World Federation of Occupational Therapists Bulletin

ISSN: 1447-3828 (Print) 2056-6077 (Online) Journal homepage: http://www.tandfonline.com/loi/yotb20

Supporting children with special educational

needs (SEN): An introduction to a 3-tiered school-
based occupational therapy model of service
delivery in the United Kingdom

Sidney Chu

To cite this article: Sidney Chu (2017): Supporting children with special educational needs
(SEN): An introduction to a 3-tiered school-based occupational therapy model of service
delivery in the United Kingdom, World Federation of Occupational Therapists Bulletin, DOI:
10.1080/14473828.2017.1349235

To link to this article: http://dx.doi.org/10.1080/14473828.2017.1349235

Published online: 14 Jul 2017.

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WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN, 2017
https://doi.org/10.1080/14473828.2017.1349235

Supporting children with special educational needs (SEN): An introduction to a

3-tiered school-based occupational therapy model of service delivery in the
United Kingdom
Sidney Chua,b,c,d
a
Fellow, Royal College of Occupational Therapists, London, UK; bHonorary Fellow, Brunel University London, Uxbridge, UK; cHonorary
Member, Sensory Integration Network – UK & Ireland, Berkshire, UK; dDirector, Kid Power Therapy and Training Co. Ltd, London, UK

ABSTRACT KEYWORDS
In the last 30 years, cumulated practice- and research-based evidence highlight that the Children; special educational
collaboration between occupational therapists, nursery/school staff, parents and other needs; model; service
professionals involved is the primal importance in supporting children with special delivery
educational needs through developing an integrated therapy programme. This clinical
practice article aims at introducing a 3-tiered school-based occupational therapy model of
service delivery with examples of clinical application used in the United Kingdom (UK).
Challenges in implementing this model, different factors of good practice and
recommendations for future development are discussed in order to further refine and
validate this model.

Introduction 2004). In the UK, different models of service delivery

have been developed and evolved from direct service
All children are required to spend considerable time in
delivery focused on individual child, to multi-tiered
various educational settings in preparation for adult
model of integrated services focused on capacity build-
roles in life. In the United Kingdom (UK), there are
ing of school staff and empowerment of parents in
more and more children with special educational needs
order to provide cost effective and quality service to
(SEN) attending various educational settings e.g. main-
children with different SEN.
stream nurseries, mainstream or special schools. They
This clinical practice article aims at introducing a
all need different therapeutic services to support their
3-tiered school-based OT model of service delivery in
education in these settings. Paediatric occupational
the UK context, along with challenges in implementing
therapy (OT) is one of these therapeutic services. Paedia-
this model and other best practice guidance. The clini-
tric occupational therapists provide service to enhance
cal application of this model will be discussed in differ-
children’s engagement in different learning and func-
ent clinical areas of practice and in terms of different
tional activities and to support their participation within
disability/diagnostic conditions. Recommendations
various contexts by promoting understanding of the
for future development will be made in order to further
child’s conditions, adapting the learning environment,
develop and validate this model of service delivery.
analysing barriers and identifying facilitators to perform-
ance, differentiating learning tasks, integrating various
supporting strategies in real life environment and facili-
Models of service delivery in paediatric OT in
tating the link between parents and school staff (Bazyk
the United Kingdom
& Case-Smith, 2010; Chu, 2009; Clark & Chandler, 2013).
In order to promote integrated work with school Traditionally, in the UK, therapy sessions were usually
staff to improve the educational outcomes of children delivered through direct hand-on treatment sessions
with SEN, occupational therapists need to adopt both with the therapist working with the child in an isolated
practice- and research-based evidence in delivering treatment room. This could be happened in a clinic
effective service in different educational settings. In room within a health centre/hospital or a room within
the last 30 years, there are recognisable advancements a nursery/school setting. In this instance, children were
of paediatric OT practice for children with SEN in being seen within an artificial environment with
school settings (AOTA, 1987, 1989, 1991, 1992, 1998; therapy strategies may/may not be integrated into the
Bazyk & Case-Smith, 2010; Bonnard & Anaby, 2016; child’s real life environment. Clinical experience indi-
Bryte, 1996; Chu, 2009, 2013, 2015; Clark & Chandler, cated that this traditional model of service delivery
2013; Hanft & Place, 1996; Hutton, 2009; Pape & Ryba, did not deliver the best outcome for children.

CONTACT Sidney Chu kid.power@btinternet.com Kid Power Therapy and Training Co. Ltd, 157 Whitmore Road, Harrow, Middx HA1 4AG, UK
© World Federation of Occupational Therapists 2017
2 S. CHU
Previous research studies indicated that similar
levels of goal attainment had been found between
direct hand-on treatment and integrated therapy
approach i.e. therapist collaborates with school staff
and parents to develop an integrated therapy pro-
gramme (Dunne, 1990; Palisano, 1989). This is also
supported by Dreiling and Bundy (2003), who found
no statistically significant differences between groups
receiving direct or integrated therapy inputs. The
advantage of integrated therapy approach is that both
parents and school staff are empowered to support
children in their daily routine within home and school
environment.
In late 1900s and early 2000s, occupational thera-
pists in the UK explored different ways of working. A
continuum of service delivery had been adopted by
some services. It included direct service (i.e. therapist
provides hand-on treatment sessions to the child), inte-
grated/supervised therapy (i.e. therapist collaborates
with school staff and parents by prescribing pro-
grammes to be integrated into a child’s school and
home environment) and consultation (therapist pro-
vides advice to address a functional difficulty experi-
enced by a child). Based on this continuum of service
delivery, some services developed different clinical
pathways and packages of care in order to describe
the level of input in a predictable and quantifiable man-
ner (Chu, 2013; Hutton, 2009).
The model of integrated/supervised therapy (i.e. col-
laboration between therapists, school staff and parents)
has moved the therapists out of the clinic/therapy room
into the child’s real life environment. Various research
studies have demonstrated that substantial and positive
student performance gains have been obtained and
reported by teachers in the areas of written communi-
cations, fine motor, pre-academic and academic, social
and behavioural, transition, work and vocational skills,
along with high levels of teacher satisfaction when a
collaborative approach to service delivery is used
(Barnes & Turner, 2001; Bayona, McDougall, Tucker,
Nichols, & Mandich, 2006; Reid, Chiu, Sinclair, Wehr-
mann, & Naseer, 2006).
Through this progress in the models of service deliv-
ery, it is recognised that the collaboration between
occupational therapists, school staff, parents and
other professionals involved is the primal importance
in supporting children with SEN in an integrated man-
ner. With the introduction of the 3-tiered Response to
Intervention (RtI) Model used in North America
(National Association of State Directors of Special Edu-
cation, Inc., 2005), some OT services in the UK begin
to re-organise their services into a systematic school-
based model of service delivery (Chu, 2015; Hutton,
Tuppeny, & Hasselbusch, 2016).
There are good examples in applying this 3-tiered
model in different areas of paediatric OT practice in
North America e.g. in school mental health (Bazyk,
2011; Schwier, 2015), in teaching keyboard skills
(Mahan, 2012), in promoting positive behaviour in
school (Pagano, 2015). Results of a national OT survey
in the USA (Cahill, Mcguire, Krumdick, & Lee, 2014)
indicated that two-thirds of respondents are working
in school districts which implement this model. How-
ever, in the UK, the development and application of
this 3-tiered model is still at the initial stage. The struc-
ture and application of this model within UK context
will be discussed below.
The 3-tiered school-based OT model of
service delivery
The 3-tiered model is based on the RtI Model used in
the educational system in North America (AOTA,
2009; Cahill, 2007; Clark & Polichino, 2013; Clark,
Brouwer, Schmidt, & Alexander, 2008; National
Association of State Directors of Special Education,
Inc., 2005). It is also consistent with the concepts of
the 3-tiered Public Health Model (i.e. primary, second-
ary and tertiary levels of interventions) (Taylor, Peck-
ham, & Turton, 1998) and also the graduated
approach recommended by the College of Occu-
pational Therapists (COT, 2016) in the UK.
The RtI is
a multi-tiered approach to general education that
focuses on helping all students, identifies students
who are at risk for academic or behavioural concerns,
and provides targeted instruction and intervention
strategies for students whose rate of progress is behind
the classroom norm. (Clark et al., 2008, p. 9)
Figure 1 illustrates the three tiers of intervention which
can be applied in the delivery of school-based OT ser-
vices to children attending nurseries or schools
(adapted from National Association of State Directors
of Special Education, Inc., 2006). In this article, main-
stream school will be used as a setting for illustration.
Tier 1: universal interventions
In general education, all children receive high-quality
teaching and learning support within tier 1. All chil-
dren are screened/assessed on a periodic basis to estab-
lish an academic and behavioural baseline and to
identify struggling learners who need additional sup-
port. Research has demonstrated that for both learning
and behaviour, 80% or more of children should be per-
forming at expectations within this level of teaching
(Fletcher, 2006).
At this level, OT inputs will aim at providing infor-
mation and training to school staff and parents
through a whole school approach. Therapists work
with school staff to adapt the learning environment
in order to facilitate the child’s participation in differ-
ent learning activities, introduce different screening
procedure to be used by teaching staff, contribute to
 WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN
Figure 1. The 3-tiered school-based occupational therapy model of service delivery (adapted from National Association of State
Directors of Special Education, Inc., 2006).
curriculum design and provide information on differ-
ent training activities to be integrated into different
subjects.
Tier 2: targeted interventions
In general education, targeted interventions may be
initiated if the performance of some students is behind
the norm of their grade and/or the national curriculum
used in the UK. Students are provided with targeted
instruction matched to their needs on the basis of levels
of performance and rates of progress, while receiving
inputs at the universal level. Examples of targeted inter-
ventions include small group teaching, differentiation
of curriculum, the use of specialist teaching methods
and enhanced learning support.
Based on evidence in the education literature
(Reschly, 2005), it would be expected that targeted
interventions would be effective for another 15%, leav-
ing no more than 5% of the students needing more
specialised services e.g. tier 3 intensive interventions.
At this level, classroom-based assessment will be
conducted by the therapist. Specific OT treatment pro-
grammes will be prescribed to be integrated into the
child’s classroom routine and environment. Targeted
training to classroom staff to implement these pro-
grammes either individually or in a small group will
be provided by the therapist who will monitor the
child’s progress regularly. This also includes advice
on the modification of the curriculum, classroom
3
environment, use of specific training techniques and
conducting parent coaching group.
Tier 3: intensive interventions
At this level, children receive individualised, intensive
educational interventions that target their skill deficits
in different learning and functional activities. They
will also receive individualised inputs from different
educational and health professionals according to
their needs e.g. educational psychologists, occupational
therapists, speech and language therapists. SMART
(Specific, Measurable. Attainable, Relevant and Time-
bound) educational/therapy goals will be set by all pro-
fessionals through a collaborative goal setting process
with parents. These SMART goals will be integrated
into the child’s individual education plan (IEP). Chil-
dren will also receive support outlined at tiers 1 and 2.
The application of the 3-tiered model in
delivering school-based OT service
This model supports a change in thinking from the
traditional, individually focused deficit-driven model
of intervention to a whole-school strength-based
approach (Ivey et al., 2012). Through this model, occu-
pational therapists provide service as a collaborative
member of the team to children through school-wide,
whole classroom, group and/or individual intervention
initiatives. Table 1 summarises the components and
4 S. CHU

Table 1. Components of the 3-tiered school-based OT model of service delivery.

Tiers of intervention
Tier 3 Intensive intervention
. Specialist assessment
. Individualised treatment
Tier 2 Targeted intervention
. Classroom-based assessment
. Classroom-based intervention
. Targeted training for Learning Support
Assistants (LSA)
Tier 1 Universal intervention
.
Whole-school approach
. Curriculum design
. Whole school training
. Participation of parents
Examples of intervention
. Specialist assessment
. Setting SMART targets for the child’s IEP
. Direct hands-on treatment
. Prescription of individualised treatment programmes to be integrated into home and school
environments
. Training or coaching of school staff/parents
. Advice on the adaptation of the curriculum
. Classroom-based assessment e.g. observe a student’s access and use of the computer and provide
suggestions that the staff carries out
. Targeted training for Learning Support Assistants
. Group intervention programmes
. Specific classroom-based intervention strategies e.g. provide standard hand strengthening exercises for
the whole class of students before doing handwriting practices
. Targeted advice for a group of students e.g. provide suggestions for strategies that often help children
enhance attention/organisational ability
. Modification of the physical and sensory components of the classroom environment e.g. advise on the
layout, arrangement of furniture, organisation of learning materials, colour scheme, lighting and control
of sensory inputs in the classroom in order to facilitate learning of students
. Parent coaching group e.g. therapist acting as a coach helps to build the parents’ capacity through
targeted programme on specific areas of concerns
. School-based screening e.g. collaborate on universal screenings that help identify students needing Tier 2
or Tier 3 interventions
. Curriculum design e.g. work with school staff to design a whole school curriculum on handwriting
programme to develop writing skills for all students
. Whole school training e.g. provide an in-service to school staff on sensory strategies and environmental
adaptation to enhance alertness and attention to learning
. Information sharing with school staff e.g. create a resource pack for teaching staff that contains
information and training strategies related to different conditions
. Parents training programme e.g. general information on play, learning and self-care skills training at
home

examples of intervention can be provided at the three
tiers by occupational therapists.
In the UK, paediatric OT services can market
school-based service to health and education commis-
sioners by using this 3-tiered model (Chu, 2013).
The clinical application of this 3-tiered model can
be conceptualised into two areas: (1) in
different clinical areas of practice, and (2) for children
with different disability/diagnostic conditions (Chu,
2015).
The application of the 3-tiered model in
different clinical areas of practice
Describing what occupational therapists can do in
different clinical areas of practice is probably a better
way to develop and market the service to schools,
especially those areas which are directly related to
the national curriculum and have impact on the
learning of children. The following clinical areas of
practice are particularly relevant to school:-
1. Sensory processing functions – related to regu-
lation of arousal level and attention control for
learning.
2. Perceptual functions, especial visual perception –
related to the child’s learning style and development
of different literacy and numeracy skills
3. Postural-motor control and gross motor skills –
related to the child’s ability to participate in
different physical education and movement
activities.
4. Fine motor skills – related to the child’s ability to
participate in different learning (e.g. cutting with a
pair of scissors, drawing line with a ruler) and func-
tional activities (e.g. doing up zip and button, tying
shoelaces).
5. Handwriting skills – related to the development of
school handwriting policy, including the type of
writing scheme to be adopted for the whole school
curriculum and the use of different teaching pro-
grammes/techniques.
6. Environmental adaptation for accessibility/thera-
peutic handling/use of specialist equipment –
related to the integration of children with physical
disabilities in different school environments/
activities.
Table 2 illustrates an example of applying the 3-
tiered model in the clinical practice area of fine
motor skills.
The application of the 3-tiered model in the
treatment of children with different disability/
diagnostic conditions
Describing what occupational therapists can do for
children with different diagnostic condition by using
the 3-tiered model forms the bases for developing an
integrative treatment plan for a child and also to quan-
tify the level of inputs required. A case example will be
used to illustrate the application of the 3-tiered model
in this aspect of service delivery.
 WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN 5

Table 2. The application of the 3-Tiered model in the clinical area of fine motor skills.
Examples of intervention for fine motor skills
Tier 3 – Intensive intervention (Individual)
. Specialist assessment on the child’s fine motor skills
. Setting SMART targets for the child’s IEP
. Direct hands-on treatment
. Prescription of individualised fine motor skills treatment programmes to be integrated into home and school environments
. Training or coaching of school staff/parents
. Advice on the adaptation of the curriculum with respect to the child’s fine motor difficulties

Tier 2 – Targeted intervention (classroom-based)

. Classroom-based assessment e.g. hand grasp, in-hand manipulation, eye-hand and two-handed coordination, functional fine motor skills
. Targeted training for Learning Support Assistants and parents in using specific fine motor skills training programmes e.g. Give Yourself a Hand, Fine Motor
Olympics, Hands at Work and Play, Fingermania programmes
. Group intervention programmes e.g. modelling therapy programmes with LSAs so that they can carry out the programmes independently
. Specific classroom-based intervention strategies e.g. create fine motor boxes with graded activities to be used by teachers and LSAs for the whole class.
. Targeted advice for a group of students e.g. work on hand-strengthening, building hand arches and posture, distal finger control, scissor skills etc.
. Modification of the physical environment e.g. check dimension of chair and table, advise on the use of different fine motor training materials

Tier 1 – Universal intervention (Whole school)

. School-based screening e.g. introduce fine motor skills screening procedures to identify children who may need further assessment and inputs
. Curriculum design e.g. work with school staff to design a whole school fine motor skills programme to develop fine motor skills for all students, especially
for children at nursery, reception and year 1
. Whole school training e.g. provide an in-service to school staff on the development and training of fine motor skills
. Information sharing with school staff e.g. create a resource pack for teaching staff that contains strategies based on scientifically-based evidence to use
with various fine motor problems
. Parents training programme e.g. educate parents on the development of fine motor skills and training strategies they can use at home

The name of the child has been changed in order to out the task. The package lasts for 3 months, with 12
protect the identity of the child. Verbal consent has weekly contacts with the child, parents and teacher i.e.
been obtained from parents. over a period of a typical school term in the UK.

A case example in mainstream school
Daniel was diagnosed as having Attention Deficit
Hyperactivity Disorder (ADHD) – Combined Type,
with comorbid Developmental Coordination Disorder
(DCD) and Sensory Processing Disorder (SPD), at
the age of 9 years 0 months, by the local Child and
Adolescent Mental Health Services (CAMHS). He pre-
sented a range of inattentive, hyperactive and impulsive
behaviours both at home and school. He has difficulties
in staying seated for different learning tasks. He needs
constant movement stimulation or else he will fidget or
squirm on his seat. He will call out in the classroom
and try to get attention from his teacher. In the play-
ground, Daniel tends to run about or interrupt other
children’s games. As he shouts out a lot, he has a
very distinctive husky voice.
The CAMHS operates a transdisciplinary team
approach with the use of a case manager (or pri-
mary care provider) to integrate and coordinate
input for a family. As Daniel presents to have
more problems related to OT practice, the occu-
pational therapist in the service has been allocated
as the case manager.
A multi-faceted intervention package for children
with ADHD (Chu & Reynolds, 2007) was applied
through the tiers 1 and 2 of the school-based model.
The package involves a multidimensional evaluation
and a multifaceted intervention, which are aimed at
achieving a goodness-of-fit between the child, the task
demands and the environment in which the child carries
Treatment goals for school and home
The goals of treatment include reduction in the ADHD
clinical features (i.e. hyperactivity, impulsivity and
inattentiveness) and also functional goals in both
school and home environment.
For measuring change in ADHD clinical features,
the Reliable Change Index (RCI) will be calculated by
comparing the scores of the ADHD Rating Scale – 5
Home and School Versions (DuPaul, Power, Anasto-
poulos, & Reid, 2016) before and after treatment.
When the value of RCI exceeds 1.96, it indicates that
the change from pretreatment to posttreatment is not
due to chance (p < 0.05). Thus, the RCI serves as a
measure of the degree to which an improvement in
functioning is likely to be due to the effects of treatment
rather than to imprecise measurement.
For functional goals, a modified version of the Goal
Attainment Scaling (GAS) (Kiresuk, Smith, & Cardillo,
1994; Turner-Stokes, 2009) is used to set the targeted
goals and measure the change before and after treat-
ment. The following goals have been set to be achieved
at the end of the 3 months package in conjunction with
parents and teachers:-
1. Daniel is able to stay seated during the daily literacy
lesson 80% of the time with verbal prompt provided
by his Learning Support Assistant.
2. Daniel is able to complete a handwriting task which
consists of four sentences within five minutes
independently.
6 S. CHU
3. Daniel is able to participate in group games with his
peers in the playground 80% of the time with facili-
tation provided by his Learning Support Assistant.
4. Daniel is able to tie shoelaces by using a single loop
method independently.
For parents and teacher, they had been asked to rate
their level of understanding of ADHD and level of con-
fidence in supporting Daniel by using an analogue scale
of 1 to 10, whereas 1 is the lowest score and 10 is the
highest level.
Description of the treatment programme
Tier 1 – Universal Intervention: The occupational
therapist did a school visit with Daniel’s parents to
share information with his teacher, learning support
assistant and special educational needs coordinator
(SENCO) about the specific problems and needs of
children with ADHD, DCD and SPD. In order to
adopt a whole school approach in supporting Daniel
to participate in different educational and social activi-
ties, the SENCO arranged a talk by the occupational
therapist about ADHD for parents, all teaching and
support staff in the school. The therapist also provided
the school with information packs on ADHD, DCD
and SPD so that they can have an up-to-date resource
on these conditions for future reference.
Tier 2 – Targeted Intervention: An OT programme
with specific goals was set up in conjunction with
Daniel’s teacher and parents. It includes specific behav-
ioural management strategies and also a sensory diet
programme to be integrated into his classroom routine
in order to improve Daniel’s level of self-control and
attentive behaviour.
General classroom rules were set for the whole class
as a supporting background for good behaviour, e.g.
raise your hand before talking, and walk slowly in the
school instead of run. As children with ADHD need
immediate, regular and constant feedback to regulate
their behaviour, a token system by using response
cost was set up to develop desirable behaviour for
Daniel. The behavioural management programme is
consistent between home and school.
In order to reduce his movement seeking behav-
iour, a move-and-sit cushion (a special air inflatable
wedge-shaped cushion) was provided as part of the
sensory diet programme so that Daniel can still get
the necessary movement stimulation while staying
seated on a chair. Other sensory strategies were used
to provide regular movement stimulation to him by
using meaningful tasks, e.g. handing out learning
materials for the teacher, taking a basket of books
back to the library.
As children with ADHD are mostly visual-based
learners, the use of different visual strategies was
suggested e.g. a visual timetable (a visual chart using
pictures or symbols to illustrate the sequence of learn-
ing activities throughout the day in school). The use of
a colour coding system was suggested for indicating
different signals e.g. the colour blue means quiet
time. The occupational therapist also advised the tea-
cher to adapt the classroom environment so that it is
less stimulating for Daniel, e.g. a more calming colour
scheme, mechanisms to control light intensity and
noise level, and reduce the amount of display of chil-
dren’s work. Specific treatment activities also devised
and integrated into P.E. and classroom activities in
order to improve his postural control, motor skills
and hand strength for better gross motor, fine motor
and handwriting skills. At home, he learned to tie shoe-
laces by using a single-loop method.
Treatment outcomes
After a term of implementing the programme through
12 weekly meetings between the therapist, parents and
teacher, Daniel gradually improved in his behavioural
and attention control. The RCI of the ADHD Rating
Scale 5 and GAS calculator (Turner-Stokes, 2009)
were used to measure the outcomes. Daniel showed
positive reduction in his ADHD clinical features and
achieved all the goals set. Both parents and teachers
demonstrated increase in their understanding of
ADHD and also confidence in supporting Daniel.
They are able to carry on all the management strategies
suggested by the occupational therapist.
Challenges in implementing the 3-tiered
model in clinical practice
As this model is very different from the traditional
direct therapy model used by therapists in the UK,
there are many challenges to overcome in order to
implement this model by using existing resources.
From the management perspective, therapy managers
need to adopt a new approach to calculate the demand
and capacity of the service by using the concept of
workload rather than the traditional caseload approach
i.e. distribute staff time into the 3 tiered of intervention
and define the levels of needs of children with different
conditions (AOTA, 2014). They also need to negotiate
with commissioners in changing the way of working
and develop new data collection protocol for monthly
statistics.
In term of clinical knowledge and skills, therapists
will need to enhance their knowledge on educational
environment and the wide breadth of practice areas;
including skills in conducting universal screening,
relationship building, collaborative team work and
goal setting processes, coaching parents and consulta-
tive role in service delivery. They also need effective
teaching skills to translate and disseminate knowledge
when working at the tiers 1 and 2 of the model.

As most existing clinical resources and treatment
materials are designed for traditional direct therapy
model, therapists will need to collaborate to develop
and share resources in order to facilitate work at tiers
1 and 2 levels. They also need to make sure information
for parents and teaching staff is disseminated accu-
rately and at the appropriate level, and with monitoring
system in place to support the implementation of any
treatment advice or management strategies.
Other barriers could be related to the recognition of
OT services in schools, expectation of school staff and
parents on direct hand-on therapy input, and resistant
to change in some therapists into a new way of work-
ing. However, these barriers are vary in different
parts of the country.
Other best practice guidance
In order to apply this systematic school-based model of
service delivery successfully, besides addressing chal-
lenges mentioned above, occupational therapists
should adhere to the following well established best
practice guidance:-
1. Occupational therapists should adopt the most con-
temporary model of practice to guide their practice.
For example, the Person-Environment-Occupation
Model provides good guidance in the evaluation
and intervention framework which is highly rel-
evant to school-based OT work (Hasselbusch &
Dancsz, 2012; Law et al., 1996; Strong et al., 1999).
2. Occupational therapists use different bottom-up
and top-down assessment and treatment
approaches/methods in supporting children with
different disability conditions (Weinstock-Zlotnick
& Hinojosa, 2004). It is important for the therapist
to select the most appropriate approaches/methods
for a child with a particular condition. For example,
when applying sensory integration theory (a bot-
tom-up approach) in school-based practice, thera-
pists need to refer to relevant practice guidance
for safe and effective service delivery (AOTA, 2015).
3. Occupational therapists should work in an inter-
disciplinary/transdisciplinary approach so that an
integrated treatment programme could be estab-
lished to promote the development and function
of a child in an integrative manner (Barnes &
Turner, 2001; Hinojosa et al., 2001; Nochajski,
2001)
4. Research studies demonstrate that children will
have better outcome when services are delivered
in a family-centred care approach (Holloway &
Chandler, 2010; Popp & You, 2016; Rosenbaum,
King, Law, King, & Evans, 1998). In this approach,
parents work as a member of the team as they are
the constant factor in the child’s life. OT input
should aim at enabling parents to understand and
WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN 7
support the child’s difficulties so that they feel
empowered through the process (Fingerhut, 2013;
Fingerhut et al., 2013). Therapists should also
acquire skills in using effective parent coaching
technique framed from the OT perspective e.g. the
Occupational Performance Coaching (Graham,
Rodger, & Ziviani, 2009, 2010, 2013).
5. Occupational therapists should provide service which
is outcome-focused (Majnemer & Limperopoulos,
2002; Tam, Teachman, & Wright, 2008). They should
also introduce method to evaluate the effectiveness of
the treatment programme prescribed. For example,
use the GAS to measure the effectiveness of treatment
(Chu, 2016; King, Mcdougall, Palisano, Gritzan, &
Tucker, 1999; Steenbeek, 2010).
6. Occupational therapists should continuously review
and shape their practice by using different research-
and practice-based evidence (Cahill, Egan, Walling-
ford, Huber-Lee, & Dess-Mcguire, 2015; Villeneuve
& Shulha, 2012).
7. Occupational therapists should contribute to
the child’s IEP target in order to facilitate the
child’s participation in different learning and func-
tional activities (Clark, 2005; Harney & Kramer,
2007).
8. Occupational therapists should support the tran-
sition of children at different timing of their edu-
cational pathway e.g. from nursery to school, from
school to adult’s service (Kardos & White, 2005;
Orentlicher & Michaels, 2003a, 2003b).
Recommendations for future development
Besides addressing challenges discussed, different prac-
tice- and research-based evidence should be accumu-
lated over a period of time in order to refine and
validate this 3-tiered model.
For practice-based evidence, all practising school-
based occupational therapists should collaborate to sys-
tematically document the focus of current practice in
various areas e.g. the use of screening and assessment
tools, intervention approaches used, the use of soft
and hard outcome measures to evaluate clinical effec-
tiveness and also qualitative feedback from parents
and teachers. Careful identification of barriers and
facilitators to the implementation of this model could
inform the development of new interventions to
address gaps in practice. A synthesis of this practice-
based evidence will help to inform effective school-
based OT practice strategies.
As training on school-based OT practice is not
usually included in the undergraduate courses in the
UK, it will be useful to carry out a needs assessment
to reveal areas of continuous professional development
for therapists working in this field. This can also be
extended to OT educators so that they can develop/
modify the OT course curriculum accordingly.
8 S. CHU
For research-based evidence, research should
include longitudinal studies that measure clinical effec-
tiveness to promote children participation in different
learning and functional activities, parents and teacher
responses to collaboration, and their ability to apply
and generalise intervention strategies into the child’s
real life environment. Further research is required to
guide the direction of school-based OT practice and
skill development for clinicians in response to the
changing needs of children and changes in the edu-
cational system.
Conclusion
This clinical practice article outlines the foundation for
reframing OT’s role in schools. A 3-tiered model focus-
ing on the delivering of OT services specific to schools
is introduced. This model emphasises a collaborative
approach by sharing focus, responsibility, and account-
ability for the success of all children, and it demon-
strates the unique value of OT’s contribution to
education and learning. It emphasises on early inter-
vention and addresses student learning needs before
a student gets too far behind or is referred to specialist
service. It will help to strengthen the preventive and
proactive components of the whole education system.
Challenges in implementing the model and other
best practice guidance have been discussed. Rec-
ommendations for future development have been
made in order to further develop and validate the
model. This model will continue to evolve with new
research- and practice-based evidence.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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