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School-based Occupational Therapy

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 24
School-Based Occupational Therapy
Susan M. Cahill, Susan Bazyk

GUIDING QUESTIONS
1. What major legislation guides and regulates education for students
with and without disabilities?
2. How do the Individuals with Disabilities Education Act (IDEA),
Section 504 of the Rehabilitation Act, and Elementary and
Secondary Education Act (ESEA) affect the role of occupational
therapists in schools?
3. What major amendments to IDEA have been implemented over
the past 3 decades?
4. What are the major provisions of Part B of IDEA—free
appropriate public education (FAPE) in the least restrictive
environment (LRE)?
5. How do occupational therapists provide services under Part B of
IDEA, including referral, evaluation, individualized education
program (IEP), and interventions?
6. How are occupational therapy services that support students with
and without disabilities integrated into the classroom and across
school environments?
7. What are examples of indirect and direct occupational therapy
services?
8. How do occupational therapists under the IDEA 2004 and ESEA
provide services?
9. How do occupational therapists promote school mental health
within a multitiered, public health model?

KEY TERMS
Coaching Health-related quality of life Related services
Coteaching Individuals with Disabilities Education Act Response to intervention
Early intervening services Individualized Education Program School mental health
Educational model Integrated service delivery School transitions
Every Student Succeeds Act Least restrictive environment Section 504 of the Rehabilitation Act
Free and appropriate Multitiered systems of support
  

Educational systems prepare students for adult roles associated with
work and community life. In recent years, educational reform in
the United States has focused on increasing the accountability of
schools to meet this aim. Greater academic rigor, pressure to keep
up with the growth of technology in a global society, and emphasis
on reducing the gap between K–12 education and college and career
readiness have led to a changing educational landscape (Konrad
et al., 2014). In addition to being technologically savvy and con-
sumers of information, today’s K–12 students need well-honed
problem-solving, interpersonal, and intrapersonal skills (National
Research Council, 2012).
Occupational therapy practitioners working in today’s school
systems have the unique opportunity to support students with and
without disabilities to maximize their performance and partici-
pation in the student role and across educational environments
(American Occupational Therapy Association, 2011). This chap-
ter provides information to prepare occupational therapists to
meet the traditional demands associated with school-based prac-
tice and the knowledge to expand their scope in this dynamic
environment.
FEDERAL LEGISLATION AND STATE-LED
INITIATIVES INFLUENCING SCHOOL-BASED
PRACTICE
Federal policy, which is shaped by trends in health and education
practice, directly influences services for children. In the 1930s, federal
legislation establishing the rights of children related to education and
general well-being were established. However, it was not until 1975,
with the introduction of the Education for All Handicapped Children
Act (EHA; P.L. 94-142), that policy specifically addressed the needs of
children with disabilities. This legislation was championed by parent
advocacy groups who were seeking opportunities for their children
to participate fully in everyday routine activities (Shapiro, 1994). The
introduction of the EHA occurred at a time when it was estimated
that more than 1 million children with disabilities were excluded from
school, and many were institutionalized. Although occupational ther-
apists’ early work with children occurred primarily in medical rather
than educational settings, a rapid shift to practicing in schools took
place with the EHA legislation. Fig. 24.1 depicts a timeline of import-
ant legislation, policy changes, and practice developments influencing

627
628 SECTION V  Pediatric Occupational Therapy Services

Center for School Mental

Health Analysis & Action
(University of Maryland) Common Core
Standards
Center for Mental Health 2013
in Schools (UCLA)
1995 School
Mental Health
No Child Left Behind
(NCLB): Emphasizes
Individuals with accountability,
Disabilities Education achievement, &
Act (IDEA) effective teaching
1990 2001 General
Education

1997
IDEA Amendments
1975 1986 (Emphasizes access to 2015
Education of All EHA Amendments general education; Every Student
Handicapped Children (Preschool & Early mandates FBAs & PBIS; Succeeds Act
Act (EHA) Intervention added) includes students with (ESSA)
disabilities in
districtwide assessment

1991 2004
IDEA Amendments Individuals with Disabilities
(Assistive Technology Improvement Act (IDEA 2004)
& Transition added) (Aligned with NCLB;
increased emphasis on accountability &
outcomes) Supports EIS & Rtl
Fig. 24.1 Timeline of important legislation and developments influencing occupational therapy’s role in
schools.

school-based practice. The following section provides a more detailed
discussion of contemporary legislation, such as IDEA, ESSA, and
Section 504 of the Americans with Disabilities Act (ADA), as well as
the major shifts in occupational therapy practice that have been influ-
enced by this legislation.
Individuals With Disabilities Education Act
Most children receiving occupational therapy services in schools, as
recently as the early 2000s, did so under IDEA (2004; P.L. 108-446),
which is the current iteration of the EHA. IDEA was most recently
reauthorized in 2004 and is sometimes referred to as the Individuals
with Disabilities Education Improvement Act. IDEA requires that
states and public educational agencies provide a FAPE to children
with disabilities in the LRE. This legislation also guarantees parents
and children with special needs certain rights based on a set of pro-
cedural safeguards that dictate the policies and procedures that edu-
cational teams need to follow to comply with the law. Part B of IDEA
specifies that an IEP must be designed to include special education
and related services for all students from 3 to 21 years of age if it is
determined by the educational team that the student requires such
services to benefit from his or her public education (§ 300.17). IDEA
maintains that children with special needs are ensured both FAPE and
LRE (National Dissemination Center for Children with Disabilities
[NICHCY], 2008). Six additional assurances directing the education
of children with disabilities were adopted with the original law in 1975;
these have remained constant, except for a few subsequent amend-
ments (Box 24.1).
According to Part B of IDEA, occupational therapy is considered a
related service. Related services are described as “such developmental,
corrective, and other supportive services as are required to assist a child
with a disability to benefit from special education” (IDEA 2004, Final
Regulations, § 300.34, 2006). School districts are legally mandated to
provide the services that a child requires to benefit from their IEP, and
therefore occupational therapists are critical members of the educa-
tional team.
Eligibility.  A student is eligible for special education under IDEA
if he or she has a disability as defined by one or more of the disabil-
ity categories under IDEA. The disability categories include intel-
lectual disability, hearing impairment (including deafness), speech
or language impairment, visual impairment (including blindness),
serious emotional disturbance, orthopedic impairment, autism,
traumatic brain injury, another health impairment, specific learn-
ing disability, deaf-blindness, or multiple disabilities (34 C.F.R. §
300.8). The term child with a disability for children aged 3 through 9
years may, at the discretion of the state education agency (SEA) and
local education agency (LEA) and in accordance with § 300.111(b),
include a child who demonstrates developmental delays as defined
by the state and as measured by appropriate diagnostic instruments
and procedures in one or more of the following areas: physical
development, cognitive development, communication develop-
ment, social or emotional development, or adaptive development,
and who, by reason thereof, needs special education and related
services.
 CHAPTER 24  School-Based Occupational Therapy
BOX 24.1  Principles of the Individuals With
Disabilities Education Acta
1. Free appropriate public education (FAPE). Every eligible child is entitled to an
appropriate education that is free to families (supported by public funds).
2. Least restrictive environment (LRE). Children with disabilities are most
appropriately educated with their nondisabled peers. Special classes, sep-
arate schooling, or other removal of children with disabilities from the reg-
ular educational environment is to occur only when the nature or severity
of the disability of a child is such that education in regular classes with the
use of supplementary aids and services cannot be achieved satisfactorily
[§ 612 (a)(5)(A)].
3. Appropriate evaluation. All children with disabilities must be appropriately
assessed for purposes of eligibility determination, educational program-
ming, and individual performance monitoring.
4. Individualized education program. A document that includes an annual plan
is developed, written, and (as appropriate) revised for each child with dis-
abilities.
5. Parent and student participation in decision making. Parents and families
must have meaningful opportunities to participate in the education of their
children at school and at home.
6. Procedural safeguards. Safeguards are in place to ensure that the rights of
children with disabilities and their parents are protected, and that students
with disabilities and their parents are provided with the information they
need to make decisions. In addition, procedures and mechanisms must be
in place to resolve disagreements between parents B.
aFormerly EHA (P.L. 94-142)
Free and Appropriate Public Education.  A FAPE means that special
education and related services must do the following: (1) meet the stan-
dards of the SEA; (2) be provided at public expense; (3) be under public
supervision and direction; (4) include an appropriate education at all
levels (preschool, elementary, and secondary levels); and (5) be provided
in accordance with the child’s IEP. Free means that parents will not incur
any costs associated with these services, beyond typical incidental fees
that are charged to all students. Appropriate, a term that is less objectively
defined and means that children must receive the educational supports
and services that adequately meet their unique needs. It does not, how-
ever, guarantee that children will receive the most advanced or innova-
tive educational methods or have access to state-of-the-art technology
and materials to meet their needs. The IEP, which legally documents the
child’s educational needs, also documents the individualized set of sup-
ports and services determined to be appropriate by the special education
team to allow the student to benefit from his or her education and par-
ticipate at school. The IEP is developed based on the contributions of the
special education team, including the occupational therapist, informed
by a comprehensive, multidisciplinary assessment.
Least Restrictive Environment.  The LRE mandate requires that
students with disabilities receive their educational program, including
all their academic and related services, with children who are not dis-
abled to the maximum extent appropriate (§ 300.114). LRE does not
guarantee that all students receive services within general education
for the duration of the school day. Rather, it means that the IEP team
must first consider general education as potentially meeting the stu-
dent’s needs, before moving on to a more restrictive setting (Hanft &
Shepherd, 2008). LRE should be applied to all students with special
needs, regardless of their disabilities. Removing a child from general
education should only take place after it is determined that the nature
of the child’s disability inhibits him or her from making progress, with
the addition of supports and services. IDEA states that the “removal of
629
children with disabilities occurs only when the nature or severity of the
disability of a child is such that education in regular classes with the use
of supplementary aids and services cannot be achieved satisfactorily”
(32 C.F.R., § 612[5][A]). All decisions regarding placement must be
made on an individual basis, based on the child’s unique educational
needs, documented in the IEP, and reviewed annually. Placement deci-
sions should not be based on the availability of space or resources.
Depending on the child’s individual educational needs, students may
receive supports and services in a variety of settings. An example of LRE
is a student receiving consultative services and accommodations and
modification within a general education classroom at the child’s school
of residency, that is, his or her home school. If the child is not able to
benefit from his or her IEP at this level of LRE, he or she may receive ser-
vices in a special designated classroom or a designated school building. If
services in these settings are not adequate, the child may receive services
in a therapeutic day school, at home, in a hospital, or at a residential
facility. Most children with disabilities spend at least a portion of their
day with peers from general education. However, some children with
very significant disabilities may not be included with peers from gen-
eral education. When this is the case, it is up to the child’s IEP team to
document the severity of the child’s educational needs and to articulate
clearly why other, more inclusive settings are not adequate to meet them.
Removing a child entirely from general education without the option
for inclusion in at least some special classes (e.g., music class, physical
education, art) or nonacademic activities (e.g., lunch, recess) should be
considered by the team as the last option.
Evolution of IDEA.  Although the original goal of FAPE in the LRE
for children with disabilities has not changed, each reauthorization of
IDEA has prompted reflection and a reevaluation of educational ser-
vices, which, in turn, has brought about important shifts in the delivery
of special education and related services.
In 1986, amendments allowed states to provide preschool and early
intervention services for children with disabilities from birth to age 5
years. To reflect current language, the law’s name was changed to IDEA
in 1990. This amendment authorized additional services (assistive
technology services and devices and transition planning). The reautho-
rization in 1997 was significant in placing greater emphasis on deliv-
ering related services to children with disabilities within the context of
the student’s general education curriculum (Nolan et al., 2004). As a
result, there has been a gradual shift in service delivery from traditional
pull-out approaches to the integration of occupational therapy services
into the student’s classroom and other relevant school environments
(e.g., lunchroom, playground, restroom) (Swinth, 2007). This shift
has required occupational therapists to become knowledgeable about
educational standards so that they can better specify how a student’s
disability affects functioning within the educational environment and
access to the curriculum. The IDEA Amendments of 1997 also focused
on student outcomes by requiring students with disabilities to be
included in state- and district-wide assessments.
IDEA was most recently reauthorized in 2004 as the Individuals
with Disabilities Education Improvement Act. The primary goals of
IDEA 2004 are to increase the focus of education on results, prevention
of problems through early intervening services, and improvement of
students’ academic achievement, functional outcomes, and postsec-
ondary success (Jackson, 2007). 
Section 504 of the Rehabilitation Act and Americans
With Disabilities Act
A child with a disability who is not eligible for special education under
IDEA may be eligible for services under Section 504 of the Rehabilitation
Act of 1973. Section 504 of the Rehabilitation Act of 1973 and Title II of
630 SECTION V  Pediatric Occupational Therapy Services
the ADA 1990 complement IDEA to ensure nondiscrimination against
children with disabilities in public schools (Wright & Wright, 2008).
Section 504 requires schools receiving federal funds to provide access
to public education to students with documented disabilities. The ADA
ensures that the educational program is accessible to individuals with
disabilities and may include providing specific accommodations. The
definition of “disability” under Section 504 and ADA includes any stu-
dent with “a physical or mental impairment that substantially limits one
or more major life activities, who has record of such an impairment,
or is regarded as having such an impairment” (34 C.F.R. 104.3(j)(2)
(i)). Some examples of impairments that may substantially limit major
life activities are mental illness, specific learning disabilities, attention
deficit hyperactivity disorder (ADHD), juvenile rheumatoid arthritis,
cancer, diabetes, and hearing impairment. Major life activities include
caring for oneself, education and learning, performing manual tasks,
seeing, hearing, speaking, working, walking, and breathing. Because
this definition is broader than IDEA’s definition of disability, students
who do not meet the criteria for services under IDEA may be eligible
for accommodations and other supports under Section 504. “Under
Section 504, occupational therapy can be provided alone or in combi-
nation with other education services and may be provided directly to
students or as program supports to teachers working with the student”
(American Occupational Therapy Association, 2006, p. 1). Student eli-
gibility for Section 504 services are documented in guidelines developed
by each SEA and LEA. Although school personnel are not required to
develop IEPs for students served under the Rehabilitation Act, a team
should, at a minimum, develop a written plan that states goals, services,
and accommodations needed to meet those goals (Jackson, 2007).Refer
to the Evolve site for an example of a 504 plan.  CCS was solicited from teachers, parents, and school administrators in
Elementary and Secondary Education Act and Every
Student Succeeds Act of 2015
The ESEA of 1965 was a consequence of the “war on poverty” and
designed to ensure that all children have an equal opportunity to par-
ticipate in and receive a good education at school (Opp, 2007). This
law, which is considered a key component in the education reform
movement, covers all public schools in all states. In 2002, Congress
amended ESEA, making major changes, and reauthorized it as No
Child Left Behind (NCLB) (P.L. 107-110).
NCLB was mainly understood to be a general education law that
emphasized increased accountability for educational outcomes on
the part of school districts. Under this law, states worked to close the
achievement gap by establishing high achievement standards for all
students, especially those who were disadvantaged because of poverty
or disability (United States Department of Education, 2008). NCLB
included provisions that required educators to be highly qualified,
monitor adequate yearly progress (AYP) and allow students from low
performing schools to transfer or obtain tutoring services through
a waiver system (United States Department of Education, 2008). In
2015, Congress authorized the ESSA (Pub. L. No. 114-95) to replace
NCLB. ESSA continues to emphasize accountability. However, ESSA
allows local education agencies to establish their own accountability
goals and monitoring systems, which may be less reliant on standard-
ized assessments as a single measure of performance or improvement
than was required under NCLB. ESSA names occupational therapy
practitioners as “specialized instructional support personnel” (SISP)
(Box 24.2). As SISP, occupational therapy practitioners are expected
to engage in consultation with other personnel to support the aca-
demic achievement of students, participate in schoolwide systems of
support (i.e., multitiered systems of support to address learning and
mental health needs), and to provide professional development train-
ing (American Occupational Therapy Association, 2017).  & Bateman, 2014). Most occupational therapists that work in schools
BOX 24.2  Specialized Instructional
Support Personnel
The Every Student Succeeds Act of 2015 defines Specialized Instructional Support
Personnel as, “(i) school counselors, school social workers, and school psycholo-
gists; and’‘(ii) other qualified professional personnel, such as school nurses, speech
language pathologists, and school librarians, involved in providing assessment,
diagnosis, counseling, educational, therapeutic, and other necessary services
(including related services as that term is defined in section 602 of the Individuals
with Disabilities Education Act (20 U.S.C. 1401) as part of a comprehensive pro-
gram to meet student needs” (ESSA 2015, Sec. 8002).
Common Core Standards: A State-Led Initiative
The ESSA requires that all schools adopt academic standards. Forty-two
states, four territories, and the District of Columbia have voluntarily
adopted the Common Core Standards (CCS) (www.corestandards.org)
to guide the educational outcomes of all students, including those with
disabilities. The development of the CCS was guided by state gover-
nors and state education commissioners. The process of developing the
CCS was led by two professional organizations, the National Governors
Association (NGA) and Council of Chief State School Officers (CCSSO)
(NGA, 2010). The CCS were drafted after a review of current state stan-
dards and research regarding what students need to know to prepare for
postsecondary opportunities. In addition, the academic standards used
in other high-performing countries were also influential in the devel-
opment of the CCS. Input regarding the content and structure of the
the United States. As such, the CCS represent a set of clearly defined
goals and expectations for children in grades K–12 in math and English
language arts/literacy (NGA, 2010). The focus of these standards is to
promote college and career readiness through the development of higher
order thinking skills.
The CCS are to be used by teachers as a content guide and do
not prescribe a specific method or form of instruction. The CCS
establish high expectations for all students. Although these stan-
dards are also used to guide the education of students with dis-
abilities they do not replace the IEP. However, some students with
significant cognitive and developmental needs may require a sig-
nificant amount of supports and services to acquire and demon-
strate knowledge and skills. Access to the rigorous content aligned
with the CCS can be achieved by students with disabilities through
the use of evidence-based and individualized instructional meth-
ods, the application of Universal Design for Learning (UDL) prin-
ciples, the introduction of assistive technology, and the use of
general accommodations (NGA, 2010). In many districts, occupa-
tional therapists are encouraged to use these and other standards,
such as the Core Social Emotional Learning Competencies (www.
casel.org/core-competencies/) as a guide for developing schoolwide
systems of support, measurable IEP goals, and educationally rele-
vant intervention plans. 
Private Schools and Federal Legislation
IDEA, ESSA, and ADA regulate many aspects of general and special
education in US public schools. Public schools are generally funded
through tax dollars and subsidized by state and federal funds. Public
schools must comply with the regulations associated with these pieces
of legislation to maintain their funding (Bateman & Bateman, 2014).
If public schools do not comply, their funds can be withheld (Bateman
 CHAPTER 24  School-Based Occupational Therapy
do so in public school systems. Yet, some occupational therapists work
in private schools.
Students enrolled in private schools that do not receive federal
funding are not guaranteed a FAPE (Boyle & Hernandez, 2016).
However, public school districts are required to spend a proportion-
ate share of their federal dollars to provide services to students who
are enrolled in private schools (Boyle & Hernandez, 2016). The pro-
portionate share is determined after the school district meets with
representatives from private schools that educate children that live in
their district and is calculated based on the number of eligible children
(United States Department of Education, 2011). The needs of eligi-
ble children are prioritized, and the dollars associated with the pro-
portionate share are divided accordingly (United States Department
of Education, 2011). Providing the proportionate share means that all
private school children eligible for services may not receive services
or they may not receive all the services they would be entitled to if
they attended the public school (Boyle & Hernandez, 2016). Children
who do receive services, like occupational therapy, through the pro-
portionate share may have to be transported to and from the public
school to access them (United States Department of Education, 2011).
If a private school accepts any federal funding, including those dollars
associated with the proportionate share, they too must comply with
the provisions set out by the ADA, particularly related to maintain
nondiscriminatory practices (Bateman & Bateman, 2014).
This synthesis of federal legislation and state-led initiatives provides
the foundation for understanding the evolving role of occupational
therapists working in schools. Changes brought about by the reautho-
rization of IDEA and the ESSA have been instrumental in providing
opportunities for expanding occupational therapy’s role in serving all
children attending school (Jackson, 2007). In the following sections,
occupational therapy’s role in the educational model serving children
with and without disabilities is presented, followed by a discussion of
emerging roles in school mental health.  The occupational therapy assistant may contribute to the screening
OCCUPATIONAL THERAPY SERVICES FOR
CHILDREN AND YOUTH IN SCHOOLS
The Educational Model and Occupational Therapy
The provision of occupational therapy services in the schools is guided
by the educational model, versus a more traditional clinical model.
In the educational model all goals, related services, and supports are
focused on the child’s participation, performance, and function in the
student role. The student’s primary objective is to obtain an education.
Education has been identified by the American Occupational Therapy
Association (AOTA) as one of the key performance areas; it refers to
the “activities needed for learning and participating in the educational
environment” (American Occupational Therapy Association, 2014, p.
S20) The occupation of education includes academic (e.g., math, read-
ing, writing), nonacademic (e.g., sports, band, cheerleading, club), and
prevocational and vocational activities. Consequently, in addressing a
student’s education, attention to a broad range of occupational perfor-
mance areas, including play, leisure, social participation, activities of
daily living (ADL), and work, is necessary to help children succeed in
their student role.
Occupational therapy services must be educationally, developmen-
tally, or functionally relevant and contribute to the development or
improvement of the child’s academic and functional school perfor-
mance. The regulations of IDEA define occupational therapy broadly
as “(A) improving, developing or restoring functions impaired or lost
through illness, injury or deprivation, (B) improving ability to perform
tasks for independent functioning when functions are impaired or
lost, and (C) preventing, through early intervention, initial or further
631
impairment or loss of function” (§ 300.34(c)(6)). Occupational ther-
apy services can promote self-help skills (e.g., eating, dressing), posi-
tioning (e.g., sitting appropriately in class), sensorimotor processing,
fine motor performance, psychosocial function, and life skills training
(Jackson, 2007).
Student role performance is characterized by participating
in educational and extracurricular activities, self-management
of behavior and chronic conditions, and learning. Learning, or
academic performance, is a complex multifactorial process that
involves demonstrating knowledge, paying attention to instruction,
accessing the learning environment and educational materials, and
working collaboratively with peers. Poor academic performance
has been associated with increased risk of dropping out of school
and poor postsecondary outcomes; as such, occupational therapists
often attend to client factors, such as executive functioning, that
underlie academic performance (Mann et al., 2015). Addressing
client factors or isolated skills, such as those related to self-man-
agement, in the schools is feasible provided that such intervention
is aligned with participation and performance in the student role.
The case examples included on the Evolve website illustrate how
addressing client factors and skills can support participation and
performance in the student role. 
Occupational Therapists and Occupational Therapy
Assistant Collaboration
Services must be provided by a qualified occupational therapist
or service provider under the direction or supervision of a quali-
fied occupational therapist. Occupational therapists and certified
occupational therapy assistants may collaborate to provide services
under the educational model. The occupational therapist is respon-
sible for providing supervision to the occupational therapy assistant
and overseeing all aspects of the services provided (Jackson, 2007).
or evaluation process (e.g., completion of standardized assessment
tools and observations), assist in the development of goals and inter-
vention plans, provide direct intervention, monitor progress, and
document services (Jackson, 2007). The actual services provided by
occupational therapy assistants in school settings may vary based on
state licensure. 
Shifts in Occupational Therapy Service Provision
The reauthorization of IDEA in 1997 ended a long period during which
special education and general education were viewed as separate pro-
grams serving separate populations (Spencer et al., 2006). IDEA 1997
placed greater emphasis on the inclusion of students with disabilities in
general education by embedding special education and related services
in the classroom and extracurricular activities when possible. General
and special education practices have been further aligned as a result of
IDEA 2004 and ESSA, providing school personnel, including occupa-
tional therapists, with increasing opportunities to expand their role in
schools, particularly in the area of health promotion and prevention.
In addition, because of IDEA reauthorizations, school-based practice
has advanced to include two new groups of students more fully: (1)
those in general education without disabilities and (2) those with dis-
abilities who are older than 18 years and receiving transition services.
The shift in occupational therapy services can be attributed, in
part, to the ESSA’s emphasis on providing schoolwide systems of sup-
port and the adoption of multitiered models of service delivery (Fig.
24.2). Prior to the adoption of multitiered models of services delivery,
children experienced frustration and failure before becoming eligible
for special education and related services (Cahill, 2007). In contrast,
multitiered models of support are proactive, rather than reactive, use
632 SECTION V  Pediatric Occupational Therapy Services
Special
Education
IDEA
(~15%) (~5% of students)
General Education
Two-tiered model of education
reflected in IDEA from 1975 to 2004
Fig. 24.2  Tiered model of education.
Fig. 24.3  Occupational therapist providing tiered academic supports.
evidence-based interventions, and meet the needs of all students by
providing early identification and intervening services (Fig. 24.3 shows
an occupational therapist providing tiered academic supports to a
small group of students).
The following sections describe the process that occupational ther-
apists follow in general and special education.  dent’s progress. This team also determines when a student changes
Occupational Therapy Process in General Education
Since the passage of IDEA 2004, occupational therapists can provide
comprehensive early intervening services (EIS) to children in general
education. Comprehensive EIS are designed to help students in gen-
eral education who are not eligible for special education or found to
have an educational disability but who need additional academic and
behavioral support to succeed in school (34 CFR § 300.226). Schools
can spend up to 15% of special education funds for EIS, including
Tier 3
Intensive,
individual
intervention Tier 2
Targeted
Interventions
(~15% of students)
Tier 1
Early Identification
Screening
Prevention
(~80% of students)
Multitiered model of education
reflected in IDEA 2004, RtI, and PBIS
“scientifically based academic instruction and behavioral interven-
tions, including scientifically based literacy instruction, and, where
appropriate, instruction on the use of adaptive and instructional soft-
ware; and providing educational and behavioral evaluations, services,
and supports” (34 CFR § 300.224). In cases in which the school dis-
trict has a disproportionate number of minority students in special
education, the school district is required to spend 15% of their funds
on EIS (Individuals With Disabilities Education Act IDEA 2004 Final
Regulations § 300.34, 2006). Related services are specifically included
in IDEA 2004 (§ 300.208) as possible EIS. In addition, under ESSA,
occupational therapists may function as specialized instructional sup-
port personnel and participate in schoolwide systems of support.
One way in which school districts provide EIS is through the
Response to Intervention (RTI) process. RTI is the process of using
progress monitoring data to make decisions regarding the level of sup-
port or services a student needs to be successful with certain academic
tasks (National Association of State Directors of Special Education
[NASDSE], 2006; RTI Action Network, 2014). Many school districts
have incorporated RTI into Multi-Tiered Systems of Support (MTSS).
The overall purpose of MTSS is one of prevention and early interven-
tion: to identify and address student problems early to reduce the need
for more intensive services later. Typical practices underpinning MTSS
include the following: (1) high-quality general education instruction
based on scientific evidence; (2) continuous progress monitoring of
student performance; (3) universal screening of academics and behav-
ior; and (4) the use of multiple tiers of instruction that are progres-
sively more intense, based on the student’s response to intervention
(Jimerson et al., 2015). Many states and local districts that use MTSS
use RTI frameworks (Jimerson et al., 2015), and some have adopted
problem-solving teams to analyze and interpret progress-monitoring
data and make decisions about when specific students would benefit
from more intensive instruction (Cahill, 2007). Problem-solving teams
typically attempt to identify the reason for the student’s difficulty and
develop an intervention plan for systematically monitoring the stu-
tiers to receive more intensive services. This may happen if the student
is not demonstrating progress with the intervention, backsliding, or
if the gap between the student and the peer group continues to grow.
Box 24.3 depicts a common process that is used by many school-based,
problem-solving teams. Most MTSS models are made up of three
levels: tier 1 (universal or core instruction), tier 2 (targeted interven-
tion), and tier 3 (intensive intervention). In a three-tiered model, the
first tier provides school- or classroom-wide interventions made up
of high-quality instructional, behavioral, and social supports for all
 CHAPTER 24  School-Based Occupational Therapy
BOX 24.3  Response to Intervention
Process
1. Identify and define the problem (i.e., the discrepancy between the target
student and his or her peers).
2. Analyze the problem to hypothesize causes that are related to the discrep-
ancy.
3. Establish a student-centered performance goal.
4. Establish an intervention plan and system for monitoring progress.
5. Implement plan and monitor progress.
6. Evaluate progress using performance data.
From Illinois State Board of Education. (2008). The Illinois State
Response to Intervention (RTI) Plan, January 1, 2008. Retrieved from
https://www.isbe.net/Documents/rti_state_plan.pdf.
students. Whole-class screening is used to assess whether academic and
behavioral performance is appropriate for the student’s age and grade.
Some examples of evidence-based tier 1 interventions could include
the implementation of a handwriting curriculum, whole-class instruc-
tion in the use of specific literacy strategies, and a schoolwide charac-
ter development programs (Cahill, 2007). For the group of struggling
students, tier 2–targeted interventions may be developed by the prob-
lem-solving team, sometimes referred to as the student support team
(SST), to address specific needs. Interventions and supports at this level
may include small group interventions or more intensive instruction
such as tutoring (Cahill, 2007). Some examples of tier 2 interventions
include working with a small group of students to use multisensory
strategies for learning spelling words (Golden & McCracken, 2016),
address immature handwriting for a finite period (Zylstra & Pfeiffer,
2016), or incorporate yoga activities into daily routines to support
attention and self-regulation (Villeneuve & Shulha, 2012).
MTSS provides occupational therapists in school-based practice
with a unique opportunity to fully integrate their services, meet the
needs of all students, and educate teachers and other providers about
the full scope of their practice (Truong & Hodgetts, 2017). However,
some schools and districts have not yet included occupational therapy
practitioners and other specialized instructional support personnel
in MTSS. Further, state licensure laws determine the extent to which
occupational therapists may participate at each level of MTSS and
some districts may be extremely cautious in their interpretation of the
licensure laws. One reason for this is that tier 2 and tier 3 services par-
allel the types of services that occupational therapists have traditionally
provided in the schools because the focus is often on providing direct
intervention or consultation to meet the needs of individual students
or small groups. Tier 1 services, however, provide an opportunity for
occupational therapists to effect change at the systemic level (Box
24.4). Many occupational therapists engage in tier 1 activities, such
as providing in-services to teachers and other building staff, without
knowing that they fall under the MTSS umbrella.
Some schools and districts view MTSS as separate from special
education services. Other schools and districts may use the progress
monitoring data associated with MTSS to determine whether a student
would benefit from special education supports and services. The use of
progress monitoring data from MTSS does not limit a parent’s right to
request an evaluation for special education services.  for physical education, managing toileting at school), and difficulty
Occupational Therapy Process in Special Education
Despite recent trends in education and federal policy, occupational
therapists in school-based practice continue to spend a great deal of
time providing services to students with special needs. In collaboration
with other members of the education team, occupational therapists
633
BOX 24.4  Examples of Occupational
Therapy Tier 1 Supports
Recommend an evidence-based handwriting curriculum to be adopted by the
school district.
Identify universal screening methods for handwriting, social-emotional skills,
and presence of subjective-well-being.
Recommend changes to the physical environment to promote the access and
success of all students.
Provide professional development training to teachers on how to address the
sensory needs of their students to optimize learning and participation.
Adapted from Mallioux, Z. et al. (2007). Goal attainment scaling as a
measure of meaningful outcomes for children with sensory integration;
disorders. American Journal of Occupational Therapy, 61, 254–259;
and McLaren, C., & Rodger, S. (2003). Goal attainment scaling: Clinical
implications for paediatric occupational therapy practice. Australian
Occupational Therapy Journal, 50, 216–224.
contribute to the referral, evaluation, intervention, and outcome pro-
cesses. With these important outcomes in mind, a key question guid-
ing the special education process should be the following: “What does
the child need or want to do to be successful as a student now and to
prepare for future roles?” (Mallioux et al., 2007). The special education
process is depicted in Fig. 24.4. This section describes the occupational
therapy processes of referral, evaluation, and intervention.
Referral.  Each school district or LEA has a Child Find system that
locates, identifies, and evaluates all children who have disabilities
and need special education. A referral of a child suspected as having
a disability may be made by any source, including parents, teachers,
or other individuals. An occupational therapy evaluation may be
requested at the time of initial referral if the team perceives that infor-
mation provided by an occupational therapist will contribute to the
evaluation process. This suggests how critical it is for school admin-
istrators and other team members to have an accurate understanding
of the domain and scope of occupational therapy practice—that occu-
pational therapists address the education, ADLs, play, leisure, work,
and social participation areas of function related to the student’s aca-
demic and nonacademic expectations. If team members have a nar-
row understanding of the scope of occupational therapy practice (e.g.,
occupational therapists only address handwriting issues and provide
sensory strategies), then it is likely that the role of occupational ther-
apy in that setting will also be narrow (Casillas, 2010). Efforts spent
in informing principals, teachers, school psychologists, social workers,
and other personnel about the role of occupational therapy in special
and general education ensure that students who may benefit from
occupational therapy services are identified. Some schools and districts
use screening forms to identify students that may benefit from occu-
pational therapy services. Often such screening forms are developed at
the local level and include common concerns that are addressed by the
occupational therapy practitioners in the district. Examples of items
that could be included on a screening form include: difficulty with
following classroom directions or routines, difficulty with organizing
materials, difficulty with written communication, difficulty with social
participation, difficulty with school-related self-care (e.g., changing
with self-regulation. In other cases, a parent or a teacher may make a
referral. 
Evaluation.  “Evaluation means procedures used in accordance with
§§ 300.304-300.311 to determine whether a child has a disability and
the nature and extent of the special education and related services that
634 SECTION V  Pediatric Occupational Therapy Services
Early Intervening Services for Students Pre-K through Grade 12
Screening or Child Find efforts identify students who may
require interventions and supports within general education.
Progress monitoring determines whether adequate progress is
made or whether a referral for an evaluation to determine the
need for special education is necessary.
Referral
Child Find activities are conducted in order for the state to identify,
locate, and evaluate all children who may need special education
and related services. A referral may be made by any source
including parents, school staff, or other individuals. Findings of early
intervening services are reviewed as a part of the referral process.
Evaluation
The child is evaluated in all areas related to the suspected disability.
Results will be used to determine the child’s eligibility for special
education and related services.
Eligibility
Based on evaluation results, a group of qualified professionals and
the parents decide if the child is a “child with a disability” according
to IDEA and eligible for special education and related services.
IEP
Within 30 days after a child is determined eligible for special
education and related services, an IEP team (including the
parents and students when appropriate) must develop an IEP.
The child receives sevices as soon as possible following parental
consent of the IEP.
Services
The school ensures that the child’s IEP is being implemented as
written. Teachers and service providers are responsible for carrying
out his or her specific responsibilities as outlined on the IEP
including accommodations, modifications, and supports.
Annual Review/Re-Evaluation
The IEP is reviewed by the IEP team at least once a year, or more
often if the parents or school requests a review. At least every three
years the child must be reevaluated to determine if the child
continues to be a “child with a disability” as defined by IDEA and
what the child’s educational needs are.
Fig. 24.4 Special education process. Adapted from Office of Special
Education and Rehabilitative Services, U.S. Department of Educa-
tion. [2000]. a guide to the individualized education program, pp. 5–7.
Retrieved from http://www2.ed.gov/parents/needs/speced/iepguide/iep
guide.pdf.
the child needs” (§ 300.15). After obtaining parental consent, an eval-
uation is completed by a multidisciplinary team to determine whether
the child is eligible for special education, and, if so, it identifies edu-
cational and related service needs (§ 300.301). This multidisciplinary
evaluation is needed even when the child has a known disability (e.g.,
cerebral palsy, Down syndrome) and has received therapeutic services
in the past (e.g., in an early intervention program).
IDEA and the Occupational Therapy Practice Framework (OTPF)
define evaluation and assessment consistently (American Occupational
Therapy Association, 2014). Evaluation refers to the process of gath-
ering and interpreting information about the student’s strengths and
educational needs. Assessment refers to the tests or measures used to
obtain data about specific areas of function. IDEA specifies that school
personnel evaluate referred or eligible students in all areas of suspected
disability. Furthermore, a variety of assessment tools (see Appendix A
in this text) or evaluation strategies must be used to obtain relevant
academic, functional, and developmental information about the stu-
dent (§ 300.304(b)(1)). The evaluation must be completed within 60
days of initial parent consent, unless the state specifies otherwise.
Evaluation strategies.  “Occupation-based evaluation approaches
help the IEP team make decisions about the student’s ability to
participate and perform in the school setting and identify the ways
that the disability affects the student’s participation in school activities
and routines” (Polichino, 2001, p. 35). The occupational therapy
evaluation focuses on strengths and weaknesses in educationally
relevant occupational performance areas (e.g., education, social
participation, ADLs, play, leisure, work) related to the student’s
suspected disability (Table 24.1). Obtaining an occupational profile
initiates the evaluation process by exploring the student’s educational
history, interests, values, and needs. The student may be interviewed
using questions such as the following:
• What do you like about school?
• What kinds of things are going well for you?
• What are some of your challenges?
• What would you like to see changed?
The occupational therapist can also observe the student during typ-
ical classroom instruction, as well as during nonacademic time (e.g.,
during lunchtime and recess). (Fig. 24.5 shows an occupational therapist
observing a student in the hallway.) Such observations assist the occu-
pational therapist in understanding the child’s interests and preferences.
Observations help the occupational therapist gain important informa-
tion about the child’s social participation, as well as his or her habits and
routines. The occupational therapist might also interview the teacher
about classroom expectations for the student. The parents are also asked
to identify their priorities for the child. Information obtained from the
occupational profile assists the occupational therapist in developing ini-
tial impressions about the student’s difficulties, which may be useful
in directing the rest of the evaluation process. The AOTA offers a free
downloadable template that can be used to construct an occupational
profile (https://www.aota.org/∼/media/Corporate/Files/Practice/Man-
age/Documentation/AOTA-Occupational-Profile-Template.pdf)
In addition to observations and interviews, other useful evaluation
strategies include document or chart review to obtain background
information and construct an educational history. The evaluation pro-
cess involves an examination of the dynamic relationship among the
student’s participation and performance skills, educational context,
and specific educational and activity demands that may be contribut-
ing to the problems (Swinth et al., 2003). Refer to Appendix A of this
textbook for a list of assessment tools that are commonly used by occu-
pational therapists in public schools. For example, to understand fully
a student’s difficulty with written communication during test taking,
the occupational therapist may observe the student while taking a test,
compare work with that of peers in the same environment, and explore
curricular demands with the teacher.
Evaluation of the school environment includes the classrooms,
cafeteria, playgrounds, restrooms, gymnasium, and other spaces. For
children using wheelchairs or walkers, the focus of this part of the
assessment may be accessibility. For children with sensory processing
problems, the focus may be the degree and types of sensory stimulation
in the environment. Classrooms tend to be highly stimulating environ-
ments, and they can be disorganizing and overwhelming to students
 CHAPTER 24  School-Based Occupational Therapy 635

TABLE 24.1  School-Related Occupational Performance Addressed During Evaluation and

Intervention
Examples of Participation in
School-Related Occupational
Occupational Area Performance
Education Access to and participation in classroom
curriculum
Organizational skills
Attending to instruction
Fine motor skills and hand function
Written communication and handwriting
Social participation Successful interaction with teachers, other
school personnel, and peers
Ability to adapt to environmental demands
Play and leisure Plays with peers during recess
Participates successfully in class games
Develops structured extracurricular interests administration to ensure recess is play-based;
(e.g., sports, art, dance)
Work Prevocational
Activities of daily living Dressing (putting on and taking off coat,
(basic and instrumental) dressing for gym)
Eating lunch and/or snack
Toileting (bowel and bladder management)
Basic hygiene and grooming
Using communication devices
Self-management of chronic conditions
(e.g., diabetes, asthma)
Meal preparation in class
Using computers
Shopping
Doing laundry
Adapted from Swinth, Y., Chandler, B., Hanft, B., Jackson, L., & Shepherd, J. (2003). Personnel issues in school-based occupational therapy: Supply
and demand, preparation, certification and licensure (COPSSE document no. IB-1). Gainesville, FL: University of Florida, Center on Personnel
Studies in Special Education; and Kentucky Department of Education. (2006). Resource manual for educationally related occupational therapy and
physical therapy in Kentucky public schools. Frankfort, KY: Kentucky Department of Education.
Examples of Occupational Therapy
Intervention School-Related Outcomes
Assist with adapting assignments with high or Achieves in the learning environ-
low technology; adapt child’s positioning so ment, including academic (e.g.,
child can perform handwriting as effectively as reading, math), nonacademic (e.g.,
possible recess, lunch, relationships with
Help manage books and notebooks, desk, home- peers), prevocational, and voca-
work assignments, and backpack tional activities (e.g., professional
Enable child to use self-regulatory activities to and technical education)
foster attending; provide strategies to enhance
work completion
Provide classroom materials and activities to pro-
mote fine motor skills development and in-hand
manipulation skills
Consult with curriculum committee in selection
of a handwriting curriculum; direct services
in groups or individually to assist students
in letter formation; provide modifications to
complete written communication including use
of technology
Foster appropriate interaction with peers during Develops appropriate social
group interventions; attend to social interaction relationships at school with peers,
during lunch and recess, foster development teachers, and other school person-
of friends nel in classroom, extracurricular
Provide strategies for coping with test anxiety; activities, and preparation for work
adapt procedures to reduce stressful school
expectations
Assist in making play environments (e.g., Identifies and engages in age-appro-
playground) accessible; consult with school priate toys, games, and play activ-
ities; participates in meaningful
assist students in exploring leisure interests; selection of art, music, sports, and
consult with parents to promote structured afteschool activities; identifies and
leisure participation during after-school time; approaches peers during recess
leisure coaching
Advocate for embedding productive occupations Develops interests, habits, and work
into the school day (e.g., putting supplies away, skills needed to work or volunteer
cleaning work spaces); involve students with in the community after graduation
disabilities in work activities within the school from school
environment (e.g., wiping down lunch tables);
develop group programs to foster work skills
Provide direct intervention using a chaining Attends to basic self-care needs
approach to teach dressing or self-feeding in school (e.g., eating, toileting,
Teach appropriate transferring strategies for managing shoes and coats); uses
wheelchair to toilet public transportation to travel
Modify routines to include self-management care in community; develops health
tasks management routines; develops
Provide group activities to promote participation home management routines to
in independent living skills, such as shopping, the maximum extent possible
cooking, and clean up (e.g., cleaning, shopping, meal
preparation, safety and emergency
responses, budgeting)
636 SECTION V  Pediatric Occupational Therapy Services

TABLE 24.2  Process Depicting the

Development of the Individualized Education
Program
Step Description
Vision of Child’s Needs
1. Determine present levels Interpretation of the full and individual
of academic achievement evaluation (FIE)
and functional perfor- Consideration of how disability influences
mance access to and participation in academic and
2. Describe how the stu- functional activities
dent’s disability Identification of the student’s strengths and needs
affects participation in Discussion of parent, student, and team
general education member priorities for the child
Measurable Goals
Develop measurable and One-year goals
attainable annual goals All team members contribute to goal devel-
(academic and functional) opment
Goals may be linked to state curriculum
content standards
Plan for measuring progress toward annual goals
Related services goals must be “education-
ally relevant”
For children with disabilities who take
Fig. 24.5  Occupational therapist observing student in the hallway
alternate assessments aligned to alternate
achievement standards, a description of
with sensory processing problems. For children with social and emo- benchmarks or short-term objectives is given
tional needs, the focus may be on the student’s volition to participate at Special Education and
school, aspects of the social environment and classroom routines. Related Services
To analyze educational and/or activity demands, the expected Determine the special Represents services student needs to accom-
performance (as defined by the teacher and curriculum) must be education, related services, plish IEP goals
understood fully. When a teacher expects neat, precisely aligned, and supplemental aids and Team determines all needed services
well-formed handwriting, a student with poor handwriting will have services, modifications, and Services meet academic, functional, and
a significant problem in meeting that teacher’s standard. As another supports extracurricular needs
example, some teachers show high tolerance for disruptive behavior Services based on peer-reviewed research to
and allow students to move freely about the room. A student with a as much as practicable
high activity level and sensory-seeking behaviors would have greater Projected dates for initiating services; antic-
success in a classroom in which movement was allowed, rather than ipated frequency, location, and duration of
one in which students are expected to remain in their seats. Often a services
student’s goals and services are based more on the discrepancy between
Statement of Accom-
the student’s performance and classroom teacher’s expectations than
modations
on performance delays as determined by norms that reference the stu-
Needed to measure academic Statement of why child cannot participate
dent’s age. In addition, occupational therapists need to consider the
achievement and functional in the regular assessment and why the
CCS and their state’s specific learning and achievement standards,
performance on state and particular alternate assessment selected is
which are accessible from the state’s department of education website. 
districtwide assessments appropriate for the child
Individualized Education Program.  The IEP represents the formal Placement in Least Restric- Educate students with disabilities with their
planning process and resulting legal document that establish the ser- tive Environment nondisabled peers to the maximum extent
vices and programs that will enable the student to participate in school appropriate.
activities and receive an “appropriate education.” Refer to Table 24.2 Consider general education environment first
for a review of the IEP process. According to IDEA (34 C.F.R. §§ Placement determined annually
300.320-300.324), the IEP is a written statement for each child with a Must offer a range of service delivery options
disability that outlines the student’s educational and functional needs
Transition Plan
and the supports and services required to meet those needs. It is devel-
oped, reviewed, and revised in a meeting in accordance with the guide- Based on age-appropriate Beginning at 16 years of age
lines of the IDEA. transition assessments Identifies transition services needed to assist
The IEP team comprises at minimum the child’s parents; one reg- related to training, edu- the child in reaching goals that may include
ular education teacher; one special education teacher; a representative cation, employment, and vocational training, supported employment,
of the public agency who is authorized to make decisions on behalf of independent living skills independent living, work experience, com-
the agency; an individual who can interpret the instructional impli- munity participation, or planning appropriate
cations of the evaluation results (perhaps one of the other members); high school classes in preparation for college
 CHAPTER 24  School-Based Occupational Therapy 637

other individuals who have knowledge or special expertise regarding TABLE 24.3  Levels of Performance and
the child (e.g., related services personnel), as appropriate; and the child
Educational Need
with a disability, when appropriate (34 C.F.R. § 300.321(a) and (b)
(1)). Although related services personnel are generally considered “dis- Performance Level Educational Need
cretionary” team members (§ 300.321(a)(6)), if an occupational thera- Forms all letters correctly in isolation Increase speed and spacing so written
pist is formally identified as a member of a IEP team or if occupational words and sentences are legible
therapy is being discussed at the meeting, it is fitting and desirable that
the occupational therapist attend the meeting (Jackson, 2007). Highly sensitive to unexpected Strategies and supports to tolerate
Occupational therapy evaluation data provides the IEP team with touch; will push other children being close to peers; accommoda-
“information related to enabling the child to be involved in and prog- when in line or moving through tions to leave class early to avoid
ress in the general education curriculum, or for preschool children, to the hallways crowded hallways
participate in appropriate activities” (§ 614(b)(2)(A)(ii)). If the team Eyes remain fixed when reading Accommodations and instruction
determines that a child is eligible for special education, the IEP process to read text without skipping or
begins; the IEP team meets to develop a special education plan and to rereading words
determine if related services are necessary. The determination of need Desk and workspace cluttered; Learning to use an organizational
for occupational therapy services should not be based on evaluation unable to locate assignments system
data alone but should be driven by the student’s educational program and homework
and annual goals. Since occupational therapy is considered a related
service, the IEP team determines whether or not occupational therapy Enjoys recess but tires after 5 Frequent rest breaks and strategies
services should be provided to a student based on the student’s educa- minutes on the playground to understand and communicate
tional needs and the occupational therapist’s recommendation. fatigue to teaching staff
Collaborative planning. The development of IEPs can be a Has adequate skills for hands-on Awareness and training for increased
daunting task because of the changing legal requirements with each prevocational work experiences; independence and carryover in self-
reauthorization of IDEA and the changing face of each IEP team. personal hygiene not sufficient care areas
Occupational therapists need to develop the skills to work effectively for work settings
with a multitude of parents and professionals. Although IEP teams Sits alone at lunchtime Friendship promotion strategies; social
have characteristics that make them similar to other types of working skills training
teams, there are also characteristics unique to IEP teams that need to
be considered by the various members. It has been suggested that IEP Adapted from Knippenberg, C., & Hanft, B. (2004). The key to edu-
teams differ from other teams in the following ways: (Jackson, 2007) cational relevance: Occupation throughout the school day. School
1. There is a legal framework of required relationships among part- System Special Interest Section Quarterly, 11(4), 1–4.
ners. Federal, state, and local laws and policies spell out in some
detail who must participate and what they must do. This is espe- minimum, a plan for measuring progress must be documented, spec-
cially true for the school district, which has many legal responsibil- ifying how the child is meeting IEP goals and when periodic progress
ities regarding the education of students with disabilities. reports will be provided (e.g., using quarterly reports concurrent with
2. The team members share responsibility and accountability for the the issuance of report cards; 34 C.F.R. § 300.320(a)(2)). It should be
success of the student in meeting his or her goals. noted that the frequency of reporting progress must be at least as often
The process is “results-oriented,” meaning that what matters is not as the progress reports received by the parents of nondisabled students,
how happy everyone is with the process, but the success of the student’s often on a quarterly basis. Occupational therapists are responsible for
educational program. The collaborative planning procedure that guides measuring progress toward annual goals and objectives when they are
the process of developing an IEP involves many components that are one of the services listed to support that student’s goal. Often, several
mandated as general requirements by IDEA (34 C.F.R. § 300.320(a)). members of the IEP team share data keeping for a student’s progress
The first steps involve interpretation of the child’s most recent eval- toward general education goals. 
uation, consideration of the child’s performance on any general state or Goals in the educational model.  Goal writing is a collaborative
districtwide assessments, and identification of the student’s strengths process completed at the IEP meeting with the input of all team
and needs through discussion with the parents, the student, and edu- members, including the parents and, in some cases, the student.
cational team members. This information is documented on the IEP Goal writing in many districts is facilitated by online programs (e.g.,
as the present levels of academic achievement and functional perfor- EmbraceIEP https://www.embraceeducation.com/iep-software/ and
mance and includes a description of how the student’s disability affects TeachIEP http://wvde.state.wv.us/teachiep/) that allows the IEP to
participation in general education. Table 24.3 provides examples of be developed on a shared website. Some of these online programs
educationally relevant levels of performance and statements of need. include drop-down menus that provide examples for target behaviors,
The next step involves the development of measurable annual goals conditions, criteria, and time frames. Although such programs have
designed to enable the student to participate and make progress in the the potential to save time, many occupational therapists feel limited
general education curriculum (34 C.F.R. § 300.320(a)(2)(i)(B)). The by the selections offered in the drop-down menus. Fortunately, many
goals are statements of measurable and attainable behaviors that a stu- of the IEP programs provide the option to override the drop-down
dent is expected to demonstrate within 1 year. Many states are linking menus and type in an original goal.
goals to the CCS or their state curriculum content standards (Holbrook, All team members must be knowledgeable about the classroom
2007). This ensures that the goals are related directly to the learning curriculum, behavioral expectations, and state educational standards.
objectives mandated by the SEA for all students. IDEA 2004 eliminated Goals and target behaviors need to address academic achievement and
the requirement of writing short-term objectives (benchmarks) in the functional performance, such as participating in physical education,
IEP, except for children with disabilities who take alternate assessments writing an essay, eating lunch independently, playing with friends
aligned to alternate achievement standards (§ 300.320(a)(2)(ii)). At a during recess, and participating in afterschool clubs (Knippenberg &
638 SECTION V  Pediatric Occupational Therapy Services
Hanft, 2004). Although occupational therapists may identify limita-
tions in discrete performance skills that negatively affect school par-
ticipation, such separate clinical goals should not be suggested to the
IEP team. For example, an IEP team may identify that a second-grade
student is not making progress towards achieving some Common Core
Math Standards. The occupational therapist may have previously iden-
tified that the student’s visual perceptual and visual motor skills are
negatively impacting school performance. The IEP team may agree to
write an annual goal for the student aligned with the CCS 2.MD.C.7
that states that students will “tell and write time from analog and digi-
tal clocks to the nearest five minutes, using a.m. and p.m.” (http://www
.corestandards.org/Math/Content/2/MD/). The team may develop
benchmarks that lead to the annual goal. The annual goal may be
stated as:
• The student will tell and write time from analog clocks to the near-
est 5 minutes (time frame: within 1 year or by the end of the fourth
quarter; conditions: wrist watch, wall clock, analog clock drawing
on worksheet; criteria: 100% on 10 question quiz).
Some benchmarks may include:
• The student will tell and write time from an analog clock to the
nearest hour (time frame: by the end of the first quarter; condi-
tions: wrist watch, wall clock, analog clock drawing on worksheet;
criteria: 100% on 10 question quiz).
• The student will tell and write time from an analog clock to the
nearest half hour (time frame: by the end of the second quarter;
conditions: wrist watch, wall clock, analog clock drawing on work-
sheet; criteria: 100% on 10 question quiz).
• The student will tell and write time from an analog clock to the
nearest quarter hour (time frame: by the end of the third quarter;
conditions: wrist watch, wall clock, analog clock drawing on work-
sheet; criteria: 100% on 10 question quiz).
In some cases, the occupational therapist may think that a skill is a
priority for a child. However, when viewing the whole child, the team
may not agree. If this is the case, some negotiation among IEP team
members may be needed to select priorities for the child so that appro-
priate goals and objectives can be developed for the student. A descrip-
tion of how to develop goals is provided in Chapter 8 and additional
materials are located on the Evolve site.  age 16, a statement of interagency responsibility to support his or her
Program plan. Once the IEP goals have been developed, the
team determines the special education, related services, supplemental
aids and services, modifications, and supports to be provided by the
school. These pertain to the student’s advancement toward the annual
goals, access to the general education curriculum, and participation in
nonacademic and extracurricular activities across school environments.
The IEP team determines if related services are “required to assist a
child with a disability to benefit from special education” (34 C.F.R. §
300.34(a)).
If the occupational therapist is to provide services to the student, it
must be noted specifically in the IEP along with the projected date for
initiating services and anticipated frequency, location, and duration
of these services. Documentation of the type of occupational therapy
service delivery should ensure that a range of service approaches be
available to the student: direct (to the child) and indirect (on behalf of
the child) services. Based on the individualized needs of the student,
direct intervention may be necessary for 1 week, whereas indirect con-
sultation provided to the teacher on the student’s behalf may be useful
during the next week. In addition, flexibility in documenting time and
frequency is also recommended (e.g., 2 hours/month or 1 hour/grad-
ing period), rather than specifying set weekly visits. Recommendations
for duration of services, generally written as beginning and ending
dates, and location of services (e.g., cafeteria, classroom, playground,
hallway) must also be specified.
Once the IEP team has determined what the child needs in terms of
special education services, the team can determine where the services
should be provided. Placement decisions are made annually based on
where the IEP team has determined that the student’s IEP goals can
be met (Yell & Katsiyannis, 2004). In accordance with LRE as defined
in the IDEA, children with disabilities are required to be educated with
their nondisabled peers to the maximum extent appropriate (34 C.F.R. §
300.114(A)(2)(i)). This means instruction must be available in a contin-
uum of placement options, ranging from regular education classrooms to
specialized classrooms, residential facilities, and home-based programs.
Removal to separate classes is permissible only “if the nature or severity of
the disability is such that education in regular classes with the use of sup-
plementary aids and services cannot be achieved satisfactorily” (34 C.F.R.
§ 300.114(A(2)(ii)). Based on student’s IEP goals, the team should con-
sider whether supplementary aids and services provided within a general
education classroom would allow the student to receive an appropriate
education or whether such a placement would impede her or his learning
and/or the learning of other students. If a child will not be participating
fully with children without disabilities in a regular classroom in nonaca-
demic and extracurricular activities, the team must write an explanation
on the IEP as to why the child will not participate in these activities. 
Transition planning.  Finally, once the child turns 16 years old, or
before that if determined appropriate by the IEP team, the IEP must
include a written transition plan. It is recommended that students
as young as age 14 participate in transition activities, even if they
do not yet have a formal transition plan. Transition is the process
of beginning to plan for the student’s completion of education and
postgraduation life. This plan is based on age-appropriate transition
assessments related to training, education, employment, and, when
appropriate, independent living skills. The transition plan should
include a statement of the services needed and should clearly connect
the student’s goals for afterschool life and a planned course of
studies in high school. The transition services (including courses of
study) needed to assist the child in reaching those goals may include
vocational training, supported employment, independent living, work
experience, community participation, and planning appropriate high
school classes in preparation for college. When the student reaches
transition is also included in the IEP. Find more information about
transition services and transition planning in Chapter 25.
The literature suggests that occupational therapists are not fully
participating in the development of transition plans, despite their
capability to do so (Mankey, 2012). One reason for this may be because
the beliefs of the educational staff regarding the scope of occupational
therapists and their potential contributions to transition planning
(Mankey, 2011). Although educators may be knowledgeable regard-
ing the scope of occupational therapy (Mankey, 2011), occupational
therapists would benefit from educating administrators and members
of their local school board about the potential contributions that they
could make in this regard. Occupational therapists may be involved
in transition planning by completing assessments to target the stu-
dent’s motor and process difficulties and by providing input on the
student’s functional capabilities related to postsecondary education,
vocational planning, and community living (Kardos & White, 2006).
Occupational therapists may be involved in this process by providing
input on the student’s functional capabilities related to vocational
planning and community living. 
Annual Review and Reevaluation.  The student’s IEP must be
reviewed by the IEP team at least once a year or more often if the par-
ents or school personnel request a review. Outcomes are measured
by student achievement of the IEP goals, including participation in
 CHAPTER 24  School-Based Occupational Therapy
state and districtwide assessments (American Occupational Therapy
Association, 2011). The long-term goal is for students with disabilities
to leave high school prepared to work or attend higher education, and
live independently.
Termination of related services may be decided at an annual review
if the team determines that the related service is not necessary for the
student to benefit from his or her IEP. The occupational therapist may
recommend termination when the student has acquired the needed
skills and uses them during school, when needed adaptations and sup-
ports are in place, or when services have failed to produce the targeted
IEP outcomes despite numerous approaches and lengthy attempts
(Polichino, 2007). When making a recommendation to terminate
services, occupational therapists should be prepared to bring data to
support their recommendations. The child must be reevaluated at least
every 3 years to determine if he or she continues to be a “child with a
disability,” as defined by IDEA, and to redefine the child’s educational
needs.  therapists to envision, articulate, and advocate for their role in each
Data-Based Decision Making
Data-based decision making is becoming increasingly important in
school-based practice because of recent trends in education and fed-
eral policy. Occupational therapists providing services in special and
general education need to be familiar with how to monitor a student’s
progress and objectively determine whether their intervention is effec-
tive in supporting a student’s achievement of established outcomes.
Data collected through progress monitoring may be used to justify a
change in the intensity, frequency, or type of service provided (e.g.,
moving from tier 1 services to tier 2 or 3 services or providing spe-
cial education services) (Stecker et al., 2008). Progress monitoring can
also be used to determine whether a specific intervention strategy or
accommodation is effective in supporting the student to meet his or
her IEP goals. See Chapter 9 for information regarding data-based
decision-making.  on multisensory strategies for teaching handwriting and joining a cur-
OCCUPATIONAL THERAPY SERVICES
The nature of occupational therapy practice in schools is complex
because of the considerable variability in service provision, including
the target of services (who), place of delivery (where), types of services
and how these are delivered (what and how), and scheduling of ser-
vices (when). Another factor influencing occupational therapy service
provision is a consideration of the different approaches to interven-
tion: to promote participation and health, prevent disability, restore
function, adapt or modify a task, or maintain function. Traditionally,
occupational therapy’s role in the schools has focused on restoring
function and adapting the task or environment to promote participa-
tion for children with disabilities receiving special education. However,
the reauthorization of IDEA has created new opportunities for occu-
pational therapy to contribute to health promotion and prevention in
all children. Furthermore, the health promoting school (HPS) model
advanced by the World Health Organization (WHO) was developed
to provide an organizing framework for comprehensive health pro-
motion to create school environments that support the physical and
mental health of all students (Jané-Llopis & Barry, 2005). The shift
to include promotion and preventive models of service delivery has
broadened the definition of “clients” for occupational therapists so
that it includes all children and youth in general and special education.
Given the variability of services based on meeting the occupational
performance needs of students in general and special education, occu-
pational therapists must enter school practice aware of this complexity
and the personal and interpersonal skills required to succeed in such
an environment. For example, occupational therapists need good
639
organizational and time management skills to develop and maintain
their work schedules, given the variety of school settings and types of
service needs of their workload. Occupational therapists must be as
effective and efficient as possible in meeting the complex demands of
their jobs. Providing group interventions to children with and without
disabilities or embedded classroom coteaching models, for example,
offer opportunities to serve integrated groups of students with ser-
vices that blend promotion, prevention, and restorative intervention
strategies.
Target of Services: Who Occupational Therapists Serve
General Education Students.  Within general education, occupa-
tional therapists have opportunities to provide services to children and
youth without disabilities and those at risk for developing academic
and/or functional delays. With the growing movement to a multi-
tiered system of service provision, it is important for occupational
tier. For example, occupational therapists should educate student
support teams on how their services can meet the academic, health,
developmental, functional, and behavioral needs of students in general
education (Jackson, 2007). Refer to Box 24.5 for an example of how
occupational therapists can promote a healthy lifestyle and prevent
obesity in schools.
At tier 1 (schoolwide services), occupational therapists can assist
the general education team in helping students access and participate
in the curriculum by paying careful attention to areas of function
within their scope of practice: education, social participation, play and
leisure, ADLs, instrumental activies of daily living (IADLs), and work.
For example, the occupational therapist may participate in univer-
sal screening of handwriting to identify students who are struggling,
depending on whether the state allows screening (Cahill et al., 2014).
This might be followed by providing a teacher in-service presentation
riculum committee to assist in identifying an appropriate handwriting
curriculum. To help foster student attending and positive behavior,
the occupational therapist might join committees or leadership teams
focusing on Positive Behavioral Interventions and Supports (PBIS) or
Social and Emotional Learning (SEL). In doing so, practitioners can
contribute to such schoolwide approaches and have opportunities to
assist educators in implementing programs designed to help students
regulate arousal for attending (e.g., the Alert program) in their class-
rooms (Williams & Shellenberger, 1996). In addition, the occupational
therapist might join a school team working on a student conduct and
behavior management program to become aware of issues in this area
and offer strategies from an occupational therapy perspective.
At tier 2 (targeted interventions for those at risk), the occupational
therapist might offer small group interventions during lunch or recess
for students struggling with behavior management and social interac-
tion with peers. Tier 3 interventions call for more individualized inter-
ventions for those not responding to tier 2 interventions. At this level,
students may receive such services as a part of RTI or may be referred
for special education.
With opportunities to expand occupational therapy’s role in gen-
eral education, occupational therapists might be questioning how they
can create time to provide promotion, prevention, and early interven-
tion services. Traditionally, an occupational therapist’s job expecta-
tions have been based on a caseload model of counting the number of
children receiving direct intervention as part of their IEP without con-
sidering the amount of time needed to meet the student’s needs or ther-
apist’s responsibilities at a schoolwide level (American Occupational
Therapy Association, 2006). This model often neglects to account for
essential indirect services, including collaborative consultation, team
640 SECTION V  Pediatric Occupational Therapy Services
BOX 24.5  Occupational Therapy Services Focusing on Health Promotion and Obesity
Prevention: A School-Based, Healthy Lifestyle Initiative
Program Development
The school-based healthy lifestyle initiative consists of a multitiered program
designed to do the following: (1) promote participation in healthy occupations, (2)
support the development of volition, and (3) establish healthy performance patterns
in children with and at risk for obesity. The need for the program was identified by
related service providers and the school’s principal after they noticed an increasing
number of referrals to occupational therapy and physical therapy because of concerns
related to children’s overweight status. Some examples of the concerns noted by
the school personnel included fatigue and inattention in class, as well as not being
able to perform in physical education. They were increasingly concerned about these
issues because they knew them to be symptoms of significant medical problems that
children with obesity often encounter. Medical problems that are common in this
population include diabetes, sleep apnea, high cholesterol levels, and high blood
pressure; in addition, many children with obesity face social isolation and stigma.
Prior to the introduction of the healthy lifestyle initiative, the school’s principal
had removed the vending machines from the school and required that parents
only send healthy snacks for birthday treats. In addition, a physical therapist
started a weekly open gym to allow students to participate in physical activity
before the school day. Finally, local businesses were made aware of the initia-
tive, and the school accepted donations of pedometers, other equipment, and
incentives for children who participated in the program.
1. The activities included in the first tier of the program included the weekly
open gym, a whole-school fitness walk, and a cook-off–style competition
among the different classrooms. In addition, a bulletin board space was ded-
icated to the initiative, and its content was changed on a weekly or biweekly
basis.
2. The activities included in the second tier included training on how to develop
new health-promoting habits. For example, students at this tier learned how
This program is discussed in further detail in Cahill, S. & Suarez-Balcazar, Y. (2009). Promoting children’s nutrition and fitness in the urban context.
American Journal of Occupational Therapy, 63, 113–116; and Cahill, S., & Suarez-Balcazar, Y. (2012). Using Photovoice to identify factors that influ-
ence children’s health. Internet Journal of Applied Health Sciences and Practice, 10, 1–6.
meetings, and in-service education (Swinth et al., 2003). In contrast,
the concept of workload encompasses all the direct and indirect ser-
vices performed to benefit students, making a workload approach
helpful for conceptualizing work patterns that optimize effectiveness
and impact (American Occupational Therapy Association, 2006).
Occupational therapists must have the flexibility of organizing their
work patterns to serve students in their LRE, collaborate with teach-
ers and other school personnel, attend meetings, supervise and train
occupational therapy assistants, plan interventions, and collect data.
Careful documentation of workload using a time study may help state
regulatory boards become knowledgeable about the range of occupa-
tional therapy services and encourage them to adopt a workload versus
caseload system of documenting service provision.  (in the classroom, during recess), and can take place in a variety
Range of Service Delivery Options: What Occupational
Therapists Provide
Intervention with a variety of clients occurs as a direct result of using
a range of service delivery options. Traditionally, services in schools
were provided directly for the student in an isolated therapy setting,
similar to clinical practice. This type of service delivery involves pri-
marily one client, the student. However, IDEA does not mandate any
one service model and allows for a range of services, including those
provided directly to the student (direct), on behalf of the student
(indirect), and as program supports or modifications for teachers and
other staff working with the child (indirect; § 614(d)(IV)) (Fig. 24.6).
Decisions about how occupational therapy services are provided are
to use and record steps with a pedometer, how to measure and record per-
sonal body mass indexes (BMIs), and how to keep food and activity logs.
3. The activities included in the third tier were designed by occupational therapy
students and guided by the Model of Human Occupation. The activities at
this tier centered around a collection of classroom-based groups focused on
building capacity and increasing students’ self-efficacy for participating in
physical activities. 
Program Evaluation
Although the entire school participated in this initiative, one classroom was selected
to provide qualitative information for the program evaluation. Seventeen fifth-grade
students participated in a picture-taking assignment that was integrated into their
science class. This assignment was developed based on Wang’s Photovoice meth-
odology. Students were given disposable cameras and prompted to take pictures of
things that helped them or did not help them maintain a healthy lifestyle. After the
photographs were developed, students sorted their pictures and participated in two
discussions that followed the typical Photovoice prompts. Students were asked to
reflect on their photographs and answer the following questions:
• What do you see here?
• What is really happening?
• How does it relate to our lives?
• Why does the situation exist?
• What can we do about it?
The students who participated in this assignment were able to identify activ-
ities that promoted a healthy lifestyle and those that did not. In addition, they
set goals about what they wanted to do to change specific unhealthy situations.
This program illustrates one way that occupational therapists can be involved
in promoting healthy lifestyle development in children in the school context.
based on the student’s needs, the educational program (academic and
nonacademic), and expected outcomes (Carrasco et al., 2007; Pape &
Ryba, 2004). Examples of the range of services provided by an occupa-
tional therapist include working individually with students, consult-
ing with the teacher about a student, coleading a small group in the
classroom, providing an in-service education for school personnel,
and working on a curriculum or other school-level leadership team
(Swinth, 2007).
Direct Services.  Direct services may be provided in a variety of
ways, including one to one (occupational therapist works individu-
ally with the student), small groups (lunch bunch), or large groups
of settings within the school (e.g., separate therapy room, special
education resource room, general education classroom, cafeteria,
playground, physical education). Individualized direct services in
isolated settings may be useful during initial evaluation of levels of
performance or during the initial stages of learning a skill. The ben-
efit of providing services in small groups is that interaction within a
group provides students with opportunities to develop and practice
social skills. In addition, in an effort to meet LRE, the occupational
therapist can blend students with and without disabilities in a small
group intervention, targeting those at risk of delays but who are not
eligible for special education. For example, an occupational therapist
might colead groups with a special education teacher, as discussed in
Box 24.6 (Fig. 24.7). 
 CHAPTER 24  School-Based Occupational Therapy
Indirect OT Services on behalf of students
Planning time with school personnel
Educational in-service sessions
Participation in school-wide leadership teams
Consultation with teachers and other school staff, and parents
Advocacy for students with disabilities and families
Planning for innovative services and new programs
Fig. 24.6  Range of occupational therapy service delivery.
BOX 24.6  “Brownie Busters”: An Occupation-Based Work Group for Children With Multiple
Disabilities
Program Development
The Brownie Busters program aims to do the following: (1) provide a communi-
ty-based functional curriculum for students with multiple disabilities attending ele-
mentary school; (2) provide tasks that are meaningful to elementary school students
while teaching them skills needed for future employment and independence in their
homes and neighborhood community; and (3) encourage collaboration among school
team members, including the teacher, teacher’s assistant, occupational therapist,
and parents.
The foundation for the development of the 6-week Brownie Busters work group
was based on literature regarding the development of work skills in children with
multiple disabilities, which indicated the following: (1) preparation for employ-
ment needs to begin at an early age (Kramer et al., 2014); (2) participation in
meaningful activities within an educational or work context reinforces interest
(Kramer et al., 2014; Law et al., 2005); and (3) programs for students with mod-
erate intellectual disabilities should emphasize skills that are functional and
longitudinally relevant. An occupational therapist working in a large Midwestern
municipal school district developed and facilitated the 1.5-hour weekly groups
over a period of 6 weeks. The classroom teacher, teacher’s assistant, and a par-
ent volunteer served as helpers for the groups.
The overall purpose of the Brownie Busters work group was to have the stu-
dents make and sell brownie-making kits to teachers, students, and staff at their
school. The groups were designed to promote the development of several inde-
pendent living and work skills, including the following: planning a work task,
functional reading (reading labels and recipes), safety issues related to walking
in the community, grocery shopping, simple cooking (learning about ingredients
and measuring, pouring, and mixing ingredients), using an oven, sanitary food
handling, and selling a product.  using sanitary strategies for handling of food, and preparing the jars to sell. Findings
Participants
The work group consisted of eight elementary students ages 9 to 12 years with mul-
tiple disabilities, including mild to moderate intellectual impairment and language
Indirect Services Provided on Behalf of the Child or to Provide
Program Supports.  Indirect services require the therapist to work
directly with a range of other clients, including regular and special
educators, parents, and paraprofessionals. For example, an occupa-
tional therapist might consult with the classroom teacher to help mod-
ify instructional materials and methods for a student with physical
or organizational needs requiring close interaction with the teacher.
Documentation of evaluation, intervention, and outcomes is an import-
ant service and should be included in an occupational therapist’s weekly
schedule. Educational in-service sessions to groups of school staff (e.g.,
teachers, administrators, paraeducators) or parents are beneficial for
providing information on discipline-specific areas of performance,
such as fine motor development and handwriting, sensory process-
ing, positioning for function, and mental health and well-being. Time
spent serving on schoolwide committees (e.g., PBIS, bully prevention)
is also an important indirect service, allowing occupational therapists
641
Direct OT Services
Individual or group
Coteaching
Coaching
Embedded OT programs
delays. The diagnoses of the students included cerebral palsy, Down syndrome, and
autism. 
Group Sessions
The group sessions involved weekly discussions of basic work skills, a trip to the
grocery store, making the brownie mixes, putting them in jars, decorating the jars,
and selling them. Each session also involved clean up. 
Qualitative Research Findings
Qualitative research methods were used to explore the meaning of group par-
ticipation from the children’s perspective. Each of the eight group members were
interviewed during weeks 2 and 6 of the program by the occupational therapist to
explore the personal meaning ascribed to the group experience. Participant observa-
tions served as the second form of data and consisted of weekly observations of the
group. Based on a qualitative analysis of the interviews and participant observations,
three essential themes unfolded: shopping, special ingredients, and doing everything.
When asked what comes to mind or what they liked the most when they think of
the occupational therapy groups, all the participants talked about walking to and
shopping at the neighborhood grocery store, ingredients needed for the project, and
doing the tasks necessary for making the brownie jars. By being actively involved
in the shopping process, students learned firsthand about how to locate the baking
ingredients needed for the brownies. The students began to take on the role of shop-
pers by looking for items needed for baking and using a shopping list. Students also
learned about each special ingredient’s unique properties by handling, measuring,
and tasting it. Finally, students expressed joy in doing everything and began to func-
tion like workers: doing the task, sharing, demonstrating care with the ingredients,
support the importance of occupation-based practice in fostering the link between
doing and becoming.
Contributors: Eileen Dixon, MS, OTR/L and Susan Bazyk, PhD, OTR/L, FAOTA.
opportunities to share expertise and become contributing members of
the school community. Planning time for embedding intervention is an
important indirect service and one that is not always acknowledged as
an essential part of an occupational therapist’s workload. However, one
outcome study of one occupational therapist’s full integration of ser-
vices in a kindergarten curriculum, found that 50% of indirect services
were spent in planning integrated services (Bazyk, 2007).
In addition to determining the most effective range of services for a
child, occupational therapists are also encouraged to provide services
in a flexible manner, depending on the student’s stage in the therapy
process and specific needs. For example, the occupational therapist
may choose to work directly with a student for several weeks to teach
the student how to implement the Alert Program for Self-Regulation
(Williams & Shellenberger, 1996) followed by consultation with the
teacher or paraprofessional to ensure generalization of the strategies
in the classroom. 
642 SECTION V  Pediatric Occupational Therapy Services
A B
C D
Fig. 24.7  (A–D) Brownie Busters group pictures.
Integrated Service Delivery: Where Services Should Be
Provided
Integrated service delivery involves the provision of occupational ther-
apy in the child’s natural environment (e.g., in the classroom, on the
playground, in the cafeteria, on and off the school bus), emphasizing
nonintrusive methods and common goals (Bazyk, 2007; Conway et al.,
2015). Such services give occupational therapy practitioners access to
all students, not just those on their caseload, maximizing the ability to
reach students who are at risk of developing mental health challenges.
Although sometimes viewed simply as “treatment that takes place in
the classroom,” integrated therapy is actually complex, requiring team
collaboration and a combination of teacher education, consultation
with various team members, and direct service that is skillfully embed-
ded in the natural context (Nolan et al., 2004). IDEA does not specify
the type of service delivery provided, but it does indicate that all related
services be provided in the LRE to foster participation in the general
education curriculum. Simply stated, integrating occupational therapy
services in general education settings to the maximum extent possible
is the law. Also, it is important to keep in mind that “students with
disabilities do not attend school to receive related services; they receive
services, so they can attend and participate in school” (Giangreco,
2001). Related services must be educationally relevant, which differs
from therapy that occurs in an outpatient clinic or hospital setting.
It is critical for occupational therapists to articulate these differences
to school staff and parents (United States Department of Health and
Human Services, 1999). Because occupational therapy services support
academic goals (e.g., handwriting, literacy) and nonacademic func-
tional goals (e.g., organizing learning materials, using the restroom,
playing during recess, talking with friends during lunch), the service
context can include a wide range of natural settings, including class-
room, playground, cafeteria, restroom, and hallways.
Another reason for providing services in an integrated setting is that
theories of and research on motor control have indicated that the prac-
tice of a meaningful occupation in a natural context is most effective
for achieving new skills or modifying movements (Bernie & Rodger,
2004; Mandich et al., 2001; O’Brien & Lewin, 2008). Performing
meaningful activities in natural settings requires children and youth to
problem-solve and adapt to inherent variability, which helps reinforce
learning (O’Brien & Lewin, 2008). In addition, interventions provided
in natural settings during daily routines are more likely to be applied
consistently, leading to functional changes (American Occupational
Therapy Association, 2011). Therefore pull-out services in isolated
therapy rooms filled with contrived activities and equipment are no
longer considered best practice in schools. Such services may only be
appropriate during initial stages of learning a task, when the student’s
skill level is far below the tasks presented to other students in the class-
room or when the intervention activities cannot appropriately occur in
a typical classroom (e.g., therapeutic use of equipment such as a swing).
“Although therapists may pull students out of the classroom for brief
periods to explore strategies or to introduce a new skill, time away from
instruction is minimized” (Polichino, 2007, p. 3). McWilliam (1995)
cautioned that pull-out therapy is less effective than integrated services.
 CHAPTER 24  School-Based Occupational Therapy
Benefits.  All parties benefit from integrated services. By working in
natural settings, the occupational therapist learns about the curricu-
lum, academic and behavioral expectations, teacher preferences, and
unique culture of each classroom. Observing and interacting with
students in the classroom and other school settings (e.g., art, music,
cafeteria) enables occupational therapists to analyze the relation-
ships among the child’s abilities, activity expectations, and physical
and social environment fully. When the task-environment demands
are greater than the student’s abilities, the occupational therapist and
teacher must adapt the environment or task to foster successful par-
ticipation. Integrated therapy ensures that the occupational therapist’s
focus has high relevance to the performance expected in the student’s
classroom and other school contexts.
The occupational therapist’s presence in the classroom also ben-
efits the instructional staff, who observe the occupational therapist
model interventions that are practical and realistic (Case-Smith et al.,
2011). With integrated services, teachers, paraeducators, administra-
Fig. 24.8 The occupational therapist may embed movement and/or
tors, and other related service providers have opportunities to learn
sensory strategies to help students regulate alertness for attending.
about occupational therapists’ scope of practice and skill sets. The
blending of teacher education, collaborative planning, and embedded
direct intervention provides a natural way for occupational therapists
to contribute discipline-specific information and the strategies needed
to enhance areas of function that are typically not within a teacher’s
expertise.
Students with disabilities benefit from the teacher’s increased abil-
ity to implement therapy strategies when the occupational therapist
is not present (Silverman, 2011). A study of fine motor and emergent
literacy outcomes following fully integrated occupational therapy in
a kindergarten curriculum found that children with and without dis-
abilities made significant gains in fine motor and emergent literacy
skills (Bazyk, 2007). In this particular school, the principal expressed
pleasure in these results, exclaiming that she was “getting the big-
gest bang out of her therapy buck.” When providing integrated ser-
vices, occupational therapists need to measure outcomes in students
with and without disabilities and share these data to communicate
the benefits of therapy to administrator, parents, and teachers. Fig.
24.8 illustrates an occupational therapist embedding a sensorimotor
activity into the classroom to foster self-regulation of attention for
learning.  all parties involved in working toward a shared goal (Bose &
Challenges.  Despite the well-documented benefits of integrated
services, successful implementation requires time and effort. Findings
from several survey and qualitative studies indicate that the greatest
challenge associated with providing integrated services is time for
occupational therapists, teachers, and other relevant school personnel
to meet and plan embedded services (Barnes & Turner, 2001; Bose &
Hinojosa, 2008; Hargreaves et al., 2012). Although informal collabo-
ration with teachers in the hallways or during lunch is useful, time for
regular formal meetings is essential.  cationally relevant approaches to providing service. Informally
Suggested Strategies for Moving Toward an Integrated
Service Model.  Strategies that can be used to foster the provision of
integrated occupational therapy services include the following:
1. Obtain school administrative support to free teachers and occupa-
tional therapists from their teaching and therapy schedules.
Bazyk and colleagues (2007) found that when providing integrated
services, time spent collaborating with the teacher and other
personnel outweighed time spent in direct intervention by a 2:1
ratio. As the face of occupational therapy shifts from pull-out to
embedded services, occupational therapists need to make a case
for time spent in planning as a legitimate part of service because
of the complexity of integrated therapy.
643
2. Allocate time for collaborative planning with relevant school per-
sonnel based on the specific service and setting.
When integrating sensorimotor strategies into a preschool class-
room, for example, it is important to collaborate with the
teacher and paraeducator. Embedding services in the cafeteria
will involve collaboration with the lunch supervisors. The need
for regularly scheduled meeting times is consistently reported
by therapists and teachers (Barnes & Turner, 2001; Bose &
Hinojosa, 2008; Hargreaves et al., 2012).
3. Commit to collaboration. Develop positive relationships with
teachers, paraeducators, and other relevant stakeholders (e.g., par-
ent, mentor, physical therapist, school psychologist, speech-lan-
guage pathologist, principal, cafeteria supervisor, bus driver).
Because integration of occupational therapy services requires work-
ing closely with diverse stakeholders, effective collaboration is
essential. Commit to a collaborative style of interaction built
on mutual trust and respect and effective communication sur-
rounding common goals, characterized by the equal status of
Hinojosa, 2008). Consider developing a community of practice
(CoP) to enhance collective work and impact (Wenger et al.,
2002). A CoP is a group of people who are committed to a com-
mon cause, interact regularly, and share leadership and work for
collective competence and impact (Wenger et al., 2002).
4. Learn about the unique classroom culture or school setting, the
curriculum, and performance expectations.
Occupational therapists need to understand school board policies,
curriculum, and classroom practices of teachers to develop edu-
observe physical and social aspects of the environment (e.g.,
classroom layout, teacher-student interactions). Talk with the
teacher about challenges and needs specific to occupational ther-
apy’s scope of practice (e.g., issues related to social participation,
attention, handwriting). When working with students in a class-
room, the occupational therapist needs to have a clear under-
standing of classroom expectations. This includes knowledge
of classroom rules, routines, and dynamics and of the general
education curriculum and special education adaptations. Each
classroom teacher has unique teaching and classroom manage-
ment styles. Intervention strategies conducted in the classroom
that may be acceptable to one teacher may not be acceptable to
another teacher; they may even be considered intrusive.
644 SECTION V  Pediatric Occupational Therapy Services
5. Offer interventions that fit the existing classroom structure and cul-
ture. For example, a teacher who values child-directed learning and
hands-on learning centers may respond well to an occupational
therapist’s suggestions for activities to be included in the learning
centers. Another teacher who uses a strong teacher-directed class-
room may prefer to engage in team-teaching activities with the
occupational therapist.
6. Provide information about occupational therapy’s role and full
scope of practice using informal opportunities to share information
(e.g., conversations in the hallway, one-page information briefs)
and formal in-service education.
Make a point to describe how occupational therapy can contribute
to areas of student function beyond handwriting and sensorim-
otor processing, such as social participation, play, leisure, and
work. Explain occupational therapists’ expertise in a wide range
of performance areas, including physical and motor, mental
health and well-being, sensory processing, cognitive, and behav-
ioral functioning (AOTA, 2016).
7. Explore teacher preferences for integrated services.
Be sensitive to the regular education schedule and do not disrupt
the child’s and the classroom schedule, if possible. Teachers may
prefer to have the occupational therapist in the classroom at certain
BOX 24.7 From Pull-Out to Integrated Service Provision: How One School District Made the
Transition
The top ranked, high performing Midwestern suburban school district where
I work has a reputation for academic excellence, with 97% of our graduates
attending 4-year colleges. Students receiving special education services make
up 16% of the student population. Despite the fact that integrated services
are now considered best practice in schools, related services in this progres-
sive district had not moved beyond an outdated pull-out therapy model. Factors
that may have prevented the transition to integrated services include: (1) lack
of knowledge about how to provide integrated therapy services; (2) a belief by
some school staff and parents that pull-out therapy is most effective; and (3) a
lack of planning time to change practice. Although some occupational therapists
made attempts to shift to an integrated service model in their individual schools
within the district, without the ability to meet and develop a unified plan, it was
difficult to make significant changes.
In the fall of 2011, with the assistance of an outside occupational therapy
consultant from a local university, the district occupational therapists (OTs) (6)
and physical therapist(PTs) (2) made a commitment to working together to shift
services to an integrated model. Before we began the process of shifting ser-
vice provision, we met with the Director of Pupil Personnel to communicate the
need for this work and to obtain buy-in. This was a critical first step, as her
support throughout all stages of the process has been essential (e.g., to obtain
permission to meet during school hours). A brief timeline and description of the
strategies we used to change service provision follows.
Getting Started
Become knowledgeable about integrated services: what, why, how, and where.
(December 2011).
The OTs, PTs, and Director of Pupil Personnel met for an initial 2-hour meeting
during which our OT consultant provided an overview of the requirements of the
law and the evidence supporting integrated services. Time was spent discuss-
ing the need to shift services as well as barriers and supports. We decided to
complete a time study of our services in order to obtain a baseline and to meet
afterward to begin strategic planning.
Complete a time study of services. (February 2012).
Two pieces of data were collected from the OTs and PTs: type of direct ser-
vice (individual or group) and location of service (pull-out in therapy room or
times or on certain days. These preferences should be negotiated
with the teacher before intervention, and attempts should be made
to schedule times for providing services to the child that coincide
with targeted goal areas. For example, handwriting interventions can
be integrated into the student’s language arts time, and keyboarding
skills can be integrated into the student’s computer or language arts
class. (Box 24.7). 
Informal Strategies for Integrating Direct Services.  Direct ser-
vices can be embedded throughout the school day to enhance partic-
ipation in numerous ways, including the following: (1) modify the
physical or social environment, (2) modify the activity or task, and (3)
modify the instruction or adult-student interaction.
Modifying the school environment aligns with the educational
initiative called UDL, which focuses on fostering performance in the
classroom via environmental modifications. To modify the physical
environment, the occupational therapist may give the teacher materi-
als helpful for implementing the intervention (e.g., pencil grips, slant
boards, games that foster fine motor skills) or help adapt the environ-
ment so that the child can participate (e.g., establish a sensory corner,
obtain supportive seating, set up a prone stander). To enable the person
who is chosen to implement the strategy, the occupational therapist
embedded in resource room, general education classroom, or ‘other’). Other
included any natural setting in the school including: playground, cafeteria, hall-
way, locker, restroom, or the bus. Results of our time study indicated that the
majority of our services were being delivered using pull-out therapy in isolated
settings (75.5%). Therapy was integrated in the resource room 10.1% of the
time, in the general education classroom 9.7% of the time, and ‘other’ 4.7% of
the time. Direct services were provided individually 75.3% of the time and in
groups 24.7% of the time. It was clear that our initial data supported the need for
change in how related services were being delivered in our district. 
Warming Up for Change
Explore opportunities for integrated services and invite receptive stakeholders.
(February – June 2012).
For the remainder of the school year therapists began to brainstorm and plan
how to implement change. Therapists began to identify and talk with relevant
stakeholders (administrators, teachers, staff, and parents) who were likely to
support and pilot a more collaborative integrated model. The seeds of change
were planted, mini-trials of “push in” services were implemented, and success
stories were shared. The results of brainstorming, planning, and mini-trials from
the spring of 2012 led the district to commit to a district-wide change for the
2012–2013 school year. 
Mobilize Supports for Action by Developing a Community of
Practice (CoP)
Involve relevant stakeholders by developing a Community of Practice (CoP)
(August 2012).
Because changing service provision to an integrated model affects school staff
and parents, we decided to develop a Community of Practice (CoP) of relevant
stakeholders to be a part of and assist in the change process. A CoP is a group
of people who are committed to a common cause and interact regularly for col-
lective competence and impact (Wenger, McDermott, & Snyder, 2002). A diverse
group of stakeholders representing all district school buildings were invited to
be a part of the CoP including: Director of Pupil Personnel (our direct supervisor),
two district principals, two general education teachers, several special educa-
tion teachers, a school psychologist, two parents of children with disabilities,
 CHAPTER 24  School-Based Occupational Therapy
BOX 24.7 From Pull-Out to Integrated Service Provision: How One School District Made the
Transition—cont’d
the district parent mentor, a speech pathologist, and three paraprofessionals.
During our first meeting, an overview of the requirements of the law (least
restrictive environment, LRE) and the evidence supporting integrated services
was presented followed by open discussion. Support for integrating related
services was overwhelmingly positive. Ideas of how to generate change were
discussed and the role of the CoP members was defined.
Shared leadership and collaborative work.
During the first year of implementation, four CoP meetings were held. One
concern about shifting services was that parents and some school personnel
might perceive integrated therapy as inferior to and “less than” individual pull-
out therapy and question administration about this change. Subsequently, it was
decided that the priority was to educate and communicate our message within
the district and to the community in order to obtain “buy in.” Collectively, the CoP
also decided to strategically communicate success stories of integrated services.  Pull-out services in the therapy room decreased significantly from 75% down
Implementing Change (September 2012 through June 2013)
District therapists began discussing and implementing changes in service deliv-
ery within their individual educational teams at the start of the school year in
2012. By starting at the beginning of the school year, therapists were able to
schedule integrated programing more effectively. Therapists chose teams where
they had established strong relationships, and who they believed would be open
to a more collaborative, integrated approach. Methodologies to initiate change
varied from building to building and were influenced by the age of the student as
well as individual student needs. The district goal was to shift from 24.5% to at
least 40% integrated services during the 2012–2013 school year.
The most significant challenge for most therapists was establishing time
to collaborate with teachers and other relevant school staff. Therapists often
worked on multiple teams and needed multiple planning times. Finally, thera-
pists needed to develop a new skill set which involved a role release from a
traditional clinical model to a more collaborative coteaching model.
uses modeling and coaching as the student attempts the activities in
his or her natural routine. Regular contact is necessary to update pro-
grams and supervise the way the activities are implemented. Refer to
Table 24.4 for examples of integrated services involving a combination
of indirect and direct interventions.  on curricular need. The occupational therapist’s time is scheduled for
Formal Strategies for Integrating Direct Services.  School-based
occupational therapists apply a wide array of intervention methods
based on a variety of theoretical frames of reference (e.g., sensory
integration, motor learning, behavioral, biomechanical). According
to IDEA 2004, schools are required to “ensure that such personnel
have the skills and knowledge necessary to improve the academic
achievement and functional performance of children with disabilities,
including the use of scientifically based instructional practices, to the
maximum extent possible” (§ 601(c)(5)(E)). Formal strategies for inte-
grating occupational therapy services with emerging research evidence
include coteaching models, occupational performance coaching, and
provision of specially designed programs.
Coteaching.  Although coteaching originally was designed as
an instructional strategy for general and special educators to share
teaching responsibility within an integrated classroom (Cook &
Friend, 1995), it has also been used by occupational therapists as a
formal way to integrate services (Case-Smith et al., 2011; Case-Smith
et al., 2012; Silverman, 2011). Cook and Friend define coteaching as
“two or more professionals delivering substantive instruction to a
diverse, or blended, group of students in a single physical space” (Cook
& Friend, 1995, p. 1). In general, coteaching involves collaboration
645
Within individual buildings therapists embedded services at the Tier 1, 2, and
3 levels in collaboration with educational colleagues. The net results were over-
whelmingly positive as therapists were increasingly welcomed into classrooms
and other natural settings (e.g., art, music, physical education [PE]). Word of
success and student growth using integrated collaborative approaches spread
among the faculty, administration, and parents, resulting in expanding interest
to replicate such strategies in more settings throughout the district. 
Celebrating Outcomes (June 2013)
The original time study was repeated at the end of the school year. Changes in
place of service delivery are impressive. Integrated services shifted from 24.5%
(2011) to 60.2% (2013) with 17.2% of services occurring in the general education
classroom, 31.6% in the resource room, and 11.6% in other natural settings.
to 40%. The type of direct services also shifted to more time providing group
services (44%, up from the original 24.7%) and less time providing individual
services (55.8%, down from the original 75%).
We believe the following factors contributed to overall success: therapists’
ability to reflect on practice and to be open to change; administrative buy-in and
support; development of a Community of Practice to foster collective learning
and impact; and initiating change with educational team members where we
had existing strong relationships. The success of our first year has bolstered the
interest and commitment for continued work toward integrated therapy for the
coming school year. Our next goal is to develop a related service website that
will serve as a district and community resource describing school-based therapy
using an integrated model and providing examples of implementation from pre-
school to graduation.
Contributed by Carol Conway, MS, OTR/L, Hudson City Schools, OH.
to design, plan, implement, and evaluate the learning experience. In
addition to working with teachers, occupational therapists may also
choose to coteach with other relevant school staff, such as the guidance
counselor, health educator, or speech-language pathologist, depending
the coteaching activities, rather than for individual sessions. Students
who are a part of the occupational therapist’s caseload receive services
in the classroom alongside their peers, thus allowing the occupational
therapist to served multiple students during one period within the LRE.
Cook and Friend (1995) define five variations of coteaching: (1)
one teaching and one assisting (occupational therapist takes the lead
and teacher assists, or vice versa); (2) station teaching (teachers divide
instructional content into two segments, teach half the content to half
the class at a time, and then trade student groups and repeat the same
instruction); (3) parallel teaching (teachers plan a unit of instruction
and present it simultaneously to half the class, resulting in a lower stu-
dent-to-teacher ratio); (4) alternative teaching (one person teaches a
small group of students who need specific accommodations while the
other teaches the remaining larger group); and (5) team teaching (both
teachers teach at the same time, sharing the lead in the discussion) .
Although coteaching may appear to require more time and effort,
the benefits can outweigh the cost. The benefits of coteaching include
the following: expanded instructional options because of the combined
expertise of the two teachers, improved program intensity because of a
higher teacher-to-student ratio, and enhanced educational continuity
for students with special needs who are not pulled out of the classroom
for services (Cook & Friend, 1995). Not only do the targeted students
646 SECTION V  Pediatric Occupational Therapy Services

TABLE 24.4  Examples of Indirect
Intervention Strategies When Integrating
Services
Intervention Strategies Examples
Reframe the teacher’s
perspective.
Improve the student’s skills.
Adapt the task.
Adapt the environment.
Adapt the routine.
with disabilities benefit from the interventions, but students without
disabilities in the class also benefit from the multidisciplinary input.
For example, the classroom teacher and occupational therapist might
coplan a handwriting session. Another example might involve an
occupational therapist and guidance counselor coteaching the Zones
Explain the functional consequences of the
perceptual problems observed in children/
youth with spina bifida.
Identify that a student with autism is hyper-
sensitive to tactile and auditory stimuli and
explain how this may impact behavior, social
interaction, and participation in activities.
Describe how student’s difficulty in sitting
quietly is related to his or her low arousal
level and need for enhanced sensory input.
Recommend that a student use carbon paper
to monitor the amount of force applied
with the pencil.
Recommend that a student practice letter
formation using wide-lined paper and
beginning at the top of the letter.
Recommend that a teacher provide standby
assistance when the child practices carry-
ing a lunch tray in the cafeteria.
Recommend that a student begin to use a
computer keyboard.
Introduce compensatory methods for zipping
a jacket (e.g., use of a zipper pull).
Teach one-handed techniques during toilet
training.
Recommend that a student use sound deaf-
ening earphones when participating in loud
settings (e.g., cafeteria, school rallies).
Establish a quiet and calming area in the
corner of the classroom so that students
can remove themselves from the stimulat-
ing environment.
Suggest that excess visual stimulation be
removed from the wall in front of a student.
Educate cafeteria and recess supervisors
on how to effectively promote positive
behavior and enjoyable participation
during lunch and recess.
Recommend that a student have opportu-
nities for active movement three times
each day.
Recommend that a student with anxiety
be given extra time to complete certain
written assignments.
Suggest that the student receive speech
therapy after occupational therapy so that
he or she can be focused and attentive
during the session.
of Regulation, a cognitive behavioral and social thinking curriculum
developed by Leah Kuypers, an occupational therapist, to teach chil-
dren how to regulate their emotions to improve participation, social
interaction, and emotional well-being (Kuypers, 2011).
Case-Smith and associates (2012) examined the feasibility and
effects of a 12-week, cotaught fine motor and writing program, Write
Start, using a one-group, pretest–posttest design with 36 first grad-
ers. The program, using a combination of station teaching and team
teaching, was found to benefit students with diverse learning needs
by increasing handwriting legibility and speed and writing fluency.
During final interviews, the teachers and occupational therapist
reported that the students received more individualized instruction
and that they gained skills from working together. Specifically, the
occupational therapist learned about the curriculum and behavior
management approaches and the teachers learned handwriting strat-
egies (Case-Smith et al., 2012). 
Occupational performance coaching. Occupational perfor-
mance coaching (OPC) was initially developed by Fiona Graham to
provide a process for helping parents promote their child’s occupa-
tional performance (Graham et al., 2010). OPC involves three major
components: emotional support, information exchange, and a struc-
tured process. Although originally developed to be applied with par-
ents of children with disabilities, the basic elements may be used as a
guide when working with teachers and other school-based personnel.
Emotional support, for example, may be provided in a way that
acknowledges the interpersonal challenges associated with serving chil-
dren in their specific context (e.g., classroom, cafeteria). When work-
ing with cafeteria supervisors while implementing the Comfortable
Cafeteria Program, it was important for the occupational therapist
to acknowledge their challenges and needs. One of the biggest chal-
lenges expressed by the supervisors was dealing with the noise levels
that occur when large groups of children eat together in a large room
(Bazyk, Demirjian, Horvath, & Doxsey, 2018).The occupational ther-
apist can help process reactions to and feelings about noise levels and
problem-solve positive strategies for dealing with the noise levels with-
out enforcing rules about eating in silence.
Information exchange is important to understand individual per-
ceptions of the problem and/or occupational performance expectations.
In the same cafeteria program, a discussion about noise levels resulted
in supervisors talking about their personal sensory preferences for and
tolerance of noise. Some cafeteria supervisors did not mind loud cafete-
ria environments and were happy to see children talking with each other
and having fun. Others struggled with being in a loud environment.
The final component of OPC involves a clear sequence of steps
including setting goals, exploring options, planning action, carrying
out the plan, checking performance, and generalizing abilities. The
occupational therapist’s ultimate goal is guided by the dual intention
to improve children’s occupational performance in school contexts
and assist school personnel in promoting successful participation and
enjoyment. For the cafeteria program, an initial orientation session,
embedded activities, and follow-up coaching were used to create a
comfortable cafeteria for children with and without disabilities. 
Formal occupational therapy embedded programs. With
integrated services becoming more accepted and pursued as the
most preferred form of related service delivery, a growing number of
occupational therapists have recently developed creative programs
designed to be embedded in a variety of school contexts (e.g., classroom,
cafeteria, recess) with the purpose of helping children participate in,
succeed at, and enjoy learning, socializing with peers, eating a meal,
and playing during recess. Table 24.5 provides a summary of some of
these programs. It will be critical for occupational therapists to conduct
studies that examine the feasibility and effects of embedded programs. 
 TABLE 24.5 Examples of Occupational Therapy Programs Developed for Integration Into Classrooms and Other School
Contexts
Additional Information and
Program Description Resources
Write Start This is a classroom-embedded, comprehensive activity-based program for first-grade students cotaught by a trained occupational therapist and Website: http://www
Terri Holland, Jane Case- teachers focusing on handwriting and written expression. The goal is to help first-grade students become legible and fluent writers. .write-start-handwriting.org
Smith (Case-Smith, Hol- Type of collaboration: coteaching
land, & Bishop, 2011; Length of time: 12 weeks, two 45-min sessions/week
Case-Smith, Holland, Sessions include modeling of letter formation and opportunities to practice; small group activities focusing on foundation skills (visual motor inte-
Lane, et al., 2012) gration, fine motor skills, and cognitive skills); adult modeling, monitoring, and feedback; and provision of peer supports and evaluation.
Zones of Regulation This curriculum provides a systematic, cognitive behavioral approach to teach children about their emotional and sensory needs to self-regulate Website: http://www.zonesofregula-
Leah Kuypers (Kutash, and control emotions and impulses, manage sensory needs, and improve the ability to problem solve conflicts. The Zones of Regulation program tion.com
Duchnowski, & Lynn, combines social thinking concepts and visual supports to help students identify feelings, understand how behaviors affect others, and learn tools
2006; Kuypers, 2011) that can be used to move to a more acceptable state.
The four zones are the following:
• Red zone: heightened state of alertness and intense emotions resulting in being out of control
• Yellow zone: less heightened state of alertness and elevated emotions allowing for some control but that result in stress, anxiety, silliness, or nervousness
• Green zone: calm state of alertness associated with being happy, content, focused, and ready to learn
• Blue zone: low state of alertness that may occur when one feels sad, sick, bored, or tired
Students learn strategies for regulating their emotional and sensory needs to meet the demands of the context and succeed academically and socially.
Drive-Thru Menus: Similar to how drive thru restaurants can provide food without taking a lot of time, these drive thru menus were developed to help students engage Websites: http://www.therapro

CHAPTER 24 
relaxation and stress in meaningful activities that take only a short amount of class time. .com/Drive-Thru-Menus-Attention-
busters, attention, and Type of collaboration—consultation to educate the teacher about the program and how and when to embed it into the classroom. and-Strength-C307797.aspx
strength Length of time: each activity takes about 3–5 minutes of class time to help students manage stress and relax or engage in active movement to attend. http://www.therapro
Tere Bowen-Irish Program contents: each program consists of a large, laminated colorful poster with 10 activities, a DVD of the author’s overview of the program, .com/Drive-Thru-Menus-Relaxation-
(Bowen-Irish, T, 2012) and a leader’s manual that explains the purpose, how to prepare for the activity, how to do the activity, and suggested adaptations. and-Stress-Busters-C307798.aspx
• Relaxation menu activities use visualization and meditation to bring about a sense of peacefulness and tranquility.

School-Based Occupational Therapy

• Stressbuster menu activities involve active movements to relieve stress.
• Strength menu activities help students who have difficulty completing fine motor tasks because of muscle weakness.
• Attention menu activities help students who struggle with attention and keeping their bodies quiet enough to learn.
Alert Program for The Alert Program was initially developed for children with attention and learning difficulties, ages 8–12 years, but has been adapted for preschool Website: http://www.alertprogram.com
Self-Regulation of through adult-age individuals with and without a variety of disabilities. Products include Leaders’ Guide,
Arousal The purpose of the program is to teach individuals (children and youth, school personnel, and parents) how to understand their unique sensory introductory booklet, games (Alert
Mary Sue Williams and processing to help them use sensory strategies to maintain optimal states of alertness for successful functioning throughout the day. Bingo), and songs (Alert Program
Sherry Shellenberger An engine analogy is used to teach children and adults how to self-regulate levels of alertness throughout the day to participate in activities they CD).
(Weaver & Darragh, need or want to do. Three car engine levels are taught:
2015; Williams & • High: feeling hyper
Shellenberger, 1996) • Low: feeling lethargic
• Just right: able to attend and focus on task at hand
Five strategies for changing “engine speeds” and alertness include putting something in the mouth, move, touch, look, and listen.
Children analyze how their engine speeds vary throughout the day and learn how to use sensory strategies to regulate their alertness to feel good
and function well for the task at hand.
Adapted from Case-Smith, J., Holland, T., & Bishop, B. (2011). Effectiveness of an integration handwriting program for first grade students: A pilot study. American Journal of Occupational Ther-
apy, 65, 670–678. Case-Smith, J., Holland, T., Lane, A., et al. (2012). Effect of a co-teaching handwriting program for first graders: One group pretest-posttest design. American Journal of Occu-
pational Therapy, 66, 396–405. Kutash, K., Duchnowski, A. J., & Lynn, N. (2006). School-based mental health: An empirical guide for decision-makers. Tampa, FL: Research and Training Center for
Children’s Mental Health, University of South Florida. Kuypers, L. (2011). The zones of regulation: A curriculum designed to foster self-regulation and emotional control. San Jose, CA: Social Think-
ing. Williams, M. S., & Shellenberger, S. (1996). “How does your engine run?” A leader’s guide to the Alert Program for self-regulation. Albuquerque, NM: TherapyWorks. Weaver, L. L., & Darragh,
A. R. (2015). Systematic review of yoga interventions for anxiety reduction among children and adolescents. American Journal of Occupational Therapy, 69(6), 6906180070p1-6906180070p9;

647
and from Bowen-Irish, T. (2012). Drive-Thru Menus: Exercises for attention and strength. Retrieved from http://www.therapro.com/Drive-Thru-Menus-Attention-and-Strength-C307797.aspx; and
Bowen-Irish, T. (2012). Drive-Thru Menus: Relaxation and stress busters. Retrieved from http://www.therapro.com/Drive-Thru-Menus-Relaxation-and-Stress-Busters-C307798.aspx; and Bertrand,
J. (2009). Interventions for children with fetal alcohol spectrum disorders (FASDs): Overview of findings for five innovative research projects. Research in Developmental Disabilities, 30, 986–1006.
648 SECTION V  Pediatric Occupational Therapy Services
SCHOOL MENTAL HEALTH: EMERGING ROLES FOR
OCCUPATIONAL THERAPY
School Mental Health Movement
Although mental health services for children and youth have his-
torically been provided in hospitals and community mental health
centers, the EHA of 1975 was the first federal initiative that required
schools to meet the mental health needs of students with emotional
disturbances, playing a key role in blurring the lines of responsibility
for where such services should be provided (Bazyk, 2007; Koppelman,
2004). Because IDEA focuses solely on students with identifiable dis-
abilities that interfere with educational achievement, only a small
percentage of children needing mental health services actually receive
such care in school. Nonetheless, most children receiving mental
health services obtain care in schools, making schools the “de facto
mental health system for children in this country” (Kutash et al.,
2006, p. 62)
“Education and mental health integration will be advanced when
the goal of mental health includes effective schooling and the goal
of effective schooling includes the healthy functioning of students”
(Atkins et al., 2010, p. 40). Over the past 2 decades, there has been
a national movement to develop and expand school mental health
(SMH) services because of the high prevalence of mental health
conditions among youth and an awareness that more youth can be
reached in schools. This movement is also attributed to prominent
federal initiatives, such as the President’s New Freedom Commission
on Mental Health (2003) which identified fragmentation and gaps
in care and specifically recommended that all federal, state, and
local child-serving agencies address the mental health needs of
youth in the educational system (Kutash et al., 2006). The com-
mission “emphasized building a mental health system that is evi-
dence-based, recovery-focused and consumer- and family-driven”
(Moherek Sopko, 2006).Schools must be active partners in the men-
tal health of children because it is currently accepted that a major
barrier to learning is the absence of essential social-emotional skills
and not necessarily a lack of sufficient cognitive skills (Kutash et al.,
2006). Approximately one in every five children and adolescents
has a diagnosable emotional or behavioral disorder, with the most
common being anxiety, depression, conduct disorders, learning
disorders, and ADHD (Koller & Bertel, 2006). It is estimated that
50% of adolescents with lifelong mental health challenges will expe-
rience onset of symptoms prior to age 15 (Merikangas et al., 2010).
Emotional and behavioral disorders can adversely affect a student’s
successful participation in a range of school activities, including
classroom work and social participation during lunch and recess.
Because of this, universal screening of youth at-risk of mental or
behavioral problems and early intervention is important for delay-
ing or eliminating the onset of mental illness (Cahill & Egan, 2017;
Feeney-Kettler et al., 2010).Screening for both subjective well-be-
ing as well as early warning signs has been recommended (Cahill &
Egan, 2017; Huebner et al., 2014).
Occupational therapists must be aware that students with disabili-
ties are at increased risk for developing mental and/or behavioral chal-
lenges. Almost one in three children with developmental disabilities is
diagnosed with a cooccurring mental health problem (Schwartz et al.,
2006).The cooccurrence of mental health disorders with specific devel-
opmental disabilities has also been reported. For example, increased
rates of anxiety, depression, bipolar disorder, obsessive compulsive
disorder, and ADHD have been identified in children with autism
spectrum disorder (Crabtree & Delaney, 2011). with approximately
90%–95% having one or more comorbid psychiatric disorders (Salazar
et al, 2015).
School Mental Health.  SMH refers to a framework of approaches
that have expanded on traditional methods addressing mental health
by emphasizing promotion, prevention, positive youth development,
and schoolwide approaches (http://csmh.umaryland.edu/Resources/
Foundations-of-School-Mental-Health/). This SMH framework pro-
motes interdisciplinary collaboration among mental health providers,
related service providers, teachers, school administrators, and families
to meet the mental health needs of all students. Because of federal sup-
port, two national technical assistance centers were developed in 1995
to promote mental health in schools: the Center for Mental Health in
Schools at the University of California at Los Angeles (UCLA) and the
Center for School Mental Health Analysis and Action (CSMA) at the
University of Maryland. 
Mental Health Continuum.  All too often, the term mental health
is interpreted to mean services focusing on mental illness because of
a long-standing emphasis on healing pathology. Evidence indicates,
however, that the “absence of mental illness does not imply the pres-
ence of mental health, and the absence of [or limitations in] mental
health does not imply the presence of mental illness” (Keyes, 2006).
Keyes (2006) has advocated for the adoption of a two-continuum
model, with mental health belonging to a continuum separate from
mental illness. It is important for occupational therapists to be aware
of this distinction and to help school personnel, students, and fami-
lies understand the emotional, behavioral, and functional indicators of
mental health, as well as the symptoms associated with mental illness
(Bazyk, 2011).
Mental health is defined as a “state of successful performance of
mental function, resulting in productive activities, fulfilling relation-
ships with people, and the ability to adapt to change and cope with
adversity” (United States Department of Health and Human Services,
1999).Mental health encompasses more than demonstrating the pres-
ence of good behavior. It involves feeling good emotionally and doing
well in everyday functioning (Merikangas et al., 2010).The terms men-
tal illness and mental disorders are commonly used to refer to diagnos-
able psychiatric conditions that significantly interfere with a person’s
functioning, such as bipolar disorder, schizophrenia, and dementia.
The term mental health challenges often refer to milder forms of mental
illness, such as anxiety and depression, which may be less severe and of
shorter duration but, if left unattended, may develop into more serious
conditions (Barry & Jenkins, 2007). 
Why Care About Mental Health and Happiness?.  Individuals
who are mentally healthy and feel happy demonstrate greater degrees
of everyday functioning (Keyes, 2006), healthy behaviors (Rasciute &
Downward, 2010),and perceived good health (RTI Action Network,
2014). Children and youth who experience positive mental health and
well-being function better during academic and nonacademic times of
the school day. 
Use of Naturalistic Resources.  Integrating mental health initia-
tives involves using the naturalistic resources in schools to implement
and sustain effective supports for promoting positive mental health in
students with and without disabilities. Although the mental health field
has traditionally been viewed as the domain of licensed mental health
providers, who provide services to individuals when mental health
problems interfere with everyday functioning, it is now recognized
that addressing mental health issues is far too complex to relegate to a
small number of professionals and is more effectively addressed in pro-
motional and preventive ways. Leaders in the field of SMH have been
calling for a paradigm shift to better prepare all school personnel (e.g.,
teachers, administrators, related service providers, paraeducators) to
 CHAPTER 24  School-Based Occupational Therapy
address the mental health needs of all students proactively (Koller
& Bertel, 2006). Teachers and other front-line personnel, including
occupational therapists, play a critical role in the development of chil-
dren from academic and personal, social, and emotional perspectives.
“An important component of integrating mental health efforts into
the ongoing routines of schools is the identification and support of
indigenous persons and resources within schools as agents of change”
(Atkins et al., 2010, p. 42). Occupational therapists can be important
change agents in integrating mental health efforts into everyday prac-
tice in schools.  Universal
Multitiered Public Health Model of School Mental
Health
The failure to provide mental health services adequately for children
and youth has been viewed as a major public health concern, causing
leaders in the field to propose a public health model of service delivery
to address the needs of all children and youth (Koller & Bertel, 2006).
A public health model supports a system-wide shift from an individual,
deficit-driven model of intervention to a schoolwide, strength-based
model focusing on promotion, prevention, early intervention, and
integration of services for all children. Similar to RTI, addressing the
mental health needs of students can be envisioned within a three-tiered
framework of mental health promotion (tier 1), prevention (tier 2),
and intensive individualized interventions (tier 3) (Miles et al., 2010)
(Fig. 24.9). Recent occupational therapy publications (Bazyk, 2011,
2013) and evidence-based reviews (Bazyk & Arbesman, 2013) have
applied a public health approach to mental health to occupational
therapy practice with children and youth.
At the schoolwide level (tier 1), services are geared toward the entire
student body, including most students who do not demonstrate behav-
ioral or mental health challenges. At this level, the emphasis is on pro-
moting positive mental health and preventing mental health problems.
Strategies for promoting positive mental health include the following:
(1) creating physical and social environments and activities that are
enjoyable for all students (e.g., sensory-friendly contexts, caring adults,
just right activities) and (2) embedding strategies and activities that help
children and youth cope with challenges (e.g., yoga, deep breathing).
Targeted intervention (tier 2) is geared toward students at risk of men-
tal health or behavior problems (e.g., students with disabilities, those
who are obese or overweight, students living in poverty). Students at
this level are generally not identified as needing special education and/
or mental health services and may include children with mild mental
disorders, ADHD, and those living in stressful home environments.
Screening for subjective well-being and mental health concerns is crit-
ical at tiers 1 and 2 (Cahill & Egan, 2017). General education students
demonstrating behavioral or learning difficulties because of such men-
tal health conditions may be provided coordinated early intervention
services, even if special education is not needed, according to the 2004
amendments to IDEA. For some students with mild mental health dis-
orders, accommodations provided under Section 504 are enough for
enhancing school functioning. When targeted interventions do not
meet the needs of students, intensive interventions (tier 3) are devel-
oped to address behaviors or mental health challenges that are highly
disruptive or prevent learning. All school personnel, under the lead-
ership of professionals with a background in mental health interven-
tion (e.g., occupational therapists, school psychologists, school nurses,
guidance counselors), can embed tier 3 interventions into everyday
school experiences (Bazyk, 2011).  (e.g., lunch, recess, extra-curricular). Sample occupational therapy
Role of Occupational Therapy
With occupational therapy’s rich history of addressing mental health
in all areas of practice, along with the call for all school personnel to
649
Tier 3 →
FEW
Intensive
Tier 2 → Tier 1
SOME Targeted All
Promotion
Fig. 24.9 Public health approach to school mental health in occupa-
tional therapy.
address children’s mental health proactively, the role of occupational
therapy in SMH seems clear (Atkins et al., 2010). Occupational ther-
apists have specialized knowledge and skills in addressing the psy-
chosocial and mental health needs of individuals and thus are well
positioned to contribute to all three levels of promotion, prevention,
and intervention. A continuum of occupational therapy’s early inter-
vening services, aimed at social, emotional, and mental health promo-
tion, prevention of problem behaviors, and early detection through
screening is recommended (Bazyk, 2011).
Occupation-Based Services.  Although many approaches specific
to mental health promotion are important to know about and apply,
all occupational therapy services share a common emphasis on the
use of meaningful occupation to promote participation in health-pro-
moting occupations (e.g., education, play, leisure, work, social par-
ticipation, ADLs, IADLs, sleep, and rest) within a variety of contexts
(American Occupational Therapy Association, 2014). Figs. 24.10 and
24.11 show students engaged in educational activities at school. The
findings of a recent evidence-based literature review, for example,
indicate that activity-based interventions help improve children’s peer
interactions, task-focused behaviors, and conformity to social norms
(Bazyk & Arbesman, 2013). In schools, occupation-based services
can be embedded in natural contexts, including the cafeteria (e.g.,
lunch groups), recess (e.g., game clubs), art, and physical education.
Increased emphasis is placed on participation in extracurricular activ-
ities, opening the doors wider for occupational therapists to help chil-
dren and youth develop and participate in structured leisure interests
during afterschool hours. (Hansen et al., 2003; Mahoney et al., 2005).
If questioned about how services addressing mental health by occu-
pational therapists differ from those provided by other mental health
providers (e.g., school counselors, social workers, school psychol-
ogists), it is critical to emphasize our use of meaningful activities in
promoting psychosocial skills and emotional well-being. Articulating
occupational therapy’s distinct role in mental health is important to
ensure that all school personnel and families are aware of how we can
contribute to addressing the mental health needs of students with and
without disabilities and/or mental health concerns in natural contexts
throughout the day (e.g., classroom, cafeteria, art, music, recess).
Within a three-tiered public health model, occupational therapists
can provide a continuum of services geared toward mental health pro-
motion, prevention, universal screening, and early identification, and
intervention. Intervention strategies should be integrated into the stu-
dent’s classroom schedule, school routine, and nonacademic activities
activities for each tier of the public health model of SMH are depicted
in Table 24.6 (Cahill, 2007; Cahill & Suarez-Balcazar, 2009). These
activities should be designed in accordance with research evidence as
much as possible. 
650 SECTION V  Pediatric Occupational Therapy Services
Fig. 24.10  The occupational therapist may work with recess supervi-
sors to help students participate in enjoyable activities.
Major Approaches Used in Mental Health Promotion, Prevention,
and Intervention.  In addition to traditional occupational therapy
intervention approaches (e.g. sensory processing), other approaches
developed in the fields of public health, psychology, and education can
be applied by occupational therapists, such as mental health literacy;
positive youth development; social-emotional learning (SEL); mind-
fulness, yoga, and relaxation; and PBIS. Refer to Table 24.7 for a de-
scription of each, with supporting literature.  and community.
Application to Practice: Every Moment Counts (Project
Director: Susan Bazyk, PhD, OTR/L, FAOTA)
Although all entry-level occupational therapists are prepared to
address the mental health needs of individuals with mental illness,
practitioners may struggle with knowing how to apply this knowl-
edge in school settings. The need for occupational therapists to
have a framework and language for describing the profession’s role
related to mental health is essential for ensuring that such efforts
be recognized by members of the school team (Nielsen & Hektner,
2014). In order to apply a public health approach to mental health to
practice, Every Moment Counts: promoting mental health through-
out the day, envisioned by an occupational therapy researcher and
school-based practitioners, was funded by the Ohio Department
of Education, Office of Exceptional Children (2012–2015). Every
Moment Counts is a multipronged occupational therapy-led men-
tal health promotion initiative, guided by a public health approach
to mental health, with the focus of helping all children and youth
Fig. 24.11 The occupational therapist may work with students to
enhance their participation in educational activities.
become mentally healthy in order to succeed in school, at home, and
in the community. This initiative emphasizes creating environments
that foster participation and enjoyment; embedding mental health
promotion, prevention, and intervention strategies throughout the
day; inclusion of students with disabilities and mental health chal-
lenges; integrating services in natural settings versus isolated therapy
rooms; and collaboration with all relevant stakeholders in the school
Three Major Goals.  A major goal of Every Moment Counts has
been the development, implementation, and evaluation of occu-
pation-based model programs (Comfortable Cafeteria, Refreshing
Recess, Leisure Matters, Calm Moments Cards, Making Connections
and Learning Together) and embedded strategies that reflect occupa-
tional therapy’s full scope of practice (Box 24.8). The use of enjoy-
able occupations to promote positive emotions and mental health
provides the foundation for all the model programs and embed-
ded strategies. A second major goal has been to build the capacity
of occupational therapy practitioners to strategically address the
mental health needs of children and youth (Bazyk et al., 2015) (Box
24.9). The third major goal focused on dissemination of all of Every
Moment Counts model program, embedded strategies, and research
outcomes. To promote knowledge translation and implementa-
tion among school professionals, community providers, and fami-
lies, Every Moment Counts materials are free and downloadable at
www.everymomentcounts.org. 
TABLE 24.6  Approaches Applied in School Mental Health
Approach Description
Mental health literacy Mental health literacy, a new area of study, refers to providing all children and
youth with a working knowledge of mental health as an essential part of
overall health (Barry & Jenkins, 2007). It includes many components, such as
learning about mental health and strategies for becoming and maintaining
mental health, recognizing when a disorder is developing and where to seek
help, effective self-help strategies for mild problems, and how to support
others facing a mental health crisis (Jorm, 2012).
Mental health first aid training courses for youth educate adults on how to pro-
vide support for adolescents showing symptoms of a mental health disorder
until professional help is obtained (Kelly et al., 2011). Randomized control
trials comparing mental health first aid course attendees with wait-list con-
trols found improvements in knowledge, helping behaviors, and stigmatizing
attitudes (Jorm, 2012).
Positive youth develop- Positive youth development emphasizes building and improving assets that
ment and structured enable youth to grow and flourish throughout life (Park, 2004). Larson (2000)
leisure participation emphasizes the development of initiative as a core quality of positive
youth development and makes a case for participation in structured leisure
activities (e.g., sports, arts, organized clubs) as an important context for such
development.
Supporting Evidence Implications for Occupational Therapy
Jorm, A. (2012). Mental health literacy: Empowering Look for opportunities to raise awareness of mental
the community to act for better mental health. health and educate students and staff about
American Psychologist, 67, 231–243. mental health and well-being as well as mental
Kelly, C. M., Mithen, J. M., Fischer, J. A., Kitchener, health disorders
B. A., Jorm, A. J., Lowe, A., & Scanlan, C. (2011). Reinforce the attitudes and actions associated with
Youth mental health first aid: A description of the pro- mental health such as participating in enjoyable
gram and an initial evaluation. International Journal of occupations, exercising, thinking positively, and
Mental Health Systems, 5(4), 1–9. keeping stress in check.
Pinto-Foltz, M., Logsdon, C., & Myers, J. A. (2011). Host Children’s Mental Health Awareness Day events
Feasibility, acceptability, and initial efficacy of a every May (http://www.samhsa.gov/children/)
knowledge-contact program to reduce mental illness Collaborate with health educators, teachers, and
stigma and improve mental health literacy in adoles- school nurses to embed educational activities related
cents. Social Science & Medicine, 72, 2011–2019. to mental health literacy into the school ecology.
Larson, R. W. (2000). Toward a psychology of positive Encourage students to explore and participate in
youth development. American Psychologist, 55, out-of-school interests (arts, music, sports, clubs,
170–183. etc.). Commit to helping all students engage in at
Daykin, N., Orme, J., Evans, D., Salmon, D., least one meaningful hobby and interest.
McEachran, M., & Brain, S. (2008). The impact Conduct environmental scans to identify a range of
of participation in performing arts on adolescent extracurricular participation options for students,

An important aspect of occupation-based practice when promoting mental
health in children is attention to the development of structured leisure
participation during out-of-school time. Extracurricular participation may be
included as a standard item on individualized education plans. Highly struc-
tured leisure activities are associated with regular participation schedules,
rule-guided interaction, direction by one or more adult leaders, an emphasis
CHAPTER 24 
health and behavior: a systematic review of the lit- both school- and community-sponsored options.
erature. Journal of Health Psychology, 13, 251–264. Provide coaching to help students with disabilities
McNeil, D. A., Wilson, B. N., Siever, J. E., Ronca, M., and mental health challenges successfully partici-
& Mah, J. K. (2009). Connecting children to recre- pate in structured leisure interests. Coaching may
ational activities: Results of a cluster randomized involve adapting entry into the activity and edu-
trial. American Journal of Health Promotion, 23, cating the coach or adult leader about strategies

School-Based Occupational Therapy

on skill development that increases in complexity and challenge, and perfor- 376–387. for promoting successful participation based on
mance that requires sustained active attention and the provision of feedback the individual needs of the child/youth.
(Mahoney et al., 2005). Correlational research has demonstrated a positive
relationship between participation in structured leisure and positive out-
comes such as diminished delinquency, greater achievement, and increased
self-efficacy and self-control (Larson, 2000).
Social and emotional In 1994, SEL was developed as a conceptual framework to focus on the Carter, E. W., & Hughes, C. (2005). Increasing social Investigate whether the school has adopted an SEL
learning (SEL) emotional needs of children and address the fragmented programs meant to interaction among adolescents with intellectual dis- curriculum. If so, become involved in school-wide
Website: www.casel.org address those needs (Coster et al., 1998). SEL is defined as “the process of abilities and their general education peers: Effective implementation.
acquiring the skills to recognize and manage emotions, develop caring and interventions. Research and Practice for Persons with Tune into student’s feelings daily. Simply asking,
concern for others, make responsible decisions, establish positive relation- Severe Disabilities, 30, 179–193. “How is your day going?” or “How are you feel-
ships, and handle challenging situations effectively” (Bazyk et al., 2015). Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Tay- ing?” can communicate an interest in the child’s
Programs developed to enhance SEL help children recognize their emotions, lor, R. D., & Schellinger, K. B. (2011). The impact of emotional life.
think about their feelings and how one should act, and regulate their behavior enhancing students’ social and emotional learning: Help students develop a feeling vocabulary and use
based on thoughtful decision-making (Cahill & Suarez-Balcazar, 2009). As A meta-analysis of school-based universal interven- words to express feelings. Foster the ability to
a national leader in the field, the Collaborative for Academic, Social, and tions. Child Development, 82, 405–432. recognize and respond to other’s emotions.
Emotional Learning (CASEL) focuses on the development of high-quality, evi- Payton, J., Weissberg, R. P., Durlak, J. A., Dymnicki, Refer to Illinois’ SEL academic standards to
dence-based SEL programs, promoting these as a necessary part of preschool A. B., Taylor, R. D., Schellinger, K. B., & Pachan, M. determine age-appropriate SEL expectations and
through high school education. Under the leadership of CASEL, the state of (2008). The positive impact of social and emotional intervention supports.
Illinois, by developing social and emotional learning standards for schools, learning for kindergarten to eighth-grade students: Embed SEL goals and activities into all interven-

651
has become an example for the nation. Findings from three scientific reviews. Chicago, IL: tions.
Collaborative for Academic, Social, and Emotional
Learning.
 652
SECTION V 
TABLE 24.6  Approaches Applied in School Mental Health—cont’d
Approach Description Supporting Evidence Implications for Occupational Therapy

Pediatric Occupational Therapy Services

Positive behavioral PBIS are designed to prevent problem behaviors by proactively altering a Bradshaw, C. P., Koth, C. W., Thornton, L. A., & Determine whether your school has adopted PBIS
interventions and situation before problems escalate and by concurrently teaching appropriate Leaf, P. J. (2009). Altering school climate through as the behavioral framework. If so, explore
supports (PBIS) alternatives. school-wide positive behavioral interventions and opportunities to participate in and contribute to
Website: www.pbis.org PBIS is an implementation framework designed to enhance academic and supports: Findings from a group-randomized effec- school-wide PBIS committees.
social behavior outcomes for all students by: (1) using data to inform tiveness trial. Prevention Science, 10(2), 100–115. Help create environments that focus on proactively
decisions about the selection, implementation, and progress monitoring Bradshaw, C. P., Mitchell, M. M., & Leaf, P. J. (2010). promoting positive behavior.
of evidence-based behavioral practices; and (2) organizing resources and Examining the effects of schoolwide positive Collaborate with all school personnel to foster
systems to ensure implementation fidelity. behavioral interventions and supports on student consistency in communicating behavioral
This approach recognizes that several relevant factors can influence a student’s outcomes: Results from a randomized controlled expectations and reinforcing positive behaviors in
behavior, including those existing within the child and those reflected in effectiveness trial in elementary schools. Journal of classroom and nonclassroom settings.
the interaction between the child and the environment (Mankey, 2012). Positive Behavioral Interventions, 161–179.
School-wide PBIS systems support all students along a continuum of need
based on the three-tiered prevention model. For students receiving services
under IDEA, PBIS is mandated for those whose behavior impedes the child’s
learning or that of others (§614(d)(3)(B)(i)).
Mindfulness, Yoga, Mindfulness, yoga, and relaxation approaches are found to be promising Rempel, K. D. (2012). Mindfulness for children and Consider embedding whole-class and/or whole
and Relaxation practices in school settings for improving coping abilities and reducing youth: A review of the literature with an argument school mindfulness strategies during transitions
Approaches anxiety. Such practices help students “step back” from stressful situations by for school-based implementation. Canadian Journal or before tests. These activities can be as short as
teaching them how to purposefully and nonjudgmentally “be in the moment.” of Counseling and Psychotherapy, 46(3), 201–220. 1–2 minutes or as long as 5–10 minutes. Import-
Mindfulness helps calm and clear the mind to allow for focus attention. Wall, R. B. (2005). Tai chi and mindfulness-based ant calming strategies include: deep breathing,
Learning how to cope with stressful situations and everyday challenges is an stress reduction in a Boston public middle school. yoga, short meditations, sensory strategies,
important life skill for all children and youth. All children and youth experi- Journal of Pediatric Health Care, 19(4), 230–237. creative arts activities, and time spent in green
ence stress to varying degrees because of situational challenges (e.g., taking Zoogman, S., Goldberg, S. B., Hoyt, W. T., & Miller, spaces.
a test, entering a noisy environment, being teased, completing a difficult L. (2014). Mindfulness interventions with youth: A Deep breathing: have students take 3–5 deep belly
assignment, etc.). Feeling stressed and anxious can negatively impact student meta-analysis. Mindfulness, 6(2), 290–302. https:// breathes.
learning (e.g., difficulty concentrating) and everyday functioning (sleeping, doi.org/10.1007/s12671-013-0260-4 Yoga: have students stop and do a yoga pose. Sug-
eating, and socializing). gested program: Yoga4classrooms Card Deck and
training programs (www.yoga4classrooms.org)
 TABLE 24.7  Some Activities Provided by Occupational Therapy Under a Public Health Model of School Mental Health
Tier Student Populations Suggested Intervention Strategies
Tier 3: intensive interven- Mental health challenges and disorders: Analyze the student’s unique sensory needs and develop intervention strategies to promote sensory processing and successful function in
tions for students with • Anxiety disorders multiple school contexts (e.g., classroom, cafeteria).
identified mental health • Depression Identify ways to modify or enhance school routines to reduce stress and the likelihood of behavioral challenges.
challenges • Bipolar disorder Provide individual or group intervention to students with serious emotional disturbance (SED) through special education or Section 504 to
• Reduce symptoms asso- • Schizophrenia and other thought disorders enhance participation in education, social interaction, play and leisure, and activities of daily living (ADLs).
ciated with the mental • Autism spectrum disorder Assist teachers in modifying classroom expectations based on the student’s specific behavioral or mental health needs.
health challenge • Obsessive compulsive disorder Collaborate with the school-based mental health providers to ensure a coordinated system of care for students needing intensive interventions.
• Promote mental health • Posttraumatic stress disorder Assist in the implementation of the functional behavior assessment (FBA) and development and implementation of the behavioral inter-
and well-being • Severe emotional disturbance vention plan (BIP).
Tier 2: selective or targeted Situational stressors causing children to be Assist in early identification of mental health problems by providing formal and/or informal screenings of psychosocial and mental health
intervention for students at risk of mental health challenges: function to at-risk students (e.g., Strengths and Difficulties Questionnaire).
at risk of mental health • Disabilities (e.g., attention deficit hyperac- Recognize early signs and symptoms of mental illness at their onset and create intervention and or modifications to prevent acute illness
challenges tivity disorder [ADHD], autism spectrum, from occurring.
• Provide accommodations physical disabilities) Evaluate social participation with peers during all school activities, including recess and lunch.
and supports to foster • Overweight, obesity Analyze the sensory, social, and cognitive demands of school tasks and recommend adaptations to support a student’s participation.
participation • Poverty Provide early intervening services or Section 504 accommodations for students demonstrating behavioral or learning difficulties because
• Promote positive mental • Bullying of mild mental health disorders or psychosocial issues.
health and well-being Consult with teachers to modify learning demands and academic routines to support a student’s development of specific social-emotional skills.

CHAPTER 24 
Provide parent education on how to adapt family routines or activities to support children’s mental health, especially with high-risk children.
Develop and run group programs to foster social participation for students struggling with peer interaction
Provide psychoeducation in-services to educate teachers about the early signs of mental illness and appropriate accommodations.
Provide an in-service to school personnel, including the mental health providers, about occupational therapy’s distinct role in the promo-
tion of mental health and interventions for mental health dysfunction.
Tier 1: schoolwide, universal All students with and without disabilities and • Look for opportunities to teach students about mental health, what it is, and how to develop it (Jorm, 2012).

School-Based Occupational Therapy

• Promote positive mental
health
• Foster mental health
literacy
Adapted from Bazyk, S. (Ed.). (2011). Mental health promotion, prevention, and intervention for children and youth: A guiding framework for occupational therapy. Bethesda, MD: American
mental health challenges
• Adapt activities and/or the environment to promote enjoyable participation throughout the day (e.g., lunch, recess, classroom). Experi-
encing positive emotions is thought to contribute to mental health (Fredrickson, 2004).
• Mental health prevention: informally observe all children for behaviors that might suggest mental health concerns or limitations in
social-emotional development. Bring concerns to the educational team.
• Positive behavioral interventions and supports (PBIS): assist teachers and other school personnel in developing and implementing
schoolwide PBIS for various contexts: classroom, hallways, lunchroom, playground, and restrooms (e.g., establish clear rules, foster a
positive classroom environment).
• Provide in-service training to teachers and staff on the following topics:
• Sensory processing: how to adapt classroom practices based on students’ varying sensory needs to enhance attending and behavior
regulation (e.g., Alert Program, Zones of Regulation).
• Social-emotional learning (SEL): how to embed SEL activities into classroom routines and activities (e.g., identifying feelings, thinking
about how feelings influence behavior, perspective taking).
• Psychoeducation: educate teachers about the early signs of mental illness and proactive, strength-based prevention strategies.
• Provide tips for promoting successful functioning throughout the school day, including transitioning to classes, organizing work spaces
such as desk and locker, handling stress, and developing strategies for time management.
• Consult with teachers to help them recognize the student’s most effective learning styles. Ensure that students can meet classroom
demands and create modifications, if needed.
• Clearly articulate the scope of occupational therapy practice as including social participation, social-emotional function, and mental
health (all tiers).

653
Occupational Therapy Association; Bazyk, S., Schefkind, S., Brandenburger-Shasby, S., Olson, L., Richman, J., & Gross, M. (2008). FAQ on school mental health for school-based occupational
therapy practitioners. Bethesda, MD: American Occupational Therapy Association; and Jorm, A. (2012). Mental health literacy: Empowering the community to take action for better mental
health. American Psychologist, 67, 231–243.
654 SECTION V  Pediatric Occupational Therapy Services
BOX 24.8  Every Moment Counts Model Programs
Occupation-based model programs developed to be integrated throughout the school
day and after school have been developed, implemented, and evaluated. All pro-
grams have been developed by occupational therapists with the goal of building
capacity of children/youth, school personnel, and families to promote meaningful
and enjoyable participation in inclusive contexts throughout the day to enhance posi-
tive mental health. Program descriptions, instructions for implementation, and mate-
rials are free and downloadable on Every Moment Counts website (https://www
.everymomentcounts.org). Each program is described briefly below.
• Comfortable Cafeteria: This 6-week, 1-day/week program is embedded
during lunchtime with the purpose of creating a positive cafeteria environ-
ment so that all students can enjoy their meal and socialize with friends. The
ultimate goal of the program is to provide the cafeteria staff and students
with the necessary knowledge, skills, and resources needed to sustain a com-
fortable cafeteria environment. Some of the weekly themes include how to be
a good friend, have a mealtime conversation, respect and include others, and
eat healthy foods. In a mixed methods outcome study, statistically significant
improvements in pretest–posttest ratings of participation in and enjoyment
for students with low and mid-range scores at the outset was found. Addi-
tionally, cafeteria supervisors demonstrated statistically significant improve-
ments in perceptions of having the knowledge and skills to supervise and to
encourage healthy eating based on pretest–posttest ratings (Bazyk, Demir-
jian, Horvath, & Doxsey, 2018). Developed by Demirjian, Horvath, & Bazyk.
• Refreshing Recess: This 6-week, 1-day/week program is embedded during
recess with the purpose of creating a positive recess experience so that all
students can enjoy active play and socialization with friends. The goal is to
provide the recess supervisors and students with the necessary knowledge,
BOX 24.9 Evidence-Based Practice: Building Capacity of OTs to Address Children’s Mental
Health
In order to reduce the gap between new knowledge and action, a 6-month building
capacity process was developed and implemented throughout Ohio (2012–2015 to
foster knowledge translation (KT) and implementation of a public health approach
to mental health among occupational therapy practitioners participating in a Com-
munity of Practice (CoP). A one-group (n=117) mixed methods design using quantita-
tive (pretest-posttest survey) and qualitative methods (phenomenological analysis of
written reflections) was used to explore the meaning and outcomes of participation
in the building capacity process involving reading, discussion (in-person and online),
practice reflection, and community building. Statistically significant improvements (p
<.02) in pretest-posttest scores of knowledge, beliefs, and actions related to a pub-
lic health approach to mental health were found. Four major themes reflecting the
meaning and impact of the building capacity process emerged from the qualitative
Bazyk, S., Demirjian, L., LaGuardia, T., Thompson-Repas, K., Conway, C., & Michaud, P. (2015). Building capacity of occupational therapy practi-
tioners to address the mental health needs of children and youth: Mixed methods study of knowledge translation. American Journal of Occupa-
tional Therapy, 69, 6906180060p1–6906180060p10.
SUMMARY
Occupational therapists must skillfully combine a sound understand-
ing of occupational therapy’s role with children and youth with a cur-
rent understanding of the evolving school context. Over the past 10
years, special and general education services have gradually aligned
because of IDEA 2004 and ESSA, providing occupational therapists
with opportunities to expand their role, particularly in the direction of
promotion, prevention, and early intervention. Providing integrated
skills, and resources needed to sustain a positive recess environment. Some
of the weekly themes include how to be a good friend, engage in active play,
respect and include others, and interact as a team. (Developed by Mohler,
Kerns, & Bazyk.)
• Leisure Matters: The focus of Leisure Matters is to help all children and
youth explore, select, and participate in extracurricular leisure activities to
develop enjoyable and healthy hobbies and interests. OT Leisure Coaching is
the process used either individually with a child/youth and family, or within a
small group context to educate youth and families about the health benefits
of participation in enjoyable hobbies and interests, explore and participate in
leisure activities, and advocate for inclusive leisure participation in integrated
school and community-sponsored extracurricular activities.
• Calm Moments Cards: The Calm Moments Cards program was developed
to build the capacity of OTs and diverse school personnel (e.g., teachers, par-
aeducators) to recognize signs of stress and anxiety in students during 17 typ-
ical situational stressors (e.g., taking a test, completing a writing assignment)
and embed evidence-based strategies (cognitive behavioral, mindfulness, and
sensory) to help reduce stress and enhance emotional well-being in order to
improve school function. (Developed by Kolic, Deininger, & Young.)
• Making Connections and Learning Together (MCaLT): This peer medi-
ated intervention program, cotaught by the OT and teacher, engages students
in learning activities to create a positive, caring, and respectful social emo-
tional classroom environment. The interventions utilize selected children’s
literature, cooperative learning activities and self-regulation strategies.
(Developed by Kirschenbaum.)
data: (1) the building capacity process was both meaningful and enjoyable; (2) new
knowledge regarding mental health resulted in a change in thinking about the term
“mental health” to include promotion and prevention; (3) the experience evoked
strong emotions regarding participants’ occupational therapy identity reconnecting
them to our “OT roots”; and (4) changes in practice occurred. Greater confidence
empowered practitioners to actively advocate for and address mental health in big
and small ways.
Implications: occupational therapy practitioners need to create opportunities
for expanding new knowledge and strategically reflect on and apply new knowl-
edge to practice to articulate, advocate for, and implement practice changes
reflecting occupational therapy’s role in addressing children’s mental health in
everyday practice.
services in natural contexts, collaborating effectively with school per-
sonnel and parents, shifting from caseload to workload models, devel-
oping promotional and prevention strategies, and advocating for a role
in general education are among the important roles of occupational
therapists. By embracing these changes and developing the knowledge
and skills to work in new ways, occupational therapists can help all
children and youth participate successfully in and enjoy school.
 CHAPTER 24  School-Based Occupational Therapy
Summary Points
• IDEA (2004) and ESSA (2015) guide and regulate education for
students with and without disabilities.
• IDEA legislation provides a free and appropriate public education,
learning in the LRE, early intervening services, and integration of
therapy services in natural education environments. Section 504 of
the Rehabilitation Act allows occupational therapy to be provided
alone or in combination with other education services directly to
students or as program supports to teachers working with the stu-
dent (American Occupational Therapy Association, 2006). The
ESEA of 1965 was created to ensure that all children have an equal
opportunity to participate in and receive a good education at school
(Opp, 2007). ESEA was amended to ESSA (2015). Under ESSA
occupational therapists may function as specialized instructional
support personnel and participate in schoolwide systems of support.
• IDEA 1997 placed greater emphasis on the inclusion of students
with disabilities in general education by embedding special edu-
cation and related services in the classroom and extracurricular
activities when possible. IDEA 2004 expanded the role of occupa-
tional therapy in schools, particularly in health promotion and pre-
vention. Because of IDEA reauthorizations, school-based practice
includes two new groups of students more fully: (1) those in general
education without disabilities and (2) those with disabilities who
are older than 18 years and receiving transition services.
• According to Part B of IDEA, occupational therapy is considered a
related service to assist a child with a disability to benefit from spe-
cial education. School districts are legally mandated to provide the
services that a child requires to benefit from their IEP, and there-
fore occupational therapists are critical members of the educational
team. IDEA requires that states and public educational agencies
provide a FAPE to children with disabilities in the LRE. This legis-
lation also guarantees parents and children with special needs cer-
tain rights based on a set of procedural safeguards that dictate the
policies and procedures that educational teams need to follow to
comply with the law.
• Occupational therapists provide services to children in schools
in the LRE to support their educational goals and participa-
tion in education. They respond to referrals from teachers and
parents regarding children who may be struggling to engage in
school. They conduct evaluations and create intervention plans
with the educational team, child, and parent to address areas of
need.
• Integrated occupational therapy services provide opportunities
to work within a multitiered model involving promotional and
prevention efforts related to physical and mental health in addi-
tion to intervention for students with identified disabilities. At
the schoolwide level (tier 1), services are geared toward the entire
student body, including most students who do not demonstrate
behavioral or mental health challenges. At this level, the emphasis
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