14. What does research show about PT and OT in the schools? • Very ambiguous results • Research comparing direct versus consultation found no difference in motor outcomes

15. It is very important to realize That the only way that our services can be effective is if the educational teams and families follow through on strategies offered on a daily and consistent basis.

16. The Dysfunctional Team

17. The Process: If a team member has concerns regarding the functional motor, fine/gross motor or sensory motor skills of a student… 1. Child Study Team for strategies 2. Permission to SCREEN first...teacher must at least let a parent know there are concerns and a PT or OT is being contacted 3. If screen reveals issues, PT or OT will request evaluation process

18. What is a screen? • Usually an observation of the student in his or her daily routines and observation of participation in class activities. • Includes consultation to team members • Very general

19. What is an evaluation? • Consists of use and interpretation of formal and informal assessments • Record review • Assessment across multiple settings • More in depth

20. The “BIG” Picture • Look at the full picture…why is the child having challenges?? • Rarely are PT or OT issues in isolation • The magic does not happen only when the OT or PT are present! • TEAM, TEAM, TEAM!

21. Response to Intervention Strategies 1. First Line Strategies: • For use by teacher in classroom • Assess desk / chair height/feet flat on floor • Assess pencil grip • Assess posture / positioning • Implement visual cues • Trial writing supplements • Clear pathways in room

22. 2. Physical Tools / Prompts Implemented by teacher or IST • Consider vision check by school nurse • Trial pencil grip, slant board, seat cushion, lined paper • Cues for sitting position and posture

23. 3. OT/PT Screening • Done after step before with documented strategies used • Can be informal • Screen requested submitted with parent permission to special ed supervisor for approval

24. 4. OT/PT Evaluation • After Screen done, and as a result of further testing needed • As a result of parent written request

25. The joys of writing! Or not?

26. Basic Skills for Handwriting • Visual Motor Skills (child’s ability to copy shapes, letters or numbers…it means using vision to guide written output) • Visual Perception (child’s ability to use visual information to make meaning of what he sees, when learning a letter he first must be able to recognize it, recall what a letter looks like and discriminate between letters such as “b” and “p”.

27. Fine Motor Skills • 3 hand characteristics develop • Transverse arch from thumb to pinky giving that curved look to hand • Open web space between thumb and forefinger that can be seen when holding objects • Separation of the 2 sides of the hand evolves and the thumb side of the hand is geared for dexterity as the pinky side of hand is more for strength and stability.

28. Trunk Control • Need a strong and stable trunk • Analogy of a fishing rod • Signs that a child may lack trunk control include leaning on table, propping on hands, fatigue during sustained tasks, sliding off chair or slouching

29. Shoulder Stability • All your muscles work together to hold this joint table so when writing, this helps control that slow fluent movement. If this is lacking, writing can be affected. • Strategies-write on vertical surface, encourage games in quaduaped

33. Finger Excursion • Developmentally, children begin writing using more gross movements encompassing using their whole arm. • As they mature, dexterity improves and they learn to use only their wrist and hand. • Test for excursion to indicate when they are developmentally ready for ½ inch, 1 inch etc line…

34. Research has shown that • It is very hard to change a grip after 2nd grade

35. Quick Tips for Good Grasp • Use small pencil pieces • Have the student hold a small piece of paper or penny between ring and little finger and palm • Dots or rubber band on pencil • Try pencil grips • Writing on vertical or inclined surface

36. Adaptations Using Paper • Larger paper (more space between lines) at first, gradually shrink size of writing • Red line down left side to cue to start at left margin

37. For Left Handers • To avoid the hooked wrist be sure the paper is slanted the opposite way • Hand holding the pencil is below the writing line, not above it • Pencil held slightly further back than right hander (3 cm vs. 2 cm) • Hold paper with right hand

38. Making It Work • Use a systematic approach for teaching handwriting, 10-15 min/day to teach, 15 min/day to practice. • Imitate, then copy, then write without model. Child needs to “feel” the process of letter formation. • Emphasize quality more than quantity

39. Provide instruction on spatial aspects of handwriting • Teach students to self evaluate using a laminated checklist on their desk

40. Quick Tips for Mechanics • Encourage top to bottom movements for manuscript • Encourage starting on the writing line for cursive • Bump the writing line • Practice letters in groups of similar strokes (“kinesthetic groupings”) • Handwriting Without Tears Program

41. More Quick Tips for Specific Problems • Student writes too small – practice writing on the board • Student writes too large – practice tall letters ¾ space height, small letters ½ space height and use dotted lined paper • Lack of space between words – make small box between words, use exaggerated space, use popsicle stick, finger, pencil • spaceman

42. Additional Resources: • Handwriting Without Tears Program • www.hwtears.com • http://www.zaner-bloser.com/media/zb/zaner-bloser/FontsOnline_Sampler/FontsOnline_Sampler/index.html • www.handwritinghelpforkids.com • www.handwritingworksheets.com

43. Reason NOT to request a screen

44. SENSORY PROCESSING IN THE CLASSROOM

45. Overview of the Sensory Systems • Tactile – sense of touch • Vestibular - movement and balance • Proprioceptive - sense of self in space • Visual - seeing • Auditory – hearing • Olfactory - smell • Oral-Gustatory

46. The Tactile System • Touch • Sensitivity to textures/touch • Recognizing an object by feel (physical attributes of an object) • Vibration • Temperature

47. Vestibular System • Movement • Stop/Start • Balance • Head position • Visual scanning

48. Proprioceptive System • the body moves (or is moved) and then the information about this is returned to the brain, whereby subsequent adjustments could be made • muscles and joints that tells us about muscle contraction and stretch and joint bending straightening, pulling and compression

49. Visual System • Sight • Functional Vision • Filtering visual information • Visual Scanning

50. Visual Perception • The ability to take what the eye sees and give it meaning • 80% of what we ask students to learn in school comes through visual opportunities