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Submission to the Manitoba Special Education Review

April 1998

This submission has been prepared on behalf of the Manitoba Society of Occupational Therapists, an organization that in part:

  • promotes occupational therapy and disseminates knowledge of the profession within Manitoba.
  • represents occupational therapy interests and concerns to provincial legislators and policy developers.

A significant number of occupational therapists provide services to children directly within the public school system, and to school aged children through the medical system, or by private occupational therapy practitioners.

The Association of Occupational Therapists of Manitoba, the licensing body that regulates the practice of occupational therapy in Manitoba, indicates that on April 1, 1997 there were 21 therapists who reported that their primary location of work was in the school system. An additional 7 therapists reported secondary employment took place in the school system. There were 300 licensed therapists working in Manitoba at that time.

The areas of inquiry that this submission will address will include some background information about:

  • profession of occupational therapy (O.T.)
  • the history of O.T. in the schools in Manitoba
  • the relevance of O.T. within the educational system
  • service delivery models used
  • Three short case studies will be presented to provide a picture of how the skills of an occupational therapist play an important part in IEP planning and implementation for children with special needs.
  • Finally, some of the issues and challenges of the system will be offered from the perspective of the occupational therapy profession.

Definition of Occupational Therapy

Occupational Therapists (OT's) help children with special needs take an active part in their daily life ( home, school and play). Active participation in life promotes: learning, self-esteem, self-confidence, independence, and social interaction. OT's use a holistic approach in planning programs. They take into account the physical, social, emotional and cognitive abilities and needs of children.

OT's are professionals with a university training in:

  • basic medical sciences (anatomy, neurology, physiology, kinesiology, psychiatry)
  • social sciences (psychology, sociology)
  • child development
  • occupational therapy theory and practice

OT's use these skills to assess children, analyze findings, identify strengths and areas of concern and develop program plans. The occupational therapy programs may be provided directly by the therapist, indirectly through training of other school employees or by consultation with school personnel and families.

History of O.T. in the Schools

Historically, O.T. services have been provided through a number of delivery models since the 1960's. The Ellen Douglass School had services provided by the Children's Hospital Therapy department. When the philosophy of educating students with disabilities changed and the program became integrated within a neighbourhood school (Lord Roberts School) the therapy services transferred with the program. Funding for this program continues to come from the Health budget.

In the 1970's a number of school divisions contracted O.T. to provide services to school aged, special needs students. Winnipeg #1 School Division hired a full-time O.T. in 1974 to service the needs of the children in the program for mentally challenged children at Montrose, Robertson and Prince Charles Schools. As the Lord Roberts program grew, the special program expanded to include junior and senior high students at Grant Park and Gordon Bell High Schools. As programs increased, the need for O.T. services escalated and the school divisions have attempted to continue to provide services at a sufficient level to meet the needs of students in their division.

At the present time occupational therapy services are provided to children in their schools either by a therapist hired directly by the school division, through services contracted by the school division from the Rehabilitation Centre for Children's School Therapy Services program, or by contract with therapists working in private practice.

Children's Hospital and the Rehabilitation Centre for Children occupational therapy services treat children on an outpatient basis for concerns that are largely impacting the education of these students. Students with diagnoses such as: developmental co-ordination disorder, learning disabilities and attention deficit disorder with or without hyperactivity. The Autism outreach program from the Health Sciences Psych Health program provides limited occupational therapy services to children in school. Third party payers, such as MPIC contract occupational therapy for their clients.

School Divisions that employ an occupational therapist directly are:

  • St. Vital
  • River East
  • Transcona-Springfield
  • Assiniboine South
  • Seine River
  • Hanover

Divisions that contract with School Therapy Services for O.T. are:

Winnipeg #1

Manitoba School for the Deaf

Fort Garry

Mountain

Seven Oaks

Rolling River

Portage-la-Prairie

Souris Valley

Brandon

Interlake

Frontier

Whitehorse Plains

Aggasiz

Evergreen

Mystery Lake

Morris-McDonald / Red River

 Twenty-two rural school divisions receive occupational therapy services on a limited basis through the Mobile Therapy Team, a program funded by the Department of Family Services (Children's Special Services) and delivered by the Rehabilitation Centre for Children. Through this service certain rural and remote communities are visited up to five times per year by an occupational therapist and physiotherapist to provide assessment consultation and programming for children in the community (aged birth to 17 years) who meet the criteria outlined by Children's Special Services.

Why is Occupational Therapy an educationally relevant service?

In identifying how disabling conditions interfere with students' participation in school, teachers came up with the following areas that relate to school performance:

    i. acquiring information or academic learning

    ii. expressing information that the student has learned (verbally, in writing or in some other clear way)

    iii. assuming the student role (performing non-academic tasks such as: turning in assignments in on time, getting along with classmates and teachers)

    iv. performing activities of daily living (eating, dressing, and toileting) and moving about safely and efficiently through the school environment

(School-Aged Therapy Program Resource Manual, British Columbia Ministry of Health, 1992)

Occupational therapists have a role in programming for students who have been identified as having a disability that is impacting on their school performance. There can be many factors that affect the decision to involve occupational therapy with a particular student and the role may vary from student to student. The four areas identified as relevant to a child’s education can be further looked at from the perspective of how occupational therapy would provide intervention to address needs in these areas.

i. Academic learning is primarily the domain of the classroom teacher. An occupational therapist can help teachers to modify teaching strategies and understand learning styles for students with disabilities that affect their ability to learn in traditional ways.

ii. Occupational therapists possess considerable training and skills that can be used to help students express what they have learned in the classroom. Assessment and remediation of handwriting problems encompass fine motor, visual-motor, sensory and perceptual areas as well as correct seating and positioning for optimal output. O.T.'s are well trained in the use of electronic aids (computers, word processors) and the like to help children accomplish written expression in other than traditional means. O.T.'s also work in collaboration with speech-language pathologists in the use of communication devices with children.

iii. Being able to assume the student role successfully is vitally important for students to be accepted by their peers and learn the necessary skills to become productive citizens. Many school professionals can help students in this area. The occupational therapists will have an important role with some students, helping them with: eg. appropriate seating and desk arrangements to accommodate their special needs, organizing and caring for their belongings, negotiating the school environment safely, participation in recess activities, managing their individual sensory and attentional needs.

iv. Occupational therapists are skilled in the areas of evaluation and intervention in basic activities of daily living (eating, dressing, toileting) as well as the more complex tasks (grocery shopping, doing housework, and taking public transportation). This may involve programming during snack, lunch and recess periods during the early school years. Life skills programming may become the focus of programming for students in later school years. Basic activities of daily living that are mastered in the early years may allow the child independence in later years, and reduce the need for personal attendant care.

In addition to their role of working directly for the student with identified special needs, the occupational therapist can also serve the school division directly by:

  • evaluation of the school environment to prevent, modify or alleviate architectural barriers, and to make recommendations to the school divisions for necessary changes.
  • provide inservices to staff re: specific strategies for intervention (handwriting, computer access, self-help skills, perceptual skills and coping with classroom stimulation), or regarding specific disabilities such as: autism, F.A.S., cerebral palsy, spina bifida, acquired brain injury and others.

How is occupational therapy service delivered?

Since there is no law governing the provision of therapy services to children in schools, there is no standard which school divisions must meet. The role of the occupational therapist servicing the schools varies from school to school, and division to division depending on the policies and funding structures of the particular school division. The school division will also decide which children will be eligible for the service. This may be strictly limited to those children that are funded by Manitoba Education and Training at the Low Incidence Levels 11 or 111, or the division may choose to have occupational therapy available to a wider range of students with special needs.

Service delivery models range from:

  • direct intervention by a therapist
  • indirect service where the therapist assesses the student, develops programs, teaches the assistant or teacher to carry through with the programming and then returns periodically to modify and monitor the program.
  • consultation with school personnel for such things as accessibility issues, or inservicing on topics of O.T. domain.

Although service delivery models can be defined in such a way, in actual fact the service to any one child will involve a blend of direct service, indirect service and consultation. Intervention will respond to the needs of the child as they progress through the school system. The service plan is developed through the collaborative team work of the IEP team members.

Case Study - Child with Autism

A 5-year-old student in kindergarten has a diagnosis of pervasive developmental disorder (not otherwise specified) with seizures. He has severe delays in many areas including: speech and language, fine motor skills, gross motor skills, self-help skills, social relating skills and play skills. In addition he has difficulties handling the amount and types of sensory stimuli produced in a kindergarten classroom.

The occupational therapist has developed a progression of activities for the teaching assistant to do with the child on a daily basis. These activities are tailored to meet the child's needs for growth in the areas identified, and are designed to fit in with the classroom schedule and curriculum. The student is visited by the O.T. approximately every three weeks to monitor the progress and modify the programs accordingly.

Through ongoing intervention this child has learned educationally relevant skills:

hold a marker and draw a line to join two associated pictures a pre-academic skill leading to expression of information
accept having his hands covered in sand indicative of improvement in tolerance of sensory stimuli
roll play dough a fine-motor, manipulative task
snip with scissors a fine motor skill requiring visual-motor co-ordination
hang up his coat a self-help skill
kick a ball a gross motor skill enhancing recess and gym participation

Performing therapeutic activities in the child's natural environment makes the learning relevant and practical. Children can learn productive skills where they need to be used, and they can practise them on a regular and ongoing basis.

Case Study - Child with Cerebral Palsy

A. is a twelve-year-old girl, who at the time of birth was diagnosed with cerebral palsy of quadriplegic distribution. She attends an integrated grade six class, at an elementary school. She has a full-time teaching assistant. She needs assistance for all her personal care and for all her daily functional activities in school.

The Occupational Therapist, as part of the educational team, would assess the student’s ability in the domains of personal care and daily work and play.The goals of the Occupational Therapist were developed as follows:

  • Train the teaching assistant the correct method of transferring the student from wheelchair to toilet, to walker and to power wheelchair
  • Train the teaching assistant in safe body mechanics for both the student and the teaching assistant
  • Monitor and recommend changes with the student’s power wheelchair training, and train the teaching assistant in the operation and maintenance of this equipment
  • Assess fine motor abilities and recommend and/or provide adaptive materials as necessary ie. Chin-cup joystick to operate her power chair, rather than a hand-operated joystick; headstick to be used instead of her hands, as a typing aid, page turner, etc.
  • Consult with the education team re: expectations in relation to integration, and provide adaptations to allow her to participate in the education program ie. headstick used to access computer in the classroom and in the computer lab; physical setup of the classroom so that she is able to manoeuver her power wheelchair in the classroom; word prediction programs to allow her to input her information faster
  • Consult with the student, family and education team in regards to recreation opportunities, and make recommendations ie. adaptive swimming program and adapted life jacket; using walker or adapted bike for phys-ed activities, etc.
  • Consult with the education team, make recommendations, and apply to funding bodies for special equipment to further increase the student’s independence ie. Mac Powerbook, Speaking Dynamically

Liaise with the family in regards to needs in the home, whether these are related to personal care and/or education issues

The Occupational Therapist works as part of the educational team to integrate these goals in A.’s educational plan. The goals are met on a daily basis, as A. participates in all activities with her peers. The intervention by the therapist is done in the classroom as opposed to having the student pulled out, thereby allowing the student to remain a part of the class. Additionally, her peers learn by observing what is done for her and how she accepts or rejects the intervention. The therapist is available for questions from staff and students, and can help to provide a bridge between the physically challenged student and her peers.

 

Case Study - High School Student with Cerebral Palsy

M. is an eighteen-year-old student with cerebral palsy who attends a Life Skills / Adapted Skills program at a local high school. She is based in her cluster group, but also attends several integrated classes, eats her lunch in the cafeteria and attends events such as pep rallies and school dances. M. has very limited oral speech, uses a power wheelchair, and has limited motor abilities with her upper and lower limbs. She requires assistance for most life skills and self-care tasks. She is also limited in the type of leisure skills which she can manage without considerable assistance.

The Occupational Therapist in the program worked on the following areas with M. and provided consultation to the staff working with her:

  • Determining a functional method of computer access for Marie. O.T. assessed and supervised training with an adapted joystick. She was able to learn to manage mouse driven programs independently with this method. This gives M. an enjoyable independent leisure activity as well as a method of learning and producing printed art material.
  • In conjunction with the Speech/Language Pathologist on the team, the O.T. assessed M. for a voice output communication aide. Since she had done so well with the adapted joystick on the computer, this method was chosen for access to a picture based dynamic screen communication system. Funding is pending for her to have this system purchased for her use.
  • The O.T. has helped M. become an independent operator of her power wheelchair, using the joystick system. She is now able to access community outings such as going to the mall and participating in work experience.
  • In the next few years, the emphasis at school will be to assist M. to transition from a high school to a post high school setting, one which may include a combination of vocational and leisure programming and a possible change in residential setting. Occupational therapy will be involved as part of the school team to help M. with the transition in whatever areas are needed, from architectural access and environmental modification to life skills or leisure activities.

 

Issues

The following issues have been identified as area of concern by the committee submitting this response.

1. Inconsistency in access to therapy services

As there is no legislation governing the provision of special education services across Manitoba, there are inequities in how these services are provided to children. For example, children in rural areas do not have access to the same amount and frequency of O.T. services. Within the urban areas, the type of service provision and its frequency vary from division to division, and frequently even from school to school within the same division. We perceive a lack of consistency in the criteria that is used to identify students who would benefit from O.T. intervention. Lack of consistency in service provision may relate to funding issues. There is no identified provincial funding for the provision of occupational therapy and physiotherapy in the education system, although school division may choose to use their clinician grants for this service.

2. Need for early intervention

School entry for children who have identified severe physical and cognitive challenges is usually well coordinated with early childhood programming in the community. These children generally receive adequate supports and resources to facilitate their inclusion in the education system.

There are children who have challenges that will adversely affect their ability to function in the classroom setting, but who do not have severe physical and cognitive difficulties. These children may not have access to any extra resources as they enter the school system. Our experience is that these children often experience a delay in receiving the services they require to facilitate their successful participation in school. Delays may occur because these children are considered to be too young, or their difficulties may be attributed to immaturity or inexperience. These children may be developmentally delayed, have specific learning disabilities or have diagnoses such as developmental coordination disorder or ADD/ADHD and others.

As Anne Wilcox related, in her workshop (Winnipeg, 1994) An Introduction to Verbal Self-Guidance: An experimental strategy for increasing competence in clumsy children, studies have shown that children with mild learning and coordination problems use the social, justice, and mental health systems at a greater than average rate when they reach adulthood. We advocate for early intervention for all children with learning differences.

3. The effect of shrinking resources

There has been an increase in need for resources over the past number of years. This has resulted in a tightening of the criteria being used to determine which children are eligible to receive funded services. We are concerned that this will result in a growing group of children who are unable to access the extra resources that they require in order to fully participate in their school program, or that the service that they do access is so minimal as to be ineffective.

Bibliography

  1. Association of Occupational Therapists of Manitoba 1997 statistics.
  2. Educating Children with Multiple Disabilities - A Transdiciplinary Approach (2nd ed.), Fred P. Orlove & Dick Sobsey, Brookes Publishing Co. 1991
  3. Occupational and Physical Therapy in Educational Environments, Irene R. McEwan Ed. The Hawthorne Press Inc. 1995.
  4. Pediatric Occupational Therapy - Facilitating Effective Service Provision, Winnie Dunn Ed. Stack, 1991.
  5. School-aged Therapy Program: Resource Manual. A cooperative project by the Ministry of Health and Ministry responsible for Seniors, Speech, Language and Early Intervention Program, and Sunny Hill Hospital for Children, 1992.
  6. Spreen, O. (1988) Learning disabled children growing up: A follow-up into adulthood. New York, NY: Oxford University Press.

The MSOT members who participated in the preparation of this document were:

  • Shelley Davies-Morassutti, occupational therapist and owner of Growing Years Therapy Services
  • Nicole Beauchesne-Dedio, staff occupational therapist, Growing Years Therapy Services
  • Kathy Miller, staff occupational therapist, Children’s Hospital
  • Jane Nattrass, staff occupational therapist, School Therapy Services
  • Marlene Waldron, senior occupational therapist, School Therapy Services