Related Service Consultation

1
Related Service Consultation

• Strategies for successful integrated practice

2
Goals for session

• Understand what related services bring to the
  preschool classroom
• Training of OT/PT/SP
• Resources they bring to the classroom
• Explain the roles of therapists in early
  childhood programs
• How therapists support teachers to achieve
  optimal student learning

3
Goals for session

• Identify best practice models for related service
  consultation
• Collaboration/problem solving versus expert
• Shared responsibility
• Flexible implementation
• Appropriate use of paraprofessionals
• Identify barriers to implementing these models.
• Results of a recent Ohio survey

4
Goals for the session

• Explain what administrative supports can promote
  effective consultation.
• Using your vision to empower staff
• Critical system supports to make it happen.
• Review and assess the research on related
  services consultation.
• Studies of related services consultation

5
What do OT, PT, SP bring to the preschool
classroom

• Related service professionals use a clinical
  reasoning/ problem solving approach to every
  child and every situation.
• OTs and PTs tend to focus on foundational skills
  and physiological issues
• Arousal/ attention
• Activity level
• Movement and posture
• Eye-hand coordination

6
OT/PT/SP training

• Therapists think broadly about function
• Does the child have adequate stability to safely
  get up and down from the floor, can he process
  auditory input, can he zip and snap his jacket?
• Often trained in medical schools
• Bring a health perspective to the classroom
• Receive extensive anatomy, neuroscience
  coursework
• Understand human function from biomechanical and
  neurological perspectives.

7

• Base intervention on careful analysis of
  performance and activity demands.
• Need hands on, direct observation to consult on a
  childs program.
• Child centered / family centered interventions
  are emphasized.
• Use a clinical reasoning model that always begins
  with the individual.

8
Therapists understand the medical system, but do
they understand the educational system?

• Training therapists on services in schools is
  highly variable across allied health programs.
• School based practice is not a stated standard in
  OT/PT accreditation standards.

9
How has PT training changed in recent years?

• All PT programs are doctoral level (by 2020).
• A goal of the DPT is to allow PTs to move into
  independent practice.
• Early childhood programs may be in a position of
  hiring more contract PTs who own their own
  practice.
• What is the extra year of PT training?
• Diagnostic courses, evidence based practice,
  research, medical specialization.

10
OT and SP training

• Training is primarily at the masters level.
• Curricula emphasize science based practice and
  evidence based practice.
• Therapists are trained to work across settings
  (nursing home, hospital, school, rehabilitation)
• They are trained to work with all age groups.

11
When does medical background present as an issue?

• OT/PT/SP are best integrated into the education
  system when they are employed by the school
  district.
• Contract therapists, who also work in a medical
  center, have a difficult time making the shift to
  educational practice.
• Contract therapists need to spend time with
  teachers in school buildings to understand the
  culture, the rules, the system (not always
  feasible when paid by the hour)

12
What do therapists bring to the early childhood
classroom?

• Children with medical needs
• Understanding of medical issues, how to
  accommodate the equipment, positioning.

13

• Children with assistive technology needs

14

• Children who struggle with feeding or basic
  functional skills.

15
Children with underlying physiological problems

• Children with autism
• Focus on sensory processing
• Children with cerebral palsy
• Focus on posture, movement, strength, transitions
  within the school building, activities of daily
  living.

16
What are roles of therapists in support of the
teaching staff?

• Indirect services (to teaching staff and team) on
  behalf of the child
• May reframe the childs problems identify and
  explain underlying impairments.
• What is perceived as behavior may reflect
  difficulty in sensory processing
• Behaviors may reflect disorders in motor
  planning, arousal, sensory processing.

17
Therapist roles in support of teachers

• Provide information and materials
• Create handouts for recommendations
• Provide information about a disability or
  diagnosis
• Provide information about evidence based
  practices.
• Teach alternative methods for instruction
• Introduce Picture Exchange Communication Systems
  (PECS)
• Help to write Social Stories
• Assist in creating Intellitools programs

18
Tools that we recommend for the classroom.
19

• Recommend modifications to the classroom
  environment
• Suggest a bean bag chair for a child with sensory
  needs
• Suggest a tent for quiet time of children with
  high activity levels.
• Recommend a rocking chair for calming.

20
Sensory corner for child to calm
21

• Recommend adapting activities or materials
• Obtain adapted spoon, cups, plates.
• Obtain easel for vertical surface drawing

22

• Provide support, encouragement
• Assure teaching staff that they are implementing
  appropriate interventions for difficult medical
  issues.
• Provide feedback about child response to
  teacher-designed interventions.

23
Consultation Styles

• Technical assistance
• TA is most appropriate when
• Defined problem
• Equipment needs
• May be short-term

24
Examples Create Intellikeys program Problem
solve how child will use new wheelchair on the
playground.
25
Consultation styles

• Collaborative consultation
• Uses the problem solving method
• Requires a relationship of parity
• Requires trust and follow through
• All parties take responsibility for outcomes
• Requires understanding of each others roles.

26

• Examples of collaborative consultation
• Development of a behavioral plan for child with
  ADHD
• Adapting the preschool space for a child with
  severe cerebral palsy in wheelchair.
• Creating adapted methods for child with low
  vision to participate in snack, playground, art,
  circle.

27
Best practice consultation

• Consultation is a structured type of teaming
• Begins with establishing a relationship.
• Works best when trust and respect have been
  established.
• The relationship should be one of parity and
  mutual respect.

28
How does consultation work?

• Teachers seek OT/PT/SP involvement early, prevent
  problems from escalating.
• Teachers and therapists need opportunities to
  engage in collaborative problem solving and
  functional analysis of behavior.

29
Childs problem is understood in the context of
the environment and the curriculum
30
Therapist consultation requires comprehensive
evaluation

• Therapist needs to observe child in multiple
  settings, at different times of day.
• Interview with teacher is critical to obtain
  her/his perspective of the problem.
• Consultation is based first on the teachers
  perception of the problem.
• The childs problem must be viewed within the
  demands of the preschool environment and the
  curriculum.

31
How does consultation work?

• Interview with parent, other therapists and staff
  may be helpful.
• Problem solving Teacher and therapist engage in
  problem solving (brainstorm first) and identify
  1-2 strategies to try first.
• Planning Teacher and therapist identify who is
  responsible for what action and who collects data
  on the childs response (shared responsibility)

32

• Monitoring progress Both monitor behavior and
  progress.
• Assessment Meet to assess effectiveness of
  strategy and move to next strategy or plan to
  continue

33
Flexible scheduling

• Consultation involves moving in-between direct
  services (activities with the child) and indirect
  services (instructions to teaching staff)
• It requires frequent monitoring, data collection,
  and team interaction.

34
Flexible Scheduling

• Works best with a 3 and 1 or other flexible
  scheduling model.
• The 3 and 1 model defines collaboration as a
  priority.
• Opportunities to collaborate were cited as one of
  the biggest barriers to using the consultation
  model in recent survey of school-based OTs.
• Holland (2007)

35
Appropriate use of paraprofessionals

• Paraprofessionals should be asked to perform only
  techniques that can be easily and safely
  implemented.
• Should not be given programs likely to result in
  rapid change and need for frequent upgrading of
  the program
• Therapists have certain legal restrictions on how
  they can use aides/assistance. Supervision is
  required by licensure law, but is loosely
  defined.

36
Myths dispelled

• Consultation takes less time than direct
  intervention methods.
• Consultation means handing off the problem.
• Consultation is not needed until the teacher can
  not manage the problem.
• Therapists are needed only when a child is
  failing to make progress.

37
Barriers to collaborative consultation and how
administrators can remove them

• Barriers
• Teachers and therapists do not know each others
  roles
• Teachers and therapists do not feel parity, lack
  trust.

• Potential Solutions
• Make sure therapists are invited to school
  events, in-services
• Schedule regular social activities.
• Create a collaborative culture
• Work on equity issues, pay, status, support
  proximity.

38

• Barriers
• Teachers and therapists do not have time to
  collaborate and plan.
• Holland (2007)
• Sometimes therapists and teachers do not value
  collaboration.

• Potential Solutions
• Allow for and build in planning time on a regular
  basis
• Use 3 and 1 model (therapists see child for 3
  weeks and then have a week for meeting with
  teacher).
• Encourage creative use of time, therapists meet
  with teacher while assistant runs class.

39

• Barriers
• Teacher waits until behaviors are unmanageable.
• Consulting therapist does not take ownership of
  the problem

• Potential Solutions
• Encourage use of consultation when the problem is
  first identified to prevent difficult situations.
  
• Suggest that both therapist and teacher
  monitor/assess the effects of the new strategy or
  equipment.
• Alternative solutions should be offered.

40

• Barriers
• Therapists are only needed when the child fails
  to make progress.

• Potential Solutions
• Preventive services are optimal.
• Therapy services are most effective when
  intervention is early.

41
Example of consultation for behavior problem

• Illustrates what an occupational therapist might
  bring to problem solving to complement skills of
  the teaching staff.

42
PROBLEM Child pushes and hits a child who sits
too close to him during circle time

• Teacher and OT complete a functional analysis to
  identify a basis for the behavior and to
  implement a strategy to prevent his
  pushing/hitting.
• ANTECEDENTS
• Is child angry?
• Child does not appear angry. The children close
  to him did nothing to cause anger. NO.

43

• ANTECEDENTS
• No apparent antecedents other than a child sat
  close to him.
• Possible cause is sensory defensiveness or
  hypersensitivity to touch.
• In other situations, the child appears
  uncomfortable with touch and avoids being touched
• REINFORCEMENTS
• Teacher attention
• Therapist attention

44

• REINFORCERS
• Pushing/hitting another child is reinforced
  because the child does not sit near him again.
• Child next to him moves away from him
• Antecedent (cause) takes priority
• How can the teachers and peers accommodate this
  childs hypersensitivity?

45
SOLUTIONS FOR THIS HYPERSENSITIVE CHILD

• PROCESS
• The teacher and occupational therapist meet to
  collaborate on a plan.
• Both identify ways to modify the environment
• The therapist identifies interventions that use a
  sensory processing approach.
• The combination of approaches is likely to be
  most effective and to address causative factors
  and avoid negative consequences.

46
SOLUTIONS

• Because hitting is serious, the child should be
  allowed to sit apart from the other children.
• The teachers uses carpet squares to define the
  space for each child.
• The child is provided with sensory strategies to
  decrease his hypersensitivity.
• The teacher looks for signs that he is
  over-stimulated or uncomfortable with touch and
  gives him opportunities to escape and calm.

47
Is OT/PT/SP consultation an effective service
delivery model?
48
Research on Consultation

• Dunn (1990) in a pilot study found that children
  with OT on the IEP made the same progress when a
  consultation model of services delivery was
  compared to direct services.
• The teachers reported that they valued the
  consultation model more than the direct services
  model.

49
Research on Consultation Outcomes

• Palisano (1989) compared 14 students who received
  consultation with OT/PT to 19 students who
  received direct OT/PT therapy.
• Following 6 months of once a week intervention,
  both groups improved in motor and visual
  perceptual skills.
• The consultation group made greater gains in
  gross motor skills.

50

• Davies and Gavin (1994) also found no difference
  in the gains made by preschool children when they
  received direct services OT compared to a group
  with consultation OT services.
• Both groups made significant progress in fine and
  gross motor performance.

51
Research on Consultation

• Consultation by related service personnel has
  similar child outcomes to direct services.
• Teacher outcomes are more positive with
  consultation versus direct service.
• Teachers benefit from learning new techniques,
  methods.
• Teachers appreciate a collaborative approach.

52
Research on Consultation

• We have no evidence that consultation requires
  less time, resources, or funding.
• Use of consultation supports the development of
  interdisciplinary approaches to problems.
• Consultation may support sustained effects of
  related services intervention.
• Consultation supports generalization of skills
  and mastery of skills.

53
Summary

• OT/PT/SP bring a health and medical perspective
  to early childhood programs.
• Therapists are trained to analyze performance and
  to reason by considering the environment, the
  child, and the activity demands.
• Although they know child development and human
  function well, they may not be knowledgeable
  about the preschool curriculum.

54
Summary

• Best practice consultation uses a
  problem-solving, collaborative approach
• Relationships are established.
• The teachers perspective is provided first,
  followed by assessment of the child and
  environment.
• The goal is to support the teacher to affect a
  child outcome.
• Uses collaborative problem solving process
• Involves shared responsibility and shared data
  collecting

55
Summary

• Administrators can support collaborative
  consultation by
• Allowing time for collaborative planning
• Allowing flexible scheduling
• Encouraging in-services for sharing of skills
  among team members.
• Fostering mutual respect and parity among all
  school personnel
• Allowing creative solutions in a child-first
  environment.

56
References

• Davies, P.L., Gavin, W.J. (1994). Comparison
  of individual and group/consultation treatment
  methods for preschool children with developmental
  delays. American Journal of Occupational
  Therapy, 48, 155-161.
• Dreiling, D.S., Bundy, A.C. (2003). A
  comparison of consultative model and direct
  indirect intervention with preschoolers.
  American Journal of Occupational Therapy, 57,
  566-569
• Dunn, W. (1990). A comparison of service
  provision models in school-based occupational
  therapy services A pilot study. Occupational
  Therapy Journal of Research, 10 (5), 300-320
• Holland, T.L. (2007). Survey of Ohio
  School-based occupational therapists to describe
  current practice patterns. The Ohio State
  University.