Models of Practice in School-Based Occupational Therapy

The scope of occupational therapy evaluation and intervention in the school setting includes areas that affect the child’s participation in educational activities, routines, and environments (AOTA, 2015). The occupational therapy practice framework promotes occupation-based, client-centered, contextual, and evidence-based services (AOTA, 2014). Despite best practice in pediatrics being occupation based (Estes & Pierce, 2012) and the current trends promoting top-down, occupation-based frames of reference such as the Model of Human Occupation (MOHO), evidence suggests that school-based occupational therapy practitioners (OTP) are predominantly using bottom-up, impairment-focused theoretical frameworks and assessments to guide their practice (Kiraly-Alvarez, 2015). Regardless of the approach utilized, OTPs work within the framework of occupational therapy towards participation in occupations that facilitate engagement in a child’s everyday activities (AOTA, 2015).

Current Model

One approach currently used is sensory integration (SI). The American Occupational Therapy Association (AOTA) recognizes sensory integration as one of several theories and methods used by OTPs working with children in schools to improve a child’s ability to access their educational curriculum and to participate in education-related learning experiences (AOTA, 2015). SI methods are used within occupational therapy when sensory-related issues are impacting a child’s ability to access the education curriculum, behave adaptively, and participate in activities at school (AOTA, 2009). When children demonstrate sensory-related deficits that interfere with their ability to access the general education curriculum, a sensory integrative approach is appropriate (AOTA, 2015).

For example, if a child demonstrates an adverse response to touching glue, soap or other textures, or if a child demonstrates difficulty with body awareness and constantly trips and falls in his classroom, the SI frame of reference and sensory-based interventions are utilized. Sensory-based interventions can address specific sensory needs related to sensory modulation or sensory discrimination (AOTA, 2015). The OTP designs interventions that consider the sensory needs of the child within the context of the classroom (AOTA, 2015). Interventions may include implementing daily routines that incorporate sensory-based activities, modifying the environment to accommodate students’ sensory needs and facilitate participation, and teaching self-regulation strategies (AOTA, 2015). Occupational therapy using a sensory integrative approach is grounded in the work of A. Jean Ayres, PhD, OTR (AOTA, 2015).

The American Occupational Therapy Association (AOTA) also recognizes the Model of Human Occupation (MOHO) as one of several theories and methods used by OTPs in schools (AOTA, 2014). This approach includes the therapeutic use of everyday occupations with individuals or groups to enhance or enable participation in roles, habits, and routines at school (AOTA, 2014). The MOHO approach and occupation-based practice can be more effective because it is more enjoyable and rewarding. This approach is highly customized, and is valued and understood by children and families (Estes & Pierce, 2015). Lastly, this approach incorporates the views of early OTPs and the founding members of the profession. This approach may be accessed when addressing activities of daily living such as shoe tying, mealtime skills, or handwriting.

A positive part of this frame of reference is that through the child’s engagement in occupation, positive change occurs as motivation is highly influenced by their interests (Estes & Pierce, 2015). Participation in occupation is self-organizing and allows the child to adapt and change, and to learn about him or herself as an occupational being (Estes & Pierce, 2015). A negative part of this approach is that it can be perceived as challenging, because it takes more time to plan, prepare and implement (Estes & Pierce, 2015). Additionally, some OTPs feel that the environment is not realistic, thus impeding the quality of intervention (Estes & Pierce, 2015), and oftentimes culture can impede occupation-based practice (Estes & Pierce, 2015). Overall, occupation-based practice is more family-centered, is more motivating for children, and generalizes better to the classroom (Estes & Pierce, 2015).

Although many differences have been highlighted, the MOHO and SI approaches have several commonalities. Both propose that the OTP consider the situation of the individual, and caution against applying the same solution to what may appear to be similar difficulties. Both models assert that the focus should be on the process underlying the human system, and both encourage OTPs to look at how the individual is able to function or perform in his or her daily environment. Additionally, the MOHO and SI approaches consider the whole child, and intervention involves experimentation to find the best solutions. With both approaches, the OTP can address the needs of the child through play, and offers the child opportunities to experiment to discover solutions. Finally, the outcome in both approaches is to improve function in various daily occupations (AOTA, 2015).

If OTPs choose to use theories related to sensory integration, motor control, or development, considering components of the MOHO can complement the information gathered through the use of those theories (Kiraly-Alvarez, 2015). For example, there is significance in considering a child’s volition when using a primarily sensory integrative approach to treatment, noting that a child’s behavior cannot be completely explained by examining only the physical and sensory aspects of his or her performance (Kiraly-Alvarez, 2015). As Gillen argued in his Slagle lecture (2013), we cannot defend our scope of practice if we do not practice some form of occupation-based intervention. Understanding a child with the use of both SI and the Model of Human Occupation contributes to a more occupation-based, client-centered, holistic, and strength-based approach to therapy (Kiraly-Alvarez, 2015).

References

American Occupational Therapy Association [AOTA]. (2009). Providing occupational therapy using sensory integration theory and methods in school-based practice. American Journal of Occupational Therapy, 63(6), 823.

American Occupational Therapy Association [AOTA]. (2014). Occupational therapy practice framework: Domain and process, 3rd edition. American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.

American Occupational Therapy Association [AOTA]. (2015). Occupational therapy for children and youth using sensory integration theory and methods in school-based practice. American Journal of Occupational Therapy, 69(Suppl. 3).

Estes, J. & Pierce, D. (2012). Pediatric therapists’ perspectives on occupation based practice. Scandinavian Journal of Occupational Therapy,19, 17–25.

Gillen, G. (2013). A fork in the road: an occupational hazard? American Journal of Occupational Therapy, 67(6).

Kiraly-Alvarez, A. (2015). Assessing volition in pediatrics: Using the volitional questionnaire and the pediatric volitional questionnaire. The Open Journal of Occupational Therapy, 3(3). Retrieved from https://doi.org/10.15453/2168-6408.1176

McLaughlin Gray, J. (1998.) Putting occupation into practice: Occupation as ends, occupation as means. American Journal of Occupational Therapy, 52, 354–364.