Effectiveness of Occupational Therapy In the School Environment
©2003, S. Sahagian Whalen, CanChild Centre for Childhood Disability Research
INTRODUCTION
The provision of occupational therapy services to students in the school
system continues to be a growing area of pediatric practice in Ontario,
through the School Health Support Services (SHSS) Programme, and
elsewhere across Canada and the United States under varying service
delivery and funding models. Recently, there has been an increasing
demand for evidence-based practice. A review of the literature related to
the effectiveness of school-based occupational therapy services was
completed. It is hoped that by sharing this information, other providers
of occupational therapy in the school system will be able to communicate
confidently the effectiveness of their interventions with funding agencies,
schools, families and children.
WHAT WE DO KNOW ABOUT THE EFFECTIVENESS OF
OCCUPATIONAL THERAPY IN THE SCHOOL ENVIRONMENT?
Occupational therapy (OT) is a health care profession that is concerned
with a person's ability to perform the daily occupations they are
expected to, need to do or want to do. Daily occupations include selfcare,
productive and leisure activities. The person's performance of their
daily occupations is influenced by the environment in which they are
performing the activity. Occupational therapists believe, and there is
evidence to support, that a person's satisfaction with their occupational
performance is an important determinant of health and well being and
helps give meaning to life (Law, Steinwender & LeClair, 1998).
In the school setting, a student's occupational performance may be
impaired by a physical, developmental, sensory, attentional and/or
learning challenge. The social, attitudinal and cultural environment,
along with the availability of supports (person support or equipment
support), impacts on the student's occupational performance in the
school setting.
GOAL OF OCCUPATIONAL THERAPY IN THE SCHOOL SYSTEM
The goal of OT in the school environment is to improve a student's
performance of tasks and activities important for school functioning. This
may involve direct intervention to improve, restore, maintain or prevent
deterioration in the skills required for functioning in the school
environment. Consultation and education of adults in the child's home
and school environment may be necessary to ensure an understanding
of and match between the child's skills and abilities and the expectations
placed on them in the school setting. Recommendations of task
adaptations, task modifications and assistive devices (e.g., mechanical
lift, writing aid) may be necessary to optimize the child's performance in
the school setting.
DOES OCCUPATIONAL THERAPY IN THE SCHOOL SYSTEM MAKE A DIFFERENCE?
Palisano (1989) conducted a six-month study with thirty-four children,
ages six through nine years of age, with learning disabilities. They were
divided into two groups, one receiving intervention twice weekly with the
OT in a small and large group setting. The second group received
consultation services from the OT through a weekly large group session
in the classroom, and one half hour per week consultation with the
teacher to provide a monthly lesson plan of follow-up activities to be
performed three times per week. Intervention occurred over a six-month
period. Both groups received an equal amount of therapeutic
intervention each week (75-105 minutes). The children in both groups
improved on the standardized assessments of gross motor and fine
motor abilities, visual-motor integration and visual-perceptual skills.
These skills are necessary for adequate school performance in the areas
of reading, writing, mathematics, manipulation of tools (e.g., scissors
and rulers) and performance in physical education.
A small study conducted by Dunn (1990) compared the results of direct
intervention by an OT to collaborative consultation by the OT with the
student's teacher over the period of one academic year. Fourteen
children (ages 35 months to 79 months of age) with a developmental
delay of at least one year in at least two areas of development
participated. Children in both groups achieved nearly 75% of their goals
as identified on their Individualized Education Plan (IEP). The teachers
reported that the OT contributed to goal attainment more in the
collaborative consultation group than in the direct intervention group.
This study supports the effectiveness of OT intervention, both in direct
intervention and collaborative consultation models, on attainment of
goals as identified on the IEP in students with developmental challenges.
Collaborative consultation appears to be seen by teachers as impacting
more on the OT's contribution to goal attainment than direct intervention
alone.
Niehues et al. (1991) used qualitative methodology to study the nature
of OT practice in the public schools with five expert school system
practitioners. Results indicated that OTs play a role in "reframing" the
views of the parents and teachers concerning discrepancies between
students' performances in school and the expectations held for them.
This enabled a more positive view of the student and provided a basis
for developing new and more effective teaching and/or parenting
strategies with students.
King et al. (1999) reported the results of a study on school-based
therapy services conducted in London, Ontario with fifty children ranging
in age from five through twelve, with a variety of special needs,
including cerebral palsy, fine motor difficulties, developmental
coordination disorder, spina bifida and/or speech/language delays. Direct
therapy, monitoring and collaborative consultation between therapists,
teachers and parents were used in the service delivery model. Twentyone
of these children had occupational therapy goals in the area of
school productivity (written communication skills, organizational skills,
functional fine motor/visual skills). Sixteen of the children had speechlanguage
goals in the area of communication and 13 had physiotherapy
goals in the area of mobility. Data were collected prior to therapy
intervention, following therapy intervention and five to six months after
therapy terminated. Standardized assessments, goal attainment scaling
and satisfaction questionnaires were used to evaluate outcomes.
Children with fine motor difficulties received OT twice a week for a
three-month period. Ninety-eight percent of the fifty children made
progress in their goals, with many gains maintained over the six-month
follow-up period. Improvement on the standardized measures was
clinically significant in the targeted area of school productivity. The rate
of change for children receiving occupational therapy exceeded that
expected due to maturation, suggesting that intervention was the reason
for the improvement measured. The productivity goals were all
educationally relevant, to support the premise that school-based therapy
should support the student's performance in the school setting. Goals
included copying from the board, holding a pencil correctly, keyboarding,
cutting, colouring, use of a computer mouse, organizing a desk and
focusing on a task, all of which underlie and support academic
performance. Both parents and teachers reported a high degree of
satisfaction with the services provided, supporting the use of a model
combining collaborative consultation and direct intervention.
A study conducted in four Southern Ontario school boards (Fairbairn and
Davidson, 1993) examined what 103 teachers in Ontario say they
receive, need and expect from OTs, and examined the value placed by
teachers on OT services. Results indicated that all the teachers valued
the work of OTs in the schools, finding them knowledgeable, supportive
and providers of practical programming, physical exercises and adapted
equipment. Eighty-nine per cent reported that the OT programme
enhanced the students' ability to learn and 80% said that the OTs
eliminate problems that interfere with a child's ability to profit from
instruction. Eighty-two percent of the teachers indicated that OTs could
provide medical, physical and developmental information in educationally
relevant terms. Seventy-nine percent believed that OTs were able to
translate assessment information into relevant programming and 96%
believed the OT held a distinct place in the school setting. Over 60% of
the teachers identified motor skills, psychosocial skills, assessment of
student needs, daily living skills, sensorimotor skills, equipment needs
and maintaining parent involvement as areas with which OTs could assist.
DO SPECIFIC CONDITIONS BENEFIT FROM OCCUPATIONAL THERAPY IN THE SCHOOL SYSTEM?
1) Developmental Coordination Disorder
The prevalence of Developmental Coordination Disorder (DCD) is
estimated at 6% of the population, with boys more commonly affected
(Fox and Lent, 1996). This disorder describes a child who lacks the
motor coordination necessary to perform tasks that are considered to be
appropriate for her/her age and may demonstrate significant difficulty
with self-care tasks such as dressing and using utensils, with academic
tasks such as handwriting and/or with leisure activities such as sports
(Missiuna, 1996). Other neurological disorders must be absent for this
diagnosis, but it commonly coexists with learning disabilities (particularly
non-verbal learning disabilities) and attention deficit disorder.
As so many daily tasks can be difficult for a child with DCD, these
children experience frequent failure, come to expect failure and the
resulting lower self-confidence can affect their social, academic and
physical performance (Fox and Lent, 1996). Fox and Lent go on to say
that persisting coordination difficulties and neurological signs suggesting
neuro-maturational delay have been recognized as predictive of many
psychiatric disorders, including affective and anxiety disorders. They cite
a longitudinal follow-up to age 16 of children identified at age 6 with
deficits in attention, motor control and perception, which showed that
nearly 60% had psychiatric, and personality disorders in midadolescence,
13% were substance abusers and 5% had attempted
suicide. Fox and Lent (1996) state that strong scientific evidence now
shows that most children's motor problems persist well into adolescence
and studies have demonstrated that these children will display poor
social competence, poor motivation, low self-esteem, unhappiness and
reluctance to engage in physical activities with the result of poor physical
fitness. The costs to the health care and social service systems in the
future are staggering, which makes early intervention with these children
essential. Fox and Lent (1996) state that OTs can quantify the disability,
advocate for modifications, including changed expectations, assist in
providing information to parents, teachers and children and offer
intervention techniques related to school work, leisure and activities of
daily living.
Dewey and Wilson (2001) cite literature stating that children with
coordination difficulties are reported by teachers to have difficulties in
physical education, writing, handling equipment in science classes and
arts and crafts. They go on to cite studies demonstrating an association
between poor motor coordination and social -emotional problems in
childhood. Children with movement problems saw themselves as less
socially competent and were more introverted and anxious than their
peers. These children often withdraw from or avoid physical activity,
which can lead to secondary health problems.
These children are often referred to OT through the school system due
to "fine motor difficulties", "poor pencil grasp", "gross and fine motor
clumsiness" or "difficulty with printing." Missiuna (1999) states that 95%
of OT referrals are due to "handwriting". She goes on to say that the
majority of these students are experiencing difficulty with more than just
handwriting. Closer observation reveals difficulty managing scissors,
handling a ruler, doing up zippers and buttons, erasing, participating in
gym class, getting ready for recess, playing games in the schoolyard
and/or participating in sports and leisure activities. These children often
have DCD but are not diagnosed, as many physicians remain unfamiliar
with this diagnosis or are reluctant to "label" the child.
Early evidence for the effectiveness of "top-down" OT approaches in
teaching specific tasks and in improving functional performance of
children with DCD is beginning to appear (Mandich et al., 2001).
Specifically, there is evidence that the Cognitive Orientation to Daily
Occupational Performance (CO-OP) approach is effective in skill
acquisition and the evidence is emerging that CO-OP also results in
generalization and transfer of skills (Polatajko et al., 2001). When using
the CO-OP approach, the evidence suggests that 12 one-to-one OT
sessions of one hour in length are necessary. (This does not include the
initial OT assessment, which is required to determine the child's specific
strengths, needs and suitability for this approach, nor does it include the
collaborative consultation time required with parents and teachers to
ensure follow-through and support generalization of the skills.)
As summarized in the first section, children with fine motor and
coordination difficulties were included in many of the studies that looked
at the effectiveness of OT in the school system. CO-OP was not used as
the treatment approach in these studies, but more traditional OT
approaches were used and found to be effective in the development of
skills and on goal attainment.
2. Written Productivity
Oliver (1990) examined the effects of occupational therapy on writing
readiness skills. One of the groups involved in the study included five
and six year olds with a discrepancy between their performance and
verbal intelligence quotients. This is the typical profile of many of the
children referred for OT in the schools. They often progress to be
identified as having a non-verbal learning disability. This group received
thirty minutes weekly occupational therapy for the duration of the school
year. Therapy intervention focused on multisensory stimulation, large
movement patterns and writing readiness skills such as attention to lines
and designs. In addition, these children received ten minutes of
additional programming three times per week by the teacher, aide or
parent. This programming was designed by the OT and complemented
the direct therapy through the use of structured work sheets and
manuscript letter practice. Results demonstrated an improvement of 17
months in writing readiness over the year. This study supports the value
of early occupational therapy intervention with children with delays in
writing readiness.
Lockhart and Law (1994) examined the effectiveness of a multisensory
cursive writing programme. Participants were nine through eleven years
of age and had a diagnosis of a learning disability and had sensorimotor
difficulties. The participants received one hour of occupational therapy
every two weeks using a multisensory cursive writing programme.
Results of the study yielded changes of statistical significance in writing
quality in specific letter groups for all of the children following
intervention. Teacher reports and an assessment of written language
suggested that intervention may have had a positive effect on selfconfidence
in written output, and on the maturity of written expression
in some of the cases.
Case-Smith (2002) reported the results of a study on the effects of
school-based occupational therapy services on students' handwriting.
Twenty-nine students, aged seven through ten years of age with poor
handwriting legibility and cognitive function within normal limits,
received a mean of 16.4 sessions of direct occupational therapy services
over the school year. Fifteen of the students had an educational
diagnosis of learning disability, and eleven had a diagnosis of
developmental disability. Ninety-five percent of the intervention was oneon-
one and included a variety of therapeutic approaches individualized to
the student's needs. The therapists reported a high level of collaboration
with the teachers. When compared with students who did not receive
services, the intervention group showed significant increases in
handwriting legibility, in-hand manipulation and position in space scores.
Legibility increased by 14.2% in the intervention group, and by 5.8% in
the comparison group.
METHODOLOGY
The literature review was guided by the question, "Does occupational
therapy make a difference in the school system?" As the majority of
referrals to OT in the Ontario School Health Support Services Programme
are for fine motor delay, clumsiness and/or written productivity
difficulties, a secondary focus of the literature search was Developmental
Coordination Disorder and written productivity.
Partnerships with the School of Rehabilitation Science at McMaster
University and the CanChild Centre for Childhood Disability Research,
along with the author's personal contacts through both formal and
informal OT networks, resulted in access to the relevant literature.
Information from these sources provided the author with relevant
articles and links to other articles.
SUMMARY OF WHAT WE DO KNOW
In summary, research evidence to date supports the effectiveness of
occupational therapy in the school setting with students experiencing
occupational performance challenges. OT is effective in helping children
attain goals and develop skills in areas underlying and supporting school
performance. Occupational therapists help in reframing the views and
expectations of the student by the adults in the environment.
Collaborative consultation with parents
and teachers appears to be an essential component of the service
delivery to maximize effectiveness of and satisfaction with the
intervention provided by the occupational therapist. The evidence
presented relates to a variety of diagnoses and needs, including students
with physical disabilities, developmental coordination disorder, fine motor
difficulties, developmental delays and learning disabilities.
WHERE DO WE GO FROM HERE?
Occupational therapists need to share the evidence supporting the
effectiveness of OT intervention in the school system with clients,
educators and funding agencies. Evidence-based service delivery models
need to incorporate direct client intervention with processes to facilitate
and support collaborative consultation with parents and teachers to
maximize effectiveness of and satisfaction with OT services.
Further research is recommended to identify effective methods for
screening referrals to occupational therapy, to evaluate the effectiveness
of OT in the prevention of secondary problems and to further evaluate
both the clinical and cost effectiveness of various service delivery models
with specific client groups.
Update written by:
Sandra Sahagian Whalen is an occupational therapist with over twenty
years of experience. She works part-time with Community Rehab as the
professional leader for pediatric occupational therapy in the Peel Region,
as well as in private practice with REACH Therapy Services.
The author and CanChild would like to acknowledge
the tremendous support received from:
Nancy Pollock, co-investigator with CanChild and Associate Clinical
Professor, School of Rehabilitation Sciences.
Debbie Jones-Snyders, Manager, Peel Branch of Community Rehab.
Mary Law, Co-director, CanChild and Professor and Associate Dean,
School of Rehabilitation Science, McMaster University.
CanChild is funded by the Ontario Ministry of Health and Long-Term Care.
Want to know more? Contact:
CanChild Centre for Childhood Disability Research
Institute for Applied Health Sciences, Room 408
1400 Main St. W., Hamilton, ON L8S 1C7
Tel: 905-525-9140 x 26074 Fax: 905-522-6095
[email protected]
REFERENCES
Case-Smith, J. (2002). Effectiveness of school-based occupational
therapy intervention on handwriting. The American Journal of
Occupational Therapy, 56 (1), 17-25.
Dewey, D. & Wilson, B.N. (2001). Developmental coordination disorder:
What is it? Physical & Occupational Therapy in Pediatrics, 20 (2/3), 5-27.
Dunn, W. (1990). A comparison of service provision models in school
based occupational therapy services. A pilot study. The Occupational
Therapy Journal of Research, 10 (5), 300-320.
Fairbairn, M.L. & Davidson, I.F.W.K. (1993). Teachers' perceptions of the
role and effectiveness of occupational therapists in schools. Canadian
Journal of Occupational Therapy, 60(4), 185-191.
Fox, A.M. & Lent, M.A. (1996). Clumsy children. Primer on
developmental coordination disorder. Canadian Family Physician, 42
(Oct.), 1965-1971.
King, G., McDougall, J., Tucker, M.A., Gritzan, J., Malloy-Miller, T.,
Alambets, P., Cunning, D., Thomas, K., & Gregory, K. (1999). An
evaluation of functional, school-based therapy services for children with
special needs. Physical and Occupational Therapy in Pediatrics, 19(2), 5-29.
Law, M., Steinwender, S., & Leclair, L. (1998). Occupation, health and
well-being. Canadian Journal of Occupational Therapy, 65(2), 81-91.
Lockhart, J., & Law, M. (1994). The effectiveness of a multisensory
writing program for improving cursive writing ability in children with
sensorimotor difficulties. Canadian Journal of Occupational Therapy,
61(4), 206-214.
Missuina, C. (1996). Keeping Current in….Developmental Coordination
Disorder. Neurodevelopmental Clinical Research Unit, KC #96-3.
Missuina, C. (1999). Keeping current in…Children with fine motor
difficulties. CanChild Centre for Childhood Disability Research, KC #99-3.
Niehues, A.N., Bundy, A.C., Mattingly, C.F., & Lawlor, M.C. (1991).
Making a difference: Occupational therapy in the public schools. The
Occupational Therapy Journal of Research, 11(4), 195-212.
Oliver, C.E. (1990). A sensorimotor program for improving writing
readiness skills in elementary-age children. The American Journal of
Occupational Therapy, 44(2), 111-116.
Palisano, R.J. (1989). Comparison of two methods of service delivery for
students with learning disabilities. Physical and Occupational Therapy in
Pediatrics, 9(3), 79-100.
Polatajko, H.J., Mandich, A.D., Miller, L.T. & Macnab, J.J. (2001).
Cognitive orientation to daily occupational performance (CO-OP): Part IIThe
evidence. Physical and Occupational Therapy in Pediatrics, 20(2/3), 83-106.
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©2003, S. Sahagian Whalen, CanChild Centre for Childhood Disability Research
INTRODUCTION
The provision of occupational therapy services to students in the school
system continues to be a growing area of pediatric practice in Ontario,
through the School Health Support Services (SHSS) Programme, and
elsewhere across Canada and the United States under varying service
delivery and funding models. Recently, there has been an increasing
demand for evidence-based practice. A review of the literature related to
the effectiveness of school-based occupational therapy services was
completed. It is hoped that by sharing this information, other providers
of occupational therapy in the school system will be able to communicate
confidently the effectiveness of their interventions with funding agencies,
schools, families and children.
WHAT WE DO KNOW ABOUT THE EFFECTIVENESS OF
OCCUPATIONAL THERAPY IN THE SCHOOL ENVIRONMENT?
Occupational therapy (OT) is a health care profession that is concerned
with a person's ability to perform the daily occupations they are
expected to, need to do or want to do. Daily occupations include selfcare,
productive and leisure activities. The person's performance of their
daily occupations is influenced by the environment in which they are
performing the activity. Occupational therapists believe, and there is
evidence to support, that a person's satisfaction with their occupational
performance is an important determinant of health and well being and
helps give meaning to life (Law, Steinwender & LeClair, 1998).
In the school setting, a student's occupational performance may be
impaired by a physical, developmental, sensory, attentional and/or
learning challenge. The social, attitudinal and cultural environment,
along with the availability of supports (person support or equipment
support), impacts on the student's occupational performance in the
school setting.
GOAL OF OCCUPATIONAL THERAPY IN THE SCHOOL SYSTEM
The goal of OT in the school environment is to improve a student's
performance of tasks and activities important for school functioning. This
may involve direct intervention to improve, restore, maintain or prevent
deterioration in the skills required for functioning in the school
environment. Consultation and education of adults in the child's home
and school environment may be necessary to ensure an understanding
of and match between the child's skills and abilities and the expectations
placed on them in the school setting. Recommendations of task
adaptations, task modifications and assistive devices (e.g., mechanical
lift, writing aid) may be necessary to optimize the child's performance in
the school setting.
DOES OCCUPATIONAL THERAPY IN THE SCHOOL SYSTEM MAKE A DIFFERENCE?
Palisano (1989) conducted a six-month study with thirty-four children,
ages six through nine years of age, with learning disabilities. They were
divided into two groups, one receiving intervention twice weekly with the
OT in a small and large group setting. The second group received
consultation services from the OT through a weekly large group session
in the classroom, and one half hour per week consultation with the
teacher to provide a monthly lesson plan of follow-up activities to be
performed three times per week. Intervention occurred over a six-month
period. Both groups received an equal amount of therapeutic
intervention each week (75-105 minutes). The children in both groups
improved on the standardized assessments of gross motor and fine
motor abilities, visual-motor integration and visual-perceptual skills.
These skills are necessary for adequate school performance in the areas
of reading, writing, mathematics, manipulation of tools (e.g., scissors
and rulers) and performance in physical education.
A small study conducted by Dunn (1990) compared the results of direct
intervention by an OT to collaborative consultation by the OT with the
student's teacher over the period of one academic year. Fourteen
children (ages 35 months to 79 months of age) with a developmental
delay of at least one year in at least two areas of development
participated. Children in both groups achieved nearly 75% of their goals
as identified on their Individualized Education Plan (IEP). The teachers
reported that the OT contributed to goal attainment more in the
collaborative consultation group than in the direct intervention group.
This study supports the effectiveness of OT intervention, both in direct
intervention and collaborative consultation models, on attainment of
goals as identified on the IEP in students with developmental challenges.
Collaborative consultation appears to be seen by teachers as impacting
more on the OT's contribution to goal attainment than direct intervention
alone.
Niehues et al. (1991) used qualitative methodology to study the nature
of OT practice in the public schools with five expert school system
practitioners. Results indicated that OTs play a role in "reframing" the
views of the parents and teachers concerning discrepancies between
students' performances in school and the expectations held for them.
This enabled a more positive view of the student and provided a basis
for developing new and more effective teaching and/or parenting
strategies with students.
King et al. (1999) reported the results of a study on school-based
therapy services conducted in London, Ontario with fifty children ranging
in age from five through twelve, with a variety of special needs,
including cerebral palsy, fine motor difficulties, developmental
coordination disorder, spina bifida and/or speech/language delays. Direct
therapy, monitoring and collaborative consultation between therapists,
teachers and parents were used in the service delivery model. Twentyone
of these children had occupational therapy goals in the area of
school productivity (written communication skills, organizational skills,
functional fine motor/visual skills). Sixteen of the children had speechlanguage
goals in the area of communication and 13 had physiotherapy
goals in the area of mobility. Data were collected prior to therapy
intervention, following therapy intervention and five to six months after
therapy terminated. Standardized assessments, goal attainment scaling
and satisfaction questionnaires were used to evaluate outcomes.
Children with fine motor difficulties received OT twice a week for a
three-month period. Ninety-eight percent of the fifty children made
progress in their goals, with many gains maintained over the six-month
follow-up period. Improvement on the standardized measures was
clinically significant in the targeted area of school productivity. The rate
of change for children receiving occupational therapy exceeded that
expected due to maturation, suggesting that intervention was the reason
for the improvement measured. The productivity goals were all
educationally relevant, to support the premise that school-based therapy
should support the student's performance in the school setting. Goals
included copying from the board, holding a pencil correctly, keyboarding,
cutting, colouring, use of a computer mouse, organizing a desk and
focusing on a task, all of which underlie and support academic
performance. Both parents and teachers reported a high degree of
satisfaction with the services provided, supporting the use of a model
combining collaborative consultation and direct intervention.
A study conducted in four Southern Ontario school boards (Fairbairn and
Davidson, 1993) examined what 103 teachers in Ontario say they
receive, need and expect from OTs, and examined the value placed by
teachers on OT services. Results indicated that all the teachers valued
the work of OTs in the schools, finding them knowledgeable, supportive
and providers of practical programming, physical exercises and adapted
equipment. Eighty-nine per cent reported that the OT programme
enhanced the students' ability to learn and 80% said that the OTs
eliminate problems that interfere with a child's ability to profit from
instruction. Eighty-two percent of the teachers indicated that OTs could
provide medical, physical and developmental information in educationally
relevant terms. Seventy-nine percent believed that OTs were able to
translate assessment information into relevant programming and 96%
believed the OT held a distinct place in the school setting. Over 60% of
the teachers identified motor skills, psychosocial skills, assessment of
student needs, daily living skills, sensorimotor skills, equipment needs
and maintaining parent involvement as areas with which OTs could assist.
DO SPECIFIC CONDITIONS BENEFIT FROM OCCUPATIONAL THERAPY IN THE SCHOOL SYSTEM?
1) Developmental Coordination Disorder
The prevalence of Developmental Coordination Disorder (DCD) is
estimated at 6% of the population, with boys more commonly affected
(Fox and Lent, 1996). This disorder describes a child who lacks the
motor coordination necessary to perform tasks that are considered to be
appropriate for her/her age and may demonstrate significant difficulty
with self-care tasks such as dressing and using utensils, with academic
tasks such as handwriting and/or with leisure activities such as sports
(Missiuna, 1996). Other neurological disorders must be absent for this
diagnosis, but it commonly coexists with learning disabilities (particularly
non-verbal learning disabilities) and attention deficit disorder.
As so many daily tasks can be difficult for a child with DCD, these
children experience frequent failure, come to expect failure and the
resulting lower self-confidence can affect their social, academic and
physical performance (Fox and Lent, 1996). Fox and Lent go on to say
that persisting coordination difficulties and neurological signs suggesting
neuro-maturational delay have been recognized as predictive of many
psychiatric disorders, including affective and anxiety disorders. They cite
a longitudinal follow-up to age 16 of children identified at age 6 with
deficits in attention, motor control and perception, which showed that
nearly 60% had psychiatric, and personality disorders in midadolescence,
13% were substance abusers and 5% had attempted
suicide. Fox and Lent (1996) state that strong scientific evidence now
shows that most children's motor problems persist well into adolescence
and studies have demonstrated that these children will display poor
social competence, poor motivation, low self-esteem, unhappiness and
reluctance to engage in physical activities with the result of poor physical
fitness. The costs to the health care and social service systems in the
future are staggering, which makes early intervention with these children
essential. Fox and Lent (1996) state that OTs can quantify the disability,
advocate for modifications, including changed expectations, assist in
providing information to parents, teachers and children and offer
intervention techniques related to school work, leisure and activities of
daily living.
Dewey and Wilson (2001) cite literature stating that children with
coordination difficulties are reported by teachers to have difficulties in
physical education, writing, handling equipment in science classes and
arts and crafts. They go on to cite studies demonstrating an association
between poor motor coordination and social -emotional problems in
childhood. Children with movement problems saw themselves as less
socially competent and were more introverted and anxious than their
peers. These children often withdraw from or avoid physical activity,
which can lead to secondary health problems.
These children are often referred to OT through the school system due
to "fine motor difficulties", "poor pencil grasp", "gross and fine motor
clumsiness" or "difficulty with printing." Missiuna (1999) states that 95%
of OT referrals are due to "handwriting". She goes on to say that the
majority of these students are experiencing difficulty with more than just
handwriting. Closer observation reveals difficulty managing scissors,
handling a ruler, doing up zippers and buttons, erasing, participating in
gym class, getting ready for recess, playing games in the schoolyard
and/or participating in sports and leisure activities. These children often
have DCD but are not diagnosed, as many physicians remain unfamiliar
with this diagnosis or are reluctant to "label" the child.
Early evidence for the effectiveness of "top-down" OT approaches in
teaching specific tasks and in improving functional performance of
children with DCD is beginning to appear (Mandich et al., 2001).
Specifically, there is evidence that the Cognitive Orientation to Daily
Occupational Performance (CO-OP) approach is effective in skill
acquisition and the evidence is emerging that CO-OP also results in
generalization and transfer of skills (Polatajko et al., 2001). When using
the CO-OP approach, the evidence suggests that 12 one-to-one OT
sessions of one hour in length are necessary. (This does not include the
initial OT assessment, which is required to determine the child's specific
strengths, needs and suitability for this approach, nor does it include the
collaborative consultation time required with parents and teachers to
ensure follow-through and support generalization of the skills.)
As summarized in the first section, children with fine motor and
coordination difficulties were included in many of the studies that looked
at the effectiveness of OT in the school system. CO-OP was not used as
the treatment approach in these studies, but more traditional OT
approaches were used and found to be effective in the development of
skills and on goal attainment.
2. Written Productivity
Oliver (1990) examined the effects of occupational therapy on writing
readiness skills. One of the groups involved in the study included five
and six year olds with a discrepancy between their performance and
verbal intelligence quotients. This is the typical profile of many of the
children referred for OT in the schools. They often progress to be
identified as having a non-verbal learning disability. This group received
thirty minutes weekly occupational therapy for the duration of the school
year. Therapy intervention focused on multisensory stimulation, large
movement patterns and writing readiness skills such as attention to lines
and designs. In addition, these children received ten minutes of
additional programming three times per week by the teacher, aide or
parent. This programming was designed by the OT and complemented
the direct therapy through the use of structured work sheets and
manuscript letter practice. Results demonstrated an improvement of 17
months in writing readiness over the year. This study supports the value
of early occupational therapy intervention with children with delays in
writing readiness.
Lockhart and Law (1994) examined the effectiveness of a multisensory
cursive writing programme. Participants were nine through eleven years
of age and had a diagnosis of a learning disability and had sensorimotor
difficulties. The participants received one hour of occupational therapy
every two weeks using a multisensory cursive writing programme.
Results of the study yielded changes of statistical significance in writing
quality in specific letter groups for all of the children following
intervention. Teacher reports and an assessment of written language
suggested that intervention may have had a positive effect on selfconfidence
in written output, and on the maturity of written expression
in some of the cases.
Case-Smith (2002) reported the results of a study on the effects of
school-based occupational therapy services on students' handwriting.
Twenty-nine students, aged seven through ten years of age with poor
handwriting legibility and cognitive function within normal limits,
received a mean of 16.4 sessions of direct occupational therapy services
over the school year. Fifteen of the students had an educational
diagnosis of learning disability, and eleven had a diagnosis of
developmental disability. Ninety-five percent of the intervention was oneon-
one and included a variety of therapeutic approaches individualized to
the student's needs. The therapists reported a high level of collaboration
with the teachers. When compared with students who did not receive
services, the intervention group showed significant increases in
handwriting legibility, in-hand manipulation and position in space scores.
Legibility increased by 14.2% in the intervention group, and by 5.8% in
the comparison group.
METHODOLOGY
The literature review was guided by the question, "Does occupational
therapy make a difference in the school system?" As the majority of
referrals to OT in the Ontario School Health Support Services Programme
are for fine motor delay, clumsiness and/or written productivity
difficulties, a secondary focus of the literature search was Developmental
Coordination Disorder and written productivity.
Partnerships with the School of Rehabilitation Science at McMaster
University and the CanChild Centre for Childhood Disability Research,
along with the author's personal contacts through both formal and
informal OT networks, resulted in access to the relevant literature.
Information from these sources provided the author with relevant
articles and links to other articles.
SUMMARY OF WHAT WE DO KNOW
In summary, research evidence to date supports the effectiveness of
occupational therapy in the school setting with students experiencing
occupational performance challenges. OT is effective in helping children
attain goals and develop skills in areas underlying and supporting school
performance. Occupational therapists help in reframing the views and
expectations of the student by the adults in the environment.
Collaborative consultation with parents
and teachers appears to be an essential component of the service
delivery to maximize effectiveness of and satisfaction with the
intervention provided by the occupational therapist. The evidence
presented relates to a variety of diagnoses and needs, including students
with physical disabilities, developmental coordination disorder, fine motor
difficulties, developmental delays and learning disabilities.
WHERE DO WE GO FROM HERE?
Occupational therapists need to share the evidence supporting the
effectiveness of OT intervention in the school system with clients,
educators and funding agencies. Evidence-based service delivery models
need to incorporate direct client intervention with processes to facilitate
and support collaborative consultation with parents and teachers to
maximize effectiveness of and satisfaction with OT services.
Further research is recommended to identify effective methods for
screening referrals to occupational therapy, to evaluate the effectiveness
of OT in the prevention of secondary problems and to further evaluate
both the clinical and cost effectiveness of various service delivery models
with specific client groups.
Update written by:
Sandra Sahagian Whalen is an occupational therapist with over twenty
years of experience. She works part-time with Community Rehab as the
professional leader for pediatric occupational therapy in the Peel Region,
as well as in private practice with REACH Therapy Services.
The author and CanChild would like to acknowledge
the tremendous support received from:
Nancy Pollock, co-investigator with CanChild and Associate Clinical
Professor, School of Rehabilitation Sciences.
Debbie Jones-Snyders, Manager, Peel Branch of Community Rehab.
Mary Law, Co-director, CanChild and Professor and Associate Dean,
School of Rehabilitation Science, McMaster University.
CanChild is funded by the Ontario Ministry of Health and Long-Term Care.
Want to know more? Contact:
CanChild Centre for Childhood Disability Research
Institute for Applied Health Sciences, Room 408
1400 Main St. W., Hamilton, ON L8S 1C7
Tel: 905-525-9140 x 26074 Fax: 905-522-6095
[email protected]
REFERENCES
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therapy intervention on handwriting. The American Journal of
Occupational Therapy, 56 (1), 17-25.
Dewey, D. & Wilson, B.N. (2001). Developmental coordination disorder:
What is it? Physical & Occupational Therapy in Pediatrics, 20 (2/3), 5-27.
Dunn, W. (1990). A comparison of service provision models in school
based occupational therapy services. A pilot study. The Occupational
Therapy Journal of Research, 10 (5), 300-320.
Fairbairn, M.L. & Davidson, I.F.W.K. (1993). Teachers' perceptions of the
role and effectiveness of occupational therapists in schools. Canadian
Journal of Occupational Therapy, 60(4), 185-191.
Fox, A.M. & Lent, M.A. (1996). Clumsy children. Primer on
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King, G., McDougall, J., Tucker, M.A., Gritzan, J., Malloy-Miller, T.,
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well-being. Canadian Journal of Occupational Therapy, 65(2), 81-91.
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Missuina, C. (1996). Keeping Current in….Developmental Coordination
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