Occupational Therapy Evaluations in the School: How do they work?
by Marie Toole, MS, OTR/L
on the School Tools From Your Pediatric Occupational Therapist Blog
Last month I wrote about the special education process and what you as a parent could expect. There was lots of information about timelines, permissions, and the kinds of evaluations that may occur. This month I want to tackle the occupational therapy evaluation in particular. When I evaluate a student, I am looking at him through the eyes of a school-based pediatric occupational therapist (OT). Let’s just clarify what a school-based OT can and will need to do to fully explore all options to best plan for your child’s educational needs.
As a school-based OT, I am required by law to represent your child’s educational needs as they relate to the curriculum. I am a related services provider, meaning the services I deliver must enhance your child’s ability to access his education, making a positive difference in his life. I have to justify these services by synthesizing the findings I’ve obtained through testing and the gathering of anecdotal information. I then make recommendations based on your child’s ability to participate in his school environment. I will make sure he has access to the playground, classroom, cafeteria, art room, music room, gymnasium, library, school bus, and field trips. Here are some of things I will look at during my evaluation of your child:
- Reason for Referral: During the initial meeting to review the referral, you and the team were given the opportunity to ask questions to gather information from both you and the classroom teacher. At that meeting, the decision may have been made to go forward with additional evaluations to answer any remaining questions about how your child best learns. Once we obtained your permission to complete the evaluations and we had explained them to you, we got started.
- Classroom Observation: If it has not been done already, I usually do a classroom observation to see your child in his natural environment. I like to check in on the playground and perhaps with the specialist teachers (art, music, PE) to make sure I am not missing any areas that may be challenging for your child. I always do a file review as well.
- Assessment and Evaluations: I like to break my OT assessment and evaluation into two parts: formal, standardized testing and more informal, observation type assessments. Let’s look at the standardized portions first.
- Standardized testing means that the evaluations we use were given to lots of children all across the country in the exact same format with the directions read in the exact same way each time. These tests were then scored and “normed,” meaning that the researchers reached a conclusion that the majority of children who were say 6 years and 6 months old performed in a particular way and had a similar type of score. They do some statistical work and reach conclusions based on thousands of children completing these assessments. Therapists then use these tests to get data that will let us know how your child compares to other students all across the nation who are the same age. You will see “scores” and lots of numbers. These will reflect statistics that show how your child performs as compared to other children his age. In our district we consider scores between the 25th and 75th percentile to be in the average range. We also use standard scores or scaled scores, which are other statistical ways to show how your child performs as compared to other students his or her age.
- Let’s review some of the standardized testing that is available to OTs. Many of the tests look at very specific areas of evaluation. For instance, to assess visual motor integration, lots of therapists use the Beery-Buktenica Developmental Test of Visual Motor Integration (VMI). It looks at how your child uses his eyes and
hands together to perform tasks. There are two additional subtests associated with the VMI: the Visual Perception subtest and the Motor Coordination subtest. Other standardized tests therapists may use to assess this area include the Test of Visual Motor Skills (TVMS), the Bruiniks-Oseretsky Test of Motor Proficiency (BOTMP), or the Peabody Developmental Motor Scales (PDMS).
- To look at visual perceptual skills, many therapists use the Test of Visual Perceptual Skills (TVPS) or a shorter version called the Motor-Free Visual Perception Test (MVPT). Some therapists may use the Developmental Test of Visual Perception (DTVP).
- Handwriting skills is another area where OTs will focus their attention. One example of a standardized test of handwriting skills is the Test of Handwriting Skills (THS). Another that is used frequently, although it is not standardized, is the Evaluation Tool of Children’s Handwriting (ETCH).
- Assessing and evaluating preschoolers can be challenging. There are not a lot of standardized tests out there. However, the Miller Assessment of Preschoolers (MAP) and the Movement ABC are two tests used by therapists to look at young children’s motor skills.
- Another aspect of school-based OT is the assessment of sensory regulation. The Sensory Profile and the Sensory Processing Measure are two common assessments that school therapists may use. Another is the School Function Assessment (SFA). Each provides checklists designed for the parent and teacher.
This is not meant to be an exhaustive list of all the standardized OT evaluations that are available. It is meant to give you a quick overview and an awareness that the OTs in your school district may use some of these assessments or they may have other assessments that they prefer to use. It truly is a personal preference.
In our district, in order to receive occupational therapy services, students must demonstrate delays in standardized test scores or delays in educationally-related functional skills, or both. Generally we need several subtest scores and the overall scores to be below the 25th percentile in order to qualify for services. Areas of function that are educationally-related include: fine motor and gross motor skills, sensory and sensorimotor performance, visual motor skills, oral motor skills, and self-help skills. All those areas of function would be addressed through more informal assessments. Remember, we must always relate these skills back to your child’s access to education and the classroom or participation in the curriculum. Let’s look at what the OT may look for when completing more informal assessments with your child.
Informal Assessments include:
- Fine motor skills encompass the small motor muscles of the wrist and hand. These are the skills we use when completing most precision tasks including buttoning, writing, and manipulating small objects in our hands. Coordinated fine motor skills are dependent on adequate postural control as a strong core is essential to support the shoulder, arm, and hand movements. Another area we look at is tactile discrimination. This is our ability to understand what we are feeling through our hands without having to look at them. Tactile discrimination is needed in order to manipulate small objects in a smooth and coordinated fashion. OTs also look at writing, cutting, and coloring skills and how they are impacting the way your child “shows what he knows” in the classroom.
- Gross motor skills in the classroom and school environment include walking, running, hopping, skipping, and playing on the outside equipment at recess as well as participation in PE class. Motor planning allows your child to move in response to instructions, plan a motor response, and execute the motor action requested.
- Visual motor skills are skills that require the coordination of the eyes, hands, and the body together in order to be successful. These skills can include copying, coloring, handwriting, throwing a ball to a designated target, and catching a ball. The development of prewriting skills follows a sequential visual motor pattern that goes from learning to scribble, to coloring, to duplicating basic designs and shapes, and finally to actual writing and the formation of letters.
- Visual perceptual skills are those that refer to the child’s ability to distinguish and determine differences in figures, designs, and letters (discrimination, spatial relations, form constancy) as well as his ability to remember individual designs and a series of designs (memory and sequential memory). It also involves the child’s ability to pull out important information and clear away confusing background information (figure ground). Visual spatial skills are important when completing math problems as math is a spatial concept (numbers on a grid, elapsed time, line segments). Right and left discrimination skills as well as position in space are also important perceptual skills.
- Ocular motor skills refer to the movement of the eyes as a team. This includes fixation (the ability to hold the eyes steady to look at objects), smooth pursuits (the ability to track a moving object across the midline and through the visual field), and saccadic eye movements (looking from one object to another). Saccadic eye movements are necessary for reading and copying from the board. Difficulties in this area can impact a child’s classroom performance especially in the area of fluid reading skills.
- Activities of Daily Living (ADL) skills include dressing, eating, bathing and grooming, and caring for personal belongings. Independently opening containers or baggies at snack or lunch is an important life skill. Making sure their face and hands are clean helps students conform to the social mores of the school community. Getting dressed in winter gear for recess in a timely manner is oh-so-important when there is fresh snow on the playground! Here is an area where OTs can incorporate home concerns. I always ask about extra curricular activities your child attends and how they are functioning there. Another area that we discuss is their role, participation, and responsibilities in the home such as chores or caring for pets.
- Sensory Processing or Sensory Modulation is an area that warrants its own separate assessment in my district. It is an integral part of many students’ educational plans, especially for those students on the Autism Spectrum. The occupational therapist will generally complete additional assessments to further clarify these areas if needed. If you have concerns about your child’s sensitivities, please do not hesitate to bring them up with the school OT.
- After completing an occupational therapy evaluation, the multidisciplinary team determines the student’s need for and level of educationally relevant services. Services are based on the needs of the student and include remediation (through direct or consultative services), adaptation, adaptive equipment, and consultation with school staff and parents. I base my recommendation for services on many factors including:
- the evaluation data,
- the educational goals for the student’s level of instruction,
- the student’s maturation and development,
- the school environment,
- the student’s chronological age,
- collaboration with the educational personnel, and
- the student’s classroom performance.
How are Occupational Therapy Services provided? The occupational therapy service delivery is based on a program of specific therapeutic techniques. Intervention is provided on a 1-to-1, small group, or classroom basis. Treatment may occur in varied environments to best fit the child’s individual needs. These can include the therapy room, gym, playground, or classroom. Consultation with the teacher, paraprofessionals, or parents may be included within the direct service time provided. Additional consultation times may be included on an as-needed basis. Consultation includes supervision, teaching, planning, and training with others to enhance the student’s optimal performance in the educational setting.
Under Section 504, students who have been diagnosed with a physical or mental impairment that substantially limits one or more major life activities AND have completed an occupational therapy evaluation that recommends therapy may be entitled to occupational therapy services as if they had IEP goals. This is considered regular education OT services and needs written parental permission just as any services being offered would require.
I hope this clears up and brings clarification to the occupational therapy evaluation and assessment process. This is meant to be an overview and does not supersede the assessment and expertise of your local school therapist. Feeling comfortable with the process puts you in a good position to have a frank and honest discussion with your school-based occupational therapist about what you hope to get out of your child’s OT evaluation. Feel empowered…and remember…YOU are the most important member of your child’s educational team!
Marie L. Toole, MS, OTR/ L, is a pediatric occupational therapist with 28 years experience in NICU, Early Intervention, and private practice with the last 20 years spent working in public schools. She is NBCOT and SIPT certified as well as a member of AOTA and NHOTA. She lives in southern New Hampshire and can be reached at firstname.lastname@example.org. 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 Go-To-For-OT Blog or affiliated Twitter, Facebook, or Pinterest sites, and shared on social or public media or as links on other sites 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 authors and administrator of these 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 author or site owners and their use should include the link provided to the contributor’s source.