EC 230 595 Hylton, Judith; And Others · Judith Hylton, Penny Reed Sandra Hall and Nancy Cicirello....

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EC 230 595

Hylton, Judith; And OthersThe Role of the Physical Therapist and theOccupational Therapist in the School Setting. TIES:Therapy in Educational Settings. Revised.Oregon Health Sciences Univ., Portland. CrippledChildren's Div.; Oregon State Dept. of Education,Salem. Regional Services for Students with OrthopedicImpairments.Office of Special Education and RehabilitativeServices (ED), Washington, DC.Sep 87G00863005578p.

Child Development and Rehabilitation CenterPublications, Oregon Health Sciences University, P.O.Box 574, Portland, OR 97207 ($8.00).Guides - Non-Classroom Use (055)

MFO1 Plus Postage. PC Not Available from EDRS.*Disabilities; Elementary Secondary Education;*Intervention; *Occupational Therapists; *PhysicalTherapists; *Staff Role; Student Evaluation; TimeManagementOregon

The manual aims to assist occupational and physicaltherapists in describing the differences between school-based therapyand clinic-based therapy, recognizing the primary role ofschool-based therapy in special education, identifying thetherapist's responsibilities in the Individualized Education Programdevelopment process, describing the therapist's role in delivering afull range of therapy services, and determining an appropriatedistribution of the therapist's tine. The manual distinguishes clinictherapy from school therapy; defines legal terms relating to schooltherapy; describes the responsibilities of therapists, therapistassistants, and classroom aides; discusses the therapist's role onthe multidisciplinary team and in the referral process; listsservices provided by therapists; outlines the range of interventionservices; presents a functional approach to treatment; and suggests aformula for determining caseloads. Appendices contain sample jobdescriptiions, excerpts from Public Law 94-142, licensing requirementsin Oregon, a list of acronyms, a directory of Oregon direct serviceproviders, and a review of "related services" requirements underPublic Law 94-142. (JDD)

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Reproductions supplied by EDRS are the best that can be madefrom the original document.

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r 1.

THE ROLE OF THEPI-IYSICAL THERAPIST

AN I) HOCCUPATIONAL

TI IIRAPIST IN rfHESCHOOL SETTING

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the ( )rt.),,mn I Icalit) tic a.nc.c s 1'ntv('rtitly And Ncelc)n I )(.1),unncnt c rl I'duc anon, 1(c gic in,11 sc.t ic es intwith )011( )pdER Impair nicnt I Cindcd by tlk 1 i S Ikiltattrrlenl kin( at lc in ()Iltcc ctl Speital

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App

THE ROLE OF THE

PHYSICAL THERAPIST

AND

OCCUPATIONAL

THERAPIST IN THE

SCHOOL SETTING

Judith Hylton, Penny ReedSandra Hall and Nancy Cicirello

September 1987

In writing this manual we have chosen to avoidawkward word combinations such as (s)he andhis/hers, and instead have selected to referto children as "he," therapists, teachers andaides as "she," and supervisors as "he." Wehope the reader will accept this style andfind it comfortable, for that is our intent.

Many people contributed their expertise, time and support to thisproject. We especially want to thank our field readers for their wellconsidered comments and suggestions. Our field readers for this manualwere:

Vicki Finn Bohling, Licensed Physical TherapistPhysical Therapy and Occupational TherapyProgram, Umatilla County Educational ServiceDistrict, Pendleton, Oregon

Patricia Tangeman, M.Ed., Physical TherapistAssistant Professor, Pacific UniversityForest Grove, Oregon

Bill Miller, Licensed Physical TherapistPhysical Therapy and Occupational TherapyProgram, Umatilla County Educational ServiceDistrict, Pendleton, Oregon

We also thank the physical and occupational therapists in schoolsthroughout Oregon who field tested these materials and offered manyvaluable suggestions for their improvement. We thank our fine supportstaff, Sharon Pearce, Dee Rauk-Besel and Jessie Taylor, for theirefficiency and good humor even while typing revisions of revisions.And we thank the children in Oregon's schools who have taught us how welearn.

We are grateful to Dr. Gerald Smith, Director of Training, UniversityAffiliated Program at Oregon Health Sciences University and toPatricia Ellis, Associate Superintendent of Speci21 Education, OregonDepartment of Education, whose vision was essential to the inception ofthis undertaking and whose support vastly contribute) to its successfulexecution.

We are iniebted to Allan Oliver, Art Director of the OHSU Design Centerfor his fine work and infinite patience in developing a cover designand to Greg Ellingson for his thoughtful translation of our scrubbymarks into clear illustrations.

I)

PREFACE

Project TIES: Therapy in Educational Settings is a collaborativeeffort conducted by the Crippled Children's Division - UniversityAffiliated Program at the Oregon Health Sciences University and theOregon Department of Education, Regional Services for Students withOrthopedic Impairment. Project TIES was funded by the U S Departmentof Education, Office of Special Education and Rehabilitative Services,grant number G008630055. The goal of this three year project is todevelop training materials for physical therapists and occupationaltherapists who work in schools with students who have a severeorthopedic impairment.

The content for these training materials was determined by therapistspracticing in schools in Oregon through a s,aries of formal and informalneeds assessments. Project staff then grouped the identified needsinto topical categories and determined which format - a manual or avideotape accompanied by a manual - would best convel, the content ofeach topic. Sixteen topics were identified, eight warranting coveragethrough both a videotape and a manual.

The training materials were developed primarily for therapists who arenew to the unique demands of the school setting or who have had littleexperience with children who have a severe orthopedic impairment.Other people such as administrators, teachers, aides and parents willfind these materials helpft.' in understanding what therapists do andthe rationale behind their efforts to integrate students' therapyprograms into the larger context of their educational programs.

The titles of thA manuals and videotapes planned for completion by May1989 are listed below. The titles are subject to change if similarmaterials become available through sources outside Project TIES.

Adapting Materials and Equipment, with videotape

Adaptive Physical Education, with videotape

Augmentative Communication, with videotape

Assessing Students' Need for Therapy

Considerations for Feeding Children Who Have a NeuromuscularDisorder, with videotape

Developing and Monitoring Intervention Programs

Developing Functional IEPs

Positioning and Handling, with videotape

Promoting Acceptance of Students Who Have a HandicappingCondition, with videotape

Role of the Physical Therapist and Occupa-ional Therapist inSchool Settings

Role of Teachers, Aides and Parents in Enhancing Therapy

Selected Articles on Feeding Children Who Have a NeuromuscularDisorder

Self Help Skills, uith videotape

Therapists as Consultants

Training School Personnel

Tri-wall Construction, with videotape

Project Director

Judith Hylton, M.S.Oregon Health Sciences UniversityCrippled Children's DivisionUniversity Affiliated ProgramPO Box 574Portland OR 97207

f" ,

Project Consultants

Penny Reed, Ph.D., Coordinator

Sandra Hall, O.T.R., Specialist

Nancy Cicirello, L.P.T.,Specialist

Regional Services for Studentswith Orthopedic Impairment

Oregon Department of Education1S7l NE Stephens StreetRoseburg OR 97470

TABLE OF CONTENTS

Competencies 1

School Therapy is Different than Clinical Therapy 2

Legal Definitions that Relate to School Therapy 4

Therapists, Therapy Assistants and Aides 5

Multidisciplinary Team 9

The Referral Process 11

Survival Kit #1 14

Services Provided by Themptsts in Schools 15

The. Range of Intervention Services 19

Survival Kit #2 28

Direct and Indirect Therapy Compared 29

A Functional Approach to Treatment 32

Survival Kit #3 33

Example of a Formula for Determining Caseloads 34

Survival Kit #4 41

APPENDICESA. Job Descriptions 42B. Excerpts from PL 94-142 52C. ORS. Occupational Therapy Licensing Law 55D. ORS. Physical Therapy Licensing Law 57E. Acronyms Used in Special Education 60F. Directory of Direct Service Providers 62G. Related Services and Medical Services 63

COMPETENCIES

Upon completing this manual, the therapist will be able to:

1. Describe the essential differences bettieen school-based therapy andclinic-based therapy.

2. Recognize the primary role of school -based therapy in specialeducation.

3. Identify the therapist's responsibilities in the different steps ofthe IEP referral process.

4. Describe the. therapist's role in ielivering a full range of therapyservices that includes direct and indirect therapy.

5. Describe how therapy activities relate to special education.

6. Determine an appropriate distribution of the therapist's time usinga formula that was devised for this purpose.

7. Demonstrate knowledge of the duties, responsibilities andqualifications of the physical therapist, occupational therapistand therapy assistant as indicated in a typical job description foreach.

1

r)

SCHOOL THERAPY IS DIFFERENT THAN CLINICAL THERAPY

It's different. It's just plain different. Therapy conducted inthe school is not the same as therapy conducted in the clinic. Therapydiffers in these two settings in terms of its intent, the role of thetherapist, the size of caseloads and the type of support available tothe therapist.

'Ierapy is usually undertaken as an adjunct to medicaltreatment for acute and chronic conditions to ameliorate an underlyingdisability. The goal of clinical therapy is to improve globalfunctioning through the use of a variety of modalities. Most studentswho receive therapy through the school have a lifelong chroniccondition for which there is no known cure. Therefore, therapy isprovided in the school to help the student access educational servicesand benefit from his educational program. In the school, educationalgoals hold a primary position while therapy goals are consideredsecondary and are undertaken to support the educational goals.

The intent of therapy in the school shapes a different rcle forthe therapist. While the clinical therapist delivers intensive directservices to fewer children, the school therapist delivers a wide rangeof services to a greater number of children. These services coverconventional individual therapy, as well as therapy within smallgroups; and consultation with others in the school, the community andthe student's home. The therapist may be asked to suggest activitiesthat will be conducted by teachers and aides. Thus, the schooltherapist is expected to share her knowledge and skills with others bydemonstrating and monitoring activities that are therapeuticallyappropriate.

Instead of enjoying ready access to the referring physicians andmedical teams as does the clinical therapist, the school therapist isoften cut off from these professionals and the availability ofinservice training related to the health sciences. Further, the schooltherapist may be perceived by others in the school as the genericmedical resource in the district and asked for advice on questionsoutside her realm of expertise.

The significant ways in which clinical therapy and school therapydiffer from one another are summarized below.

CLINICAL THERAPY SCHOOL THERAPY

Intent

Therapy goals are primary. Educational goals are primary.

2

CLIbTICAL THERAPY

To treat acute conditions

Characteristics

Smaller caseloads with extendedtherapy time

Services tend to be disciplinebased

Focus is on developmentalmilestones and components ofmovement

Few responsibilities aredelegated except to parents

Clients come to the clinics tosee the therapist

Support Available

Ready access to medical team

Inservice with other healthservices professionals

Supervision is given by anexperienced professional in thediscipline

Work with or near othertherapists

Availability of variety ofadaptive equipment

SCHOOL THFRAPY

To reduce effects of chronicconditions so child can benefitfrom the educational program

Larger caseloads with shortertime for therapy activities

Services are collaborative. Muchtime must be given tocommunicating with other serviceproviders

Focus is on functional skills andadaptations that promote theattainment of educationalobjectives

More responsibilities aredelegated

The therapist goes to thestudents who are in manydifferent settings spread over alarge geographical area

Educational team andadministration may not alwaysunderstand the therapist's role

Inservice with educationprofessionals

Supervision is given by aprofessional who is not atherapist

Little or no access to feedbackand support from other therapists

Scarcity of ready-made adaptiveequipment

3

LEGAL DEFINITIONS THAT ABLATE TO SCHOOL THERAPY

Public schools have not always provided physical and occupationaltherapy, nor have they always served children who are handicapped. Itwasn't unti 1975 when the U.S. Congress passed Public Law 94-142, theEducation for All Handicapped Children Act, that school districts wererequired by law to serve these children and to provide therapy to themso they might benefit from their education program. This law hasdramatically affected children who are handicapped, and it has shaped anew '.ole within the school3 for physical and occupational therapists.

In view of PL 94-142, physical therapy and occupational therapy inschool settings are considered to be related services that are providedto handicapped children so they may benefit from special education.These underlined terms are given very specific meanings by the lawsthat govern special education.

Related services means 'ransportation, developmental, corrective,and other supportive services such as physical and occupationaltherapy, speech pathology and audiology, psychologi.111 services,recreation, medical diagnostic and evaluation services, and counselingservices, and early identification and assessment of handicappingconditions as may be required to assist a handicapped child to benefitfrom special education.

Special education means specially designed instruction to meet theunique needs of a handicapped child. includes instruction in theclassroom, home, hospitals and institutions, and instruction inphysical education.

Handicapped children means any child who because of any of thefollowing impairments needs special education and related serlices.

mental retardationhard of hearingdeaf

speech impairedvisually handicapped

seriously emotionally disturbedorthopedically impaireddeaf-blindmulti-handicappedother health impairmentspecific learning disability

Please see appendix B for a reprint of the sections of PL 94-142 thatapply to physical therapy and occupational therapy in the school. Alsosee appendix G for a discussion of related services and medicalservices.

4

THERAPISTS, THERAPY ASSISTANTS and AIDES.

In schools therapists may work not only with therapy assistants bu'with instructional aides as well. The therapist-therapy assistantrelationship in the school and in the clinical setting is similar; thetherapist delegates work, including therapy activities she deemsappropriate to the assistant and supervises this work. Instructionalassistants, on the other hand, usually work under the direction of allassroom teacher and give no therapy, but may be trained by thetherapist in such things as positioning and handling, feeding andhelping students with motor activities.

OCCUPATIONAL THERAPY

Occupational Therapists and Certified Occupational Therapy Assistants(COTAs) provide services that promote improved quality of movement andposture, fine motor functioning, visual motor functioning andindependence in activities of daily living. They recommend, constructand teach others to use and maintain adaptive equipment for suchactivities as positioning, feeding, writing and the use of educationalequipment and materials.

PHYSICAL THERAPY

Physical therapists and Licensed Physical Therapy Assistants (LPTAs)provide services that promote improved quality of movement and posture,gross motor balance, strength and coordination, functional posture,appropriate positioning and mobility. They recommend, construct andteach others to use and maintain adaptive equipment such aswheelchairs, prone boards, and other devices used for positioning andmobility.

SUPERVISION

Assistants help the therapist assess student's needs and help planIndividual Education Programs, and they impLement therapy programs thathave been developed under direction of their supervising therapist.

All therapy given by COTAs and LPTAs must be supervised by theirrespective supervising therapist. While the therapist need not obseveall of the assistant's activities, she must regularly monitor theseactivities through at least monthly contacts. The therapist andtherapy assistant must develop a plan to follow if the student's statuschanges rapidly or in an unexpected manner, and the therapist should,of course, be available to the assistant to answer questions and Lohelp with problem solving. The therapist reevaluates tt,e stu,Ient at

least yearly or more often if needed.

ASSIGNING RESPONSIBILITIES TO THERAPY ASSISTANTS

Therapists must use good judgement when assigning responsibilities to a

5

Ia. s)

therapy assistant. Therapists should assign only thoseresponsibilities that she judges as e7propriate and safe for the childand within the ability of the assistant to perform.

QUALIFICATIONS

COTAs and LPTAs must have graduated from a program that qualifies themfor an Oregon license as an occupational therapy or physical therapyassistant. Assistants, by nature of their training, are expected to beknowledgeable about handicap,ring conditions and the application ofrecommended treatment techniques. They are expected to understand theprinciples that govern normal development and learning.

INSTRUCTIONAL AIDES

Instrw.ltional aides are not legally qualified to give therapy. Theydo, however, play an important role in special education programs bycarrying out motor activities and instructional programs under thedirection of a classroom teacher. Although an aide's assignments areusually made by a teacher, the therapist and the teacher usuallycollaborate in matching motor activities with the aides ability tocarry them out.

JOB DESCRIPTIONS

Sample job descriptions, similar to those used in schools, for anoccupational therapist, a physical therapist, a COTA and an LPTA are inAppendix A of this manual. A comparison of the performanceresponsibilities for a therapist. , a therapy assistant and a classroomaide follows.

THERAPIST THERAPIST ASSISTANT

Assess student's levelof functioning andneed for therapy

Develop an IndividualEducational Program(IEP) for student inthe area of physicalor occupationaltherapy andparticipate in IEPmeetings with parents.

Assist in theassessment ofstudent's level offunctioning and needfor therapy.

Assist in thedevelopment of anIndividual EducationalProgram (IEP) forstudent in the area ofphysical oroccupational therapyand participate in IEPmeetings with parentsat the direction ofthe therapist.

CLASSROOM AIDE

Proviaes informationto the therapistabout the student'sfunctioning based onobservation.

Do not participate.

6

THERAPIST

Develop and implementtherapy programs tomeet IEP goals.

Design motor programsand teach parents,teachers, aides andother appropriatepersonnel to implementthem.

Collect and recorddata on therapyprograms.

Monitor and evaluatetherapy programs usingobservation, dataand/or pre-posttesting.

Manage studentbehavior duringtherapy.

Work cooperatively andcommunicateappropriately withteaching and supportstaff.

Develop and adhere toa daily schedule.

Order appropriatematerials andequipment; use andmaintain them.

Monitor and reportstudent performanceand progress.

THERAPIST ASSISTANT

Implement therapyprograms to meet IEPgoals.

Teach parents,teachers, aides andother appropriatepersonnel to implementmotor program asprescribed by thetherapist.

Same

Monitor therapyprograms usingobservation, dataand/or pre-posttesting.

Same

Same

Same

Same

Same

CLASSROOM AIDE

Implement motorprograms oractivities that arerelated to therapyand are recommendedby therapist ortherapy assistant.

Do not train others.

Same

Report student'sperformance on motorprograms to therapistor therapy assistant. .

Same

Same

As directed byteacher

Use and maintainselected equipment

Same

7

THERAPIST THERAPY ASSISTANT

Attend staff meetings Sameand serve oncommittees.

Complete requiredreports, IEP's andother forms promptlyand in an acceptablemanner.

Same

Negotiate professional Samegrowth goals withsupervisor.

Perform such othereducationally relatedduties as assigned bythe supervisor.

Same

CLASSROOM AIDE



Same

Same

S

MULTIDISCIPLINARY TEAM

The primary role of the therapist and of all other specialeducational staff in the school is to provide services that will helpchildren to benefit from their educational program. All of thetherapist's activities contribute to this role, whether she isdelivering therapy, consulting with other school staff, training andmonitoring others who conduct motor activities or participating in theIEP process. Underlying all of these activities is themultidisciplinary team process.

The multidisciplinary team process was introduced into specialeducation by PL 94-142 as a means to systematically address the diverseeducational needs of children with disabilities. A typical teamincludes parents, teachers and the related service providers (0T, PT,and speech-language pathologist). For instance, a child who has anorthopedic impairment, mental retardation and a speech disorder clearlypresents a multiplicity of needs that require the expertise of peoplefrom many disciplines. However, unless these experts work as a teamand regularly exchange information, they may each see the problems intheir area as paramount and de-emphasize problems in other areas,perhaps to the detriment of the child's progress.

When the multidisciplinary process is applied, the specialeducation teacher may look to the speech and language pathologist tohelp the child develop the functional communication needed for otherlearning. The speech and language pathologist in turn may rely on thephysical and occupational therapists to determine effectivepositioning, increase breath control and facilitate the studentshandling of learning materials. No single discipline has all theanswers. In fact, rarely can a single discipline even ask all thenecessary questions. People from different disciplines who come totrust one another's judgement, to learn from one another and to work

.together will be able to carry out comprehensive and coherenteducational programs.

Generally the student's teacher assumes a leadership role on themultidisciplinary team. This arrangement capitalizes on her greaterfamiliarity with the student and the school environment in which hefunctions and increases the possibility that IEP objectives will bewell integrated into the student's day. In other words, the teacherusually guides the team in selecting or prioritizing objectives for thestudent's IEP.

As with any team, the multidisciplinary team is a group of peoplewho work together to achieve a common goal: to develop and conductappropriate Individual Educational Programs for students who have adisability. This means the multidisciplinary process operates duringtreatment while the IEP is being implemented as well as duringassessment and the IEP meeting. In order to achieve this goal, eachteam member must be committed to the following:

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1. Focusing team efforts on addressing the needs of students byintegrating assessment information and developing IEP goalsbased on input from all pertinent disciplines.

2. Meeting periodically, whether formally or informally, toexchange information and keep one another abreast of changes inthe student's program.

3. Demonstrating a high level of competence in one's owndiscipline so that contributions are valuable.

4. Demonstrating respect for the contributions from the otherdisciplines by actively seeking ways to incorporate theirassessment data and recommendetions into the IEP.

5. Consciously and contimally working to educate one ancther inone's own discipline by welcoming questions, explaining termsand concepts in everyday language and avoiding discipline-boundjargon.

10

THE REFERRAL PROCESS

Before a student may receive special education and any relatedservices such as physical or occupational therapy that are paid for bythe school, certain procedures must be completed. These procedurescomprise the Referral Process, and are required by PL 94-142 and byState law. Essentially the process provides a means to identifychildren who qualify for special education and related services,determine their needs, develop a written plan for meeting these needs,implement the plan and assess its effectiveness.

As long as school districts comply with the minimum requirementsof the laws that govern them, they may develop their own procedures.Therefore, procedures tend to vary a great deal from district todistrict.

The referral process, along with the role of the physical oroccupational therapist is outlined below.

REFERRAL PROCESS THERAPIST'S ROLE

Referral

The student is referred forassessment by a parent, teacher,or other professional.

Screening

The student is screened todetermine if he demonstrates anyproblems that should be referredfor assessment.

Assessment

The student is assessed byappropriate qualifiedprofessionals.

Therapists may refer students.

Therapists may screen students.

Under Oregon law a physicaltherapist requires a physician'sprescription to assess and treat.

If the referral questions orconcerns relate to therapy needs,or if the assessment teamidentifies such needs, thestudent is assessed by a physicaland/or occupational therapist whodetermines the his needs anddevelops recommendations formeeting those needs.

11

REFERRAL PROCESS

Eligibility

The school eligibility teamreviews the assessment data anddetermines if the student iseligible for special educationand/or related services.

Individual Education Program(IEP) Meeting

Here, a multidisciplinary teamcomprised of the student'sparents and the professionals whoassessed him meet to synthesizetheir findings and develop awritten plan for meeting thestudent's needs. The student'sschool placement is a part of theIEP. The IEP must be updated atleast annually, or as needed.

Implementation

The IEP is implemented. Specialeducation and related servicesare started.

Assessment

Periodic assessments areconducted to determine if the IEPis meeting the student's needs.

tit)

THERAPIST'S ROLE

The therapist may or may notserve on the eligibility team.However, her findings will beused to help determineeligibility.

The therapist serves as a fullmember of the team, reporting herfindings, asking questions ofothers, answering questions andmaking recommendations for thewritten IEP.

The therapist carries out theparts of the IEP that relate toher area of responsibility. Shemay provide direct service,monitor other adults or provideconsultation as indicated in theIEP.

The therapist may conduct formalassessments, informal assessmentsor serve as a consultant, asappropriate.

12

REFERRAL PROCESS

Assessment continued

Each student is formallyreassessed every three years todetermine if he is still eligiblefor special education and relatedservices. Students who no longerrequire therapy meet the criteriafor exiting from this service.These students may, however,continue to need specialeducation. The IEP is reviewedat least annually and updated.

r. A

THERAPIST'S ROLE

The therapist conducts a formalassessment every three years todocument the student'seligibility for service.

13

SURVIVAL KIT #1

Welcome to school. Your particularunderstanding of students' needs and yourexpertise are much needed.

Become knowledgeable about the policies andprocedures of your school district as theyrelate to carrying out your job. Evenfederal laws may be complied with through avariety of different procedures.

Learn how best to access the teacher so youcan discuss cases with her.

Be assertive about your professional growthand supervision needs. You know thembetter than anyone else does.

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SERVICES PROVIDED BY THERAPISTS IN SCHOOLS

Therapeutic intervention as applied in the school is typicallydivided into eleven functional areas as outlined on the following threepages. The terms used to designate these areas will be familiar tomost therapists. However, the services pl:ovided in the school settingmay differ somewhat from those provided in the clinical setting.

Often the student will receive intervention in more than onefunctional area simultaneously. For example, a student who is learningto become independent in toileting may receive services in thefollowing functional areas:

Communication To signal when he has to leavethe room to go to the bathroom.

Functional Mobility

Environmental Adaptations

Self Help

To ambulate from the classroom tothe bathroom and back. Totransfer from a walker to thetoilet and back.

To use grab bars, an adaptedbathroom stab. and adaptedfaucet.

To clean self, unfasten andfasten clothing and to wash anddry hands.

School therapists are constantly challenged to apply therapiesthat relate to the school environment. The next two pages containdescriptions of some of the services that can be provided within eachof the eleven functional areas and notes about their relationship toeducation.

FUNCTIONAL AREA

Self help

SERVICES PROVIDED RELATIONSHIP TOEDUCATION

Mobility and transferskills, feeding,adaptive equipment,wheelchairs, splints,braces, artificiallimbs, PT/OT.

Adaptive equipment forgrooming, toileting,and feeding, adaptiveclothing, OT.

To permit the studentto manage personalneeds in the classroomand school withminimum of assistance.

15

FUNCTIONAL AREA

Functional Mobility

EnvironmentalAdaptations

Positioning

SERVICES PROVIDED

Equilibrium andbalance reactions,transfer skills,PT/OT.

Gait and pre-gaitevaluation andtraining with orwithout ambulationaids, PT.

Recommend modificationof school's orstudent's equipment,removal ofarchitecturalbarriers, PT/OT.

Positioning withadaptive devices,handling methods,range of motion, skincare, splints andbraces, PT/OT.

Neuromuscular and Muscle strength,Musculoskeletal Systems endurance, range of

motion, gross and finemotor coordination,motor planning, oral-motor control, controlof muscle tone andintegration ofdevelopmentallyappropriate reflexesand reactions as thebasis for more normalmovement, PT/OT.

Adaptive equipment toimprove eye-handcontrol, OT.

Musculoskeletaldeformities anddeviations, PT.

RELATIONSHIP TOEDUCATION

To permit the studentgreatest freedom ofmovement within theeducational setting.

To permit the studentaccess to and mobilitywithin the educationalenvironment.

To maintain thestudent in the bestposition for learningand functional use ofhands.

To enable the studentto participatemaximally in schoolactivities, and remainin school a fullschool day. Toincrease speed,accuracy and strengthin manipulative skillsin pre-academic andacademic tasks.

16

FUNCTIONAL AREA

Sensory Processing

Adaptive Equipment

Fine Motor

SERVICES PROVIDED

Equilibrium andprotective reactions,muscle tone,integration of touch,visual auditory,proprioceptive, andkinesthetic input,motor planning,coordination of thetwo sides of the body,PT/OT.

Evaluate, recommendand constructpositioning devices,modify existingdevices, PT/OT.

Provide devices tofacilitate fine motortasks, e.g., improvepencil grip, OT.

Evaluate and improvefine motor functionssuch as reach, grasp,object manipulationand dexterity, OT.

RELATIONSHIP TOEDUCATION

To facilitate thestudent's ability toprocess and respond tosensory and motorinformation as afoundation fordeveloping gross andfine motor skills andfor organizingattention andbehavior. To helpbridge the gap betweenunderlying sensoryprocessing abilitiesand developing higherlevel language andlearning skills.

To provide the studentwith a stable posturalbase to allow him tofocus attention oneducational tasks.

Provide the studentwith alternative meansto accomplishfunctional activitiessuch el writing,turning pages andmanipulating learningmaterials.

To facilitate thestudent's ability tomanipulate classroomobjects and tools suchas writing implements,puzzles and artmaterials. To enhanceparticipation inmanual classes such asshop and homeeconomics.

17

FUNCTIONAL AREA SERVICES PROVIDED RELATIONSHIP TOEDUCATIOM

Communication

Prevocational andVocational Skills

Evaluate and recommendappropriatepositioning ofstudent, adaptiveequipment andcommunication devicesnecessary forfunctionalcommunication (incoordination withspeech therapists),PT/OT.

General strength,sitting and standingbalance and tolerancq,motor coordination,adaptive equipment,PT/OT.

Vocational interestand aptitudeassessment andrecommendations forplacement,pre-vocationaltraining,social-emotionalreadiness, adpativehomemaking, OT.

Physiological Function Cardiorespiratoryfunction and fitness,muscularstrengthening, PT.

Body mechanics andenergy conservationtechniques, PT/OT.

To enable the studentto communicate ideasand answers toclassroom teacher andinteract with parentsand family.

To prepare the studentfor most independentlife possible,including vocationalplacement whenappropriate(supportive toeducational andvocational programs).

To strengthenmuscular, respiratory,and cardiovascularsystems to increaseendurance to remain inschool for a full day.

Adapted from: "School AdministrA.or's Guide to Physical Therapy andOccupational Therapy in California Public Schools," California Allianceof Pediatric Physical and Occupational Therapists, 40571 Ives Court,Fremont CA 94538.

18

THE RANGE OF INTERVENTION SERVICES

Because students present a broad array of needs and their needschange over time, schools offer a rang, of both special education andrelated services. Therapy services provided in schools are outlinedbelow, and those that may follow screening and evaluatior are presentedin more detail on pages 22-27.

AssessmentScreeningEvaluation

InterventionDirect Therapy

IndividualGroup

Indirect TherapyConsultation

CaseColleagueSystem

Monitoring

Providing a range of service options is in keeping with PL 94-142that stipulates a student must be educated in the least restrictiveenvironment. This means that a student must receive his educationalprogram in the most "normal" situation from which he can profit. Theenvironment that is least restrictive differs for each child and maychange with time. For example, the least restrictive environment fordoing upper body strengthening exercises may be the school weight roomfor a student who has spina bifida and can follow directions and safetyprecautions. It may be an adaptive physical education class for astudent who needs closer supervision, or a special education classroomfor a student who is noncompliant and easily becomes overstimulated. Atherapy room may be the least restrictive environment for a studentfrom a regular classroom who must remove some of his clothing duringtherapy so the therapist can observe and shape his movements.

Therapy needs vary from student to student. The student who worksin the weight room may need only periodic monitoring while the one inthe adaptive physical education class may need the therapist to consultfrequently with the teacher about his program. The student in thespecial education classroom may require group therapy and the one inthe therapy room may need individual therapy for a period of time.

Therapy should be matched to the student's needs. Some studentsrequire both direct and indirect therapy; for example, group therapyfor developing fine motor skills and consultation for adaptingmaterials and equipment. Depending on need, therapy services may bedelivered as often as two or three times a week or as infrequently astwo or three times a year, and the length of each contact may vary froma few minutes to an hour. The type, frequency and length of therapyservices would be altered to address a student's changing needs.

19

DIRECT THERAPY

Given either individually or in a small group of students, directtherapy requires a hands-on interaction between the therapist and thestudent. Direct therapy in the school is similar to therapy deliveredin the clinical setting where the student is helped to develop orimprove particular skills. However, in the school the termination ofdirect therapy rarely means an end to the service since the therapistis avialwole to monitor the student and to consult with the schoolstaff who work with 1,im.

INDIRECT THERAPY

Indirect therapy - monitoring and consultation - is recommended forstudents whose needs require no direct therapy and can be metadequately by a rJerson who is well trained and monitored by thetherapist. Such an arrangement has many merits. First, it meets thestudent's needs. Second, when the aide who conducts the student'seducational programs is also trained to carry out the motor programs,the student's 0601V is less disrupted, he has to adapt to fewer adults,and the people who work with him across several areas can build aconsistency into his environment. Third, an aide who is well trainedmay develop greater confidence and more easily learn new skills whenworking with other students during the same year or in subsequentyears, thus increasing the pool of competence within the school.Fourth, some therapists find that they gain an even betterunderstanding of their own discipline when they teach parts of it toother people.

CONSULTATION

Consultation can be divided into three levels: case, colleague andsystem. Case consultation focuses on a specific student. Here thetherapist trains teachers and other staff to carry out motor activities

other intervention strategies. In colleague consultation thetherapist may consult with another therapist about a student who isassigned to that therapist, provide training tc staff, or recommendsources of equipment, journal articles or other resources. Systemconsultation deals with school or district-wide issues such as planninga year-long inservice training program, making recommendations aboutdistrict special education policiies and overcoming or removingarchitectural barriers.

2.1P.ause the therapist brings a unique and much needed expertise to theschool, other staff members will look to her for general informationand for assistance with problem solving. Therapists may be presentedwith situations for which they have no ready answer and mustcollaborate with other staff persons in order to solve problems. Forexample, consider a situation in which a student ambulates with awalker and .an independently manage the distance between two classroomsbut requires supervision during class changes because she dawdles andtakes "side trips." This situation may require assistance from the

20

therapist, the school psychologist or the special education teacher.When these peoplo pool their knowledge of the student and of theirrespective disciplines, they can arrive at strategies that will teachthe student to function more independently by moving directly andunsupervised between two classrooms within a given period of time.

MONITORING

A student may require only periodic monitoring from the therapist ifhis physical condition remains stable and his educational needs arebeing met by his learning program. Monitoring may consist of directlyobserving the student in different school environments, talking withhis parents and school staff and conducting any needed assessments. Ifchanges in the student's physical status or learning program indicate aneed for further intervention from the therapist, then a brief periodof direct therapy and/or consultation may become the method fordelivery of this intervention. For instance, if a student's physicalstatus has remained static, but a new plan calls for him to activateelectric switches on a language board, he may need devices that promotethe most functional range of motion in his arms.

CONCLPSION

The lines between direct service, indirect service, case consultationand monitoring are often blurred. All may occur during a singleactivity. For example, while monitoring an assistant who is conductingtherapy activities such as positioning with a student, the therapistmay work directly with the rudent to determine which approach is mostappropriate for him. She may then consult with the assistant andteacher to explain and demonstrate this approach and to determine howthe positioning techniques can best be used throughout the student'sday. Thus, consultation is always a part of direct service (at theleast to apprise others of what is going on with the student) and somedirect service is always a part of consultation and of indirect service(using hands-on techniques to determine and demonstrate techniques thatare appropriate for the student).

During any of these activities: direct therapy, indirect therapy(monitoring and consultation) and training others, it is important thatall of the staff members recognize that they are participating in themultidisciplinary team process and that their common goal is to meetthe education needs of children who have a disability.

The following six pages present the range of intervention services,criteria that may be used for matching services to a student's need,and the characteristic of children for whom each service may beappropriate. These criteria and characteristics represent only one wayto conceptualize service delivery and may not represent your schooldistrict's policy.

21

DIRECTINDIVIDUAL THERAPY: The therapist works directly with the student in ahands-on or 1:1 manner. Included in this service is the very necessarycommunication with educational staff, family and medica) serviceproviders and participation in developing the IEP.

GENERAL CRITERIA

A student making rapid or moderate changes (improving or declining)

A new referral who will be reassessed after a trial period

A eery complex condition that requires skills from the therapist thatcannot easily be taught to other staff

TYPICAL APPLICATIONS

Children birth to approximately6 years

Student with muscular dystrophy,cerebral palsy, active juvenilearthritis, spina bifida,osteogenesis imperfecta,arthrogryposis

Student with recent head traumaor spinal cord injury,post-operative exercise needs

Student with hypotonia - "floppybaby"

Multiple involvement, i.e.,hearing impairment with motorproblems which interfere withsigning

EXAMPLES OF SERVICE

Feeding (oral/intor), gross motorand fine motor developmentrelated to educational andfunctional needs

Frequent re-evaluation todocument changes and revise IEP

Adaptive equipment (wheelchairs,splints)

Classroom positioning andadaptation of academic materialsand environment (posture seating)

Mobility training to attainindependence in school

Range of motion to preventdeformity and to promotestrengthening, sensory motor orself-help skills

Train staff to help student usenew skills under a variety ofconditions

Training to promote gross andfine motor skills

22

DIRECTGROUP THERAPY: The therapist works with a group of two to fourstudents. Other school staff may work with the therapist to servelarger groups of students. Service includes the necessary coordinationwith educational staff, family and community resources, andparticipation in IEP development.

GENERAL CRITERIA

Student is able to function as part of a group

Student is making steady but not rapid change (usually improving)

Student has needs similar to others in the group

School staff participates in conducting group, when possible


Developmental delay in studentsprimarily 3-9 years

Student with Down's Syndrome

Student with socio-emotionaldysfunction - autistic, behaviordisorder

Student with poor self-help .

Student with scoliosis skills

Student with sensory-integrativedysfunction

Students needing adaptations inorder to perform pre-vocationalskills

EXAMPLES OF SERVICE

Gross and fine motor development

Parent and staff training tocarryover program throughout thestudent's environment

Classroom positioning andadaptation of environment(posture seating)

Strengthening, self-help andsensory motor

23

INDIRECTCASE CONSULTATION: The therapist evaluates the student, observes himin the classroom and trains other staff to carry out herrecommendations. The therapist then periodically consults with thestaff. Consultation may include providing information and trainingthat will enable staff to carry out motor activities and problemsolving. At mid-year or at the teacher's request, the therapist willre-evaluate the student.

GENERAL CRITERIA

Student has achieved adequate skills for participation in theeducational program. The motor intervention program is static.

Student is making slow and predictable progress and needs opportunityto generalize skills through daily practice.

Teachers and aides can be taught to implement the therapy objectives.

Consultation may be ongoing.


Older student with cerebral palsywho has the needed adaptiveequipment and has reached maximumfunctional level

Student with muscular dystrophywho is not changing at presert

Student with spina-bifida, headinjury, or spinal cord lesion whohas developed adequate functionalskills and requires onlymonitoring of these skills

Student with inactive juvenilearthritis

Student who has received directtherapy for a substantial periodof time and can now benefit fromremaining in the classroom

EXAMPLES OF SERVICE

Training staff in positioning andhandling, and in use of adaptiveequipment

Adapting academic material

Consultation with adaptivephysical education staffregarding implementing program

Consultation with other therapyresources, educational staff, ormedical personnel

24

INDIRECTCOLLEAGUE CONSULTATION: This type of consultation addresses the needsof other professionals in the educational environment. It may or maynot be student specific.

GENERAL CRITERIA

Provides information to teachers, classroom assistants, speech andlanguage pathologists, other occupational or physical therapists andparents.

Occurs in response to requests.


New teacher or classroom Student moves to new school whereassistant who requires training staff are unfamiliar with histo adopt classroom activities needs

Therapist new to school whorequires consultation

EXAMPLES OF SERVICES

Training staff in appropriate Adopting therapy recommendationslifting techniques for classroom activities

25

INDIRECTSYSTEM CONSULTATION: These consultation services are related tosystemwide issues and require no direct involvement with students.

GENERAL CRITERIA

Provide information to administration staff, parents andrepresentatives from community agencies regarding systemwide policiesand procedures


Transportation

Architectural barriers

Community resources

Inservicing: Provide informationto better facilitate therapy as a"related service" such issues asthe referral process, screening,assessment, evaluation, andtherapy-related inservice

Administrative Services:Establish policies andprocedures, supervising PT/OTprograms, budget planning,screening applicants, supervisingPT/OT personnel, recruitment,clinical education, PT/OTstudents, PTA/OTA students,forms, letters

EXAMPLES OF SERVICES

Recommendations fortransportation and safetyprocedures: buses, ramps,wheelchairs, restraints, carseats

Analysis of and recommendationsfor removing architecturalbarriers

Recommendations for recreation,equipment, counseling

Providing inservice for:

AdministratorsTeachers, consultantsPhysical educatorsParentsBus drivers

26

INDIRECTMONITORING: "Monitor" means to watch or check on a person or thing.After a therapist evaluates a student, she may monitor his progress byperiodically observing him or talking with his parents or school staffwhether he receives therapy related activities or not. Monitoring mayinclude occasional hands-on interaction between the therapist and thestudent to assess the student's status so the therapist can update orrefine her recommendations. Monitoring is usually done in conjunctionwith consultation.

GENERAL CRITERIA

Student no longer needs direct service but is monitored on amaintenance basis.

Student showing little or no change.

The school program is meeting the student's needs.

The staff and parents need only a few recommendations from thetherapist.


Older mild cerebral palsy

Mild sensory integrativedysfunction with aocomodation

Mild muscle weakness with goodadaptive physical educationprogram

EXAMPLES OF SERVICE

Staff training regardingdisability and level of function,and signs of possible dysfunction

Parent training regardingadaptations for maximum functionand home therapy program

Consultation to support personnel(especially adaptive physicaleducation) so they can provideappropriate activities

Check on appropriate continuedcare i.e., keeping clinicappointments, monitoringappliances and adjustingclassroom equipment

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SURVIVAL RIT #2

Accept that therapy in the school mustsupport the student's functioning in thevarious school environments.

Recognize the classroom teacher as theperson in charge. She is in a position todecide how much time and effort will bedevoted to carrying out many of yourrecommendations.

Support others as they carry out motoractivities with students. People need yourfeedback in order to learn and they willprobably welcome a compliment about theirefforts.

Work with the educational team by givinginformation, ideas, enthusiasm and byencouraging contributions from others.

Before changing a student's program,observe him in the classroom and discussplanned changes with the teacher.

*******************************************

28

DIRECT AND INDIRECT THERAPY COMPARED

Direct and indirect therapy share many common features but dodiffer in significant ways. In both cases, the therapist assesses thestudent's needs, develops educational objectives and strategies to meetthese needs and, after the program has been implemented, assesses itseffectiveness. During direct therapy the therapist works with thestudent in a hands-on manner. However, during indirect therapy thetherapist works not on a one to one basis with the student but monitorshis progress and consults with the teacher or aide who is carrying outthe recommendations or the motor activities she has developed.

Direct Therapyvia "hands on"

interaction with the student

Indirect Therapyvia

monitoring and consultation

1. Assess the student to identify 1. Samehis areas of need, e.g., grossmotor, fine motor, self-help,etc.

2. Develop educational objectives 2. Samethat are based on assessmentinformation and environmentalneeds of the student.

3. Design a plan that includes 3. Sameteaching strategies, materialsand activities foraccomplishing the objectives.

4. Implement the interventionplan. The therapist worksdirectly with the student in ahands-on manner and mayinvolve others in implementingthe activities whenappropriate. Collect data onthe student's performance inorder to measure progress andto use in making decisionsabout changing programs.

4. Plan for the generalist toimplement the interventionactivities. Assess the schoolstaff's ability to implementthe plan and, if necessary,train them.

Periodically monitor theschool staff's performance toensure that the program ivcarried out appropriately andto recommend any neededchanges. Monitor for the datacollected by the school staff.

29

Direct Therapy Indirect Therapy

5. Assess the results of theimplementation plan. Alterthe program as needed.

r-; )

Monitor the student's progress byobserving him, discussing hisprogress with the teacher andparents and applying hands-onassessment and treatment, asneeded. Change his program asneeded.

5. Same

30

A FUNCTIONAL APPROACH TO TREATMENT

Clinic based therapists are adept in employing a developmentalapproach to treatment where they assess the child's developmentallevels, design a treatment program to move him to the nextdevelopmental milestone and then deliver the treatment. While it isappropriate to the clinical setting, a developmental approach alonedoes not meet the demands of the educational setting because it doesnot prepare the student to develop the functional skills needed in theclassroom. A functional approach considers the skills a student needsin the school and other environments and undertakes to help him achievethem.

GOALS Functional therapy aims to help students to benefit from theireducational program by providing therapy that focuses ongeneralization, independence, and transition. Therapy becomes morefunctional for a student when ha is able to generalize new skillsbeyond the therapy situation and apply them in a variety of everydaysettings. For example: the use of a simple communication board atschool to express needs becomes more functional if the board is used inall of the student's environments - at school, at home, grandmother'sand camp. Functional therapy strives to provide the student withskills and adaptations that allow him to become as independent aspossible in a variety of environments - the school, the home and thecommunity. Recognizing that life is not static for even the mosthandicapped student, functional therapy prepares students and theirparents for the inevitable transitions from one school setting toanother and from high school to a post high school, vocational schooland living settings. For example, before entering junior high school,a student may work on operating a combination lock for his locker,dressing down more quickly for gym and mastering a tape recorder fortaking classroom notes.

PROCESS Practitioners of functional therapy view the student from abroad perspective that includes the many environments in which thechild operates and the environments in which he is expected to operatein the future. The process of developing and delivering therapy thatis functional involves three basic steps: assessment, planning andimplementation as outlined below.

1. Assessment: Consider the student's various school, home andrecreational environments and the skills needed in theseenvironments.

A. Review the student's records and year-end reports to determinewhat treatment goals and strategies have been used before andwith what success. Ask yourself, "What has worked for thisstudent and what has not?"

B. Ask the teacher for her concerns. You might ask, "What areyour concerns for this student? What is interfering with hisparticipation in class and ability to learn?"

31

C. Observe the student in the classroom to determine thefunctional expectations that are held for him, and to identifythose he can and L.,nnot meet. Try to pinpoint why he is notmeeting these functional expectations. Ask yourself if hecould be more successful with environmental adaptations, betterpositioning, adaptive equipment, skill acquisition or alteredexpectations.

D. Conduct a formal assessment as appropriate. You may want tocollect some baseline data against which to measure progress.

E. Discuss with the parents the student's functioning at home.Determine how the parents help him gain skills for self-helpactivities, activities of daily living, and participating infamily recreational and work activities. Identify skills thatcould be used at home that will also be useful at school.

F. Consider whether the student is facing a major transition forwhich he needs to prepare.

2. Planning

A. In collaboration with the parents and other members of themultidisciplinary.team, develop functional goals for thestudent's IEP. Specify motor activities and otherrecommendations for meeting these goals.

B. During the IEP meeting, identify who will carry out the motoractivities and other recommendations that are developed by thetherapist.

C. Recommend ways therapy can help the student to meet othereducational goals that are developed during the meeting.

D. Identify opportunities for the student to generalize histherapy experiences to other situations and make generalizationa part of his IEP.

3. Implementation

A. Implement the IEP.

B. Mon.*.i*cr the student's progress and consult with the teacher oraide who is carrying out the motor activities andrecommendations you developed.

C. Be alert for needed changes in the student's program and makethem.

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SURVIVAL RIT #3

********************************* *** *It **

Do your part to maintain clear 4)communications. Ask questions when youdon't understand and accept questions fromothers as attempts to gain clarity.

Be flexible and go with the flow.

Sell therapy to educators in terms of itsability to promote educational coals. Planyour interventions around the educationalneeds that have been identified by the IEPteam.

Don't make the teacher's job more difficultby recommending numerous time consuming andhard-to-execute interventions. Remember,your job is to develop ways that help theteacher address a student's educationalneeds.

******************************************

33

EXAMPLE OF A FORMULA FOR DETERMINING CASELOADS

Many factors determine the amount of time available forintervention and thus influence the size of caseload a therapist canmanage. Tnese factors may vary from one setting to another and overtime. For example, more hours are needed at certain times forstaffings and documentation; at other times more are needed forevaluations and screenings. Fine tuning of a therapist's schedule andcaseload will permit maximum use of her time. Some of these factorsthat affect the size of a caseload are listed below:

1. Type and complexity of the handicapping conditions of students.

2. Type and amount of asseisment and intervention needed.

3. Amount of time required to travel to different schools.

4. Other duties required of the therapist: record keeping, meetings,diagnostic staffings, parent education, research, etc.

5. Amount of support available from aides, assistants, and clericalpersonnel, and the amount of monitoring time needed from thetherapists. (Allow three to five hours per week for each personthe therapist monitors, depending on that person's skill level. Anaide with basic training needs daily monitoring; an experiencedCOTA may need less direct monitoring.)

6. Number of community contacts with other agencies and physiciansthat are required.

7. Type of space and equipment available.

8. Amount of inservice training required for the therapist.

A common breakdown of a therapist's week who is employed 37.5 hours aweek follows.

Total working hours/week

Assessment, includingdocumentation andinformation gathering

Staffings and meetings

Consultation

Lunch

37.5

- 5.0

32.5

- 3.0

29.5

- 2.0

27.5

- 2.5

Instructional Time Available 25.0

34

The remaining 25 hours available for a caseload of students, includingdocumentation, preparation, and planning is shown graphically asfollows:

Lunch

IEPStallings, Meetings

Assessment

Consultation

{Intervention,Documentation,Planning

You can determine the instructional time available to you bysubstituting figures that reflect the amount of time you spend eachweek on each activity. Fo_ example, if you spend 5 hours per week inmeetings, substitute 5 hours for the 3 in the example. If all theother times remain the same then the instructional time available toyou is 23.0 hours.

The maximum number of students that can be accomodated on a therapist'scaseload is influenced by the types of assessment and interventionwhich are needed by the students. The following service deliverypattern forms a basis for the caseload formula.

I. AssessmentA. Screening

1. Type I (identify from the larger population)2. Type II (determine need for further assessment)

B. EvaluationC. Reassessment

II. InterventionA. Direct therapy

1. Individual2. Small group

B. Consultation1. ,Type I (Case)2. Type II (Colleague)3. Type III (System)

C. Monitoring

A formula which considers the variables of travel time, supervisiongiven, and type of service delivered can be applied to determine themaximum number of clients that can be served by a therapist.Documentation time (notes, reports, charts), planning and preparationare figured on a 1:4 ratio, or one hour documentation time for everyfour hours spent with students. Each type of intervention generallyrequires the following amount of time per week:

35

1 4,

DI - Direct, individual: one student per session, hour twice aweek plus * hour for documentation (1 hour + .25 hour = 1.25hours per student).

DG - Direct, group: group of four students, one hour, twice aweek (one-half hour per student) plus 1/8 hour documentation(.5 hour + .125 hour = .625 hour per student).

M MonitL.Ang: regular contact with student and/or teacher ofone leaf hour per week plus documentation (.625 hour perstudent).

T - Travel between schools (actual time).

S - Supervising aides and assistants (3 to 5 hours for eachperson supervised).

ITA - Intervention time available.

The formula for determining amount of intervention time available uses25 hours minus the amount of time devoted to travel and supervision.

Intervention Time Available = 25 - Travel time - Supervision time

ITA = 25 -

Caseload numbers can be figured using this formula:

ITA = 1.25 DI + .625 DG + .625 M

DIRECT SERVICE ONLYIn this formula the number of hours available for intervention

(ITA) equals the types of interventions (DI, DG, or M) times the timeneeded fcr each student. Therefore, a therapist who does not travel orsupervise and gives only individual therapy would figure a maximumcaseload as follows:

ITA = 1.25 Direct, Individual

25 = 1.25 DI

25/1.25 = DI

DI = 20

The maximum caseload for this therapist is 20 students.

MONITORING ONLYA therapist who monitors her entire caseload and does not travel

or supervise would figure her caseload as follows:

36

ITA = .625 Monitoring

25 = .625 M

25/.625 = M

M = 40

The maximum caseload is 40 students.

By substituting the number of intervention hours available in theformula, one can determine the appropriate number of students on amixed caseload. Conversely, by substituting caseload numbers in theformula, one can determine the number of therapy hours required perweek and the number of therapists needed for the caseload.

Example #1: An itinerant therapist travels five hours a week; one-half the intervention time is spent in monitoring and one-half indirect, individual sessions. Her intervention time available is 20hours (ITA = 25 - T); 10 hours each for monitoring and 10 forindividual sessions. Time for monitoring students equals the ITAdivided by .625. Therefore, the therapist can monitor 16 students(10/.625 = 16). The number of students for individual sessions equalsthe intervention time available divided by 1.25 or 8 students. Thetherapist's maximum caseload is 24 students. For the mathematicallyinclined, the formula is as follows:

t(25-T) = .625 M t(25-T) = 1.25 DI

1(25-5) = .625 M t(25-5) = 1.25 DI

20/2 = .625 M 20/2 = 1.25 DI

10 = .625 M 10 = 1.25 DI

10/.625 = M 10/1.25 = DI

M = 16 DI = 8

This therapist can handle a maximum of 24 students.

Example #2: A therapist travels three hours a week, has a caseload of12 for individual therapy. She has been requested to work withadditional students in small groups. The therapist needs to determinehow many students can be added. Intervention time available (ITA) is22 hours (25 T = 22). The time needed for individual students is thenumber of students times 1.25 or 15 hours, which leaves 7 hoursavailable for group sessions. The number of students which can beadded for group sessions equals the ITA divided by .625 or 11.2 (7/.625= 11.2). The therapist can add 11 students for a total caseload of 23.

37

25 - T = 1.25 DI 4. .625 DG

25 - 3 = 1.25 (12) 4. .625 DG

22 = 15 4. .625 DG

22 - 15 = .625 DG

7 = .625 DG

DG = 7/.625

DG = 11

Example #3: School district XYZ has 78 students who requireoccupational therapy services. It is estimated that 18 need individualintervention, 32 need group sessions and 28 need monitoring. The

school district needs to determine how many itinerant therapists tohire (each will travel 5 hours per week). The students who receiveindividual help will need 22.5 hours per week (1.25 times 18; thoseneeding group sessions will require 20 hours (.625 times 32), andmonitoring will require an additional 17.5 hours for the 28 students(.625 times 28). That is a total of 60 hours of intervention needed byoccupational therapists. Each therapist will have 20 hours available(because of five hours travel), so the district needs threeoccupational therapists.

X (25 - T)

X (25 - 5)

X (20)

X (20)

X

X

=

=

=

=

=

=

1.25 DI 4. .625 DG J. .625 M

1.25 (18) 4. .625 (32) 4. .625

22.5 4. 20 4. 17.E

60

60/20

3

(28)

Three therapists are needed for this caseload. ,

The following examples of caseload numbers were obtained by applyingthe formula. A maximum of 40 students is recommended.

38

,

Example #4.: The therapist spends 50% of intervention time w:Lthstudents in groups and 50% in individual sessions:

No travel

2 hrs. travel/week

4 hrs. travel/week

6 hrs. travel/week

30 (20 group, 10 indiv.)




Example #5: The therapist spends 75% of intervention time with groupsessions and 25% in individual sessions:

No travel

2 hrs. travel/week

4 hrs. travel/week

6 hrs. travel/week





Example #6: The therapist spends 100% of contact hours in groupsessions:

No travel 40

2 hrs. travel/week 36



Example #7: The therapist spends 100% of contact time in individualsessions:

No travel 20




39

The school-based itinerant occupational therapist can assume an averagecaseload of 20 - 40 students with a maximum of 40 students, includingmonitoring. If additional students will be added during the schoolyear, it is recommended that the therapist begin the school year with1 ess than a maximum caseload.

ITA = Intervention Time Available (25 hours per week)

T = Travel Time

S = Supervision Time

DI = Direct Individual (1.25 hours per student)

DG = Direct Croup ( .625 hours per student)

M = Monitoring ( .625 hours per student)

Case INo TravelNo Supervisory ResponsibilitiesCaseload of Individuals

Case IINo TravelNo Supervisory ResponsibilitiesCaseload of Monitoring

Cas,. III

Travel 5 hours per weekNo Supervisory ResponsibilitiesCaseload - Direct Individual

Monitoring

Case IVTravel 3 hours per weekSupervise 3 hours per weekCaseload - 1/3 Individual

1/3 Group1/3 Monitoring

Formula Computation

Adapted from "Guidelines for Occupational Therapy Services in SchoolSystems," American Occupational Therapy Association, Inc., 198

SURVIVAL RIT #4

Develop your organizational skills.Schools have an entirely differentstructure than a clinic does and they lackthe convenient appointment times used inthe clinic.

You are therapy's best advocate. Beprepared to exj':ess clearly and completelythe role of the therapist to teachers,administrators and parents.

Remember, what was true for the dinosaur istrue for us too. Survival depends on ourability to adapt to change.

*****************x*************************

41

AP El'ENMI CEZ

Statementof Duties:

SupervisionReceived:

SupervisionExercised:

PerformanceResponsi-bilities:

APPENDIX A

SAMPLE JOB DESCRIPTIONLICENSED PHYSICAL THERAPIST

Provide physical therapy services to handicappedstudents. These services a e assessment, directindividual and group therapy and indirect therapy in theform of consultation and monitoring. Therapy services

may include:

1. Activities that promote postural and gross motordevelopment; e.g., head control, sitting, andstanding balalnce.

2. Gait training and functional mobility for maximumindependence in the educational environment.

3. Wheelchair mobility, transfer skills, andpositioning.

4. Activities that improve strength and coordination,prevent deformity or enhance respiratory andcardiovascular function.

5. Evaluate adaptive equipment needs. Plan andconstruct adapted equipment, particularly forpositioning and mobility; e.g., fitting wheelchairs,prone boards. Monitor braces and prostheses.

Educational supervision will be provided by a certifiededucational administrator. Technical supervision will beprovided by a peer (contracted from an agency, viareciprocal peer review or by a state PT/OT specialist).

May supervise a Licensed Physical Therapy Assistant(LPTA) or an aide.

1. Under a physician's prescription, assess student'slevel of functioning and need for therapy.

2. Provide physical therapy input to the team fordeveloping individual education programs (IEPs) foreqch qualified student and participate in the IEPmeetings with parents.

3. Under a physician's prescription, implement therapyprograms to meet IEP goals.

4. Design motor programs and teach parents, teachers,aides or other appropriate personnel to implementthem.

rc

42

5. Collect and record data on therapy programs.

6. Monitor and evaluate the effectiveness of therapyprograms using observation, data and/or pre-posttesting.

7. Manage student behavior during therapy.

8. Work cooperatively and communicate appropriatelywith teaching and support staff.

9. Develop and adhere to a daily schedule.

10. Order appropriate materials and equipment; use andmaintain them.

11. Monitor and report student performance and progress.

12. Attend staff meetings and serve on committees asdirected.

13. Complete required reports, IEP's and other formspromptly and in an acceptable manner,

14. Negotiate professional growth goals with supervisor.

1 15. Perform other educational related duties as assignedby the supervisor.

Qualifica- 1. Knowledge of etiology, characteristics and prognosistions: of major handicapping conditions.

2. Knowledge of a variety of treatment techniques, andtheir indications and contraindications.

Ability to interpret physical therapy evaluations.

4. Knowledge of normal developmental sequences andlearning patterns.

5. Ability to work as part of a multidisciplinary team,consult with education staff and direct a licensedphysical therapy assistant, if necessary.

6. Graduation from a physical therapy school approvedby the Council on Medical Education of the AmericanMedical Associatior in collaboration with theAmerican Physical Therapy Association.

7. Must hold or be eligible for an Oregon Statephysical therapy assistant license.

43

8. Experience in a pediatric physical therapy settingis desirable.

9. Knowledge of the role of an assistant and theability to explain that role to others.

10. Ability to present inservice training or therapyrelated topics to parents, teachers and othersupport personnel.

44

Statementof Duties:

SupervisionReceived:

Supervision

Exercised:


SAMPLE JOB DESCRIPTIONCERTIFIED OCCUPATIONAL THERAPIST

Provide occupational therapy services to handicappedstudents. These services are assessment, directindividual and group therapy and indirect therapy in theform of consultation and monitoring. Therapy servicesmay include:

1. Fine motor functioning, e.g., grasp, coordination oftwo-handed activities.

2. Perceptual motor programs to improve motor planning,body scheme, visual and spatial perception,sequencing, and problem-solving.

3. Activities of daily living and independent lip .g,

e.g., feuding, dressing, toileting, home livingskills, working, and keyboarding to enhancefunctional ability.

4. Monitor the use of splints and other Adaptivedevices designed to enhance independence in theeducation setting, e.g., writing, typing, feedingand positioning.

Educational supervision will be provided by a certifiededucational administrator. Technical supervision will beprov.Aed by a peer (contracted from an agency, viareciprocal peer review or by a state PT/OT specialist).

May supervise a Certified Occupational Therapy Assistant(COTA) or an aide.

1. Assess studer.t's level of functioning and need fortherapy.

2. Provide occupational therapy input to the team fordeveloping individual education programs (IEPs) foreach qualified student and participate in the IEPmeetings with parents.

3. Implement therapy program:, to meet IEP goals.

4. Teach parents, teachers, aides or other appropriatepersonnel to implement motor programs.


6. Monitor and evaluate therapy programs usingobservation, data and/or pre-post testing.

tilt45







13. Complete required reports, IEP's, and other formspromptly and in an acceptable manner.


15. Perform such other educationally related dutires asassigned by the supervisor.


2. Knowledge of a variety of treattent techniques, andtheir indications and contraindications.

3. Ability to conduct and interpret occupationaltherapy evaluations.


5. Ability to work as part of a multidisciplinary team,

consult with education staff, and direct a licensedCOTA, if necessary.

6. Graduation from an occupational therapy schoolapproved by the AMA and the American OccupationalTherapy Association.

7. Hold or be eligible for an Oregon State OccupationalTherapy license.

8. Experience in a pediatric occupational therapysetting is desirable.

9. Knowledge of the role of an occupational therapistand the ability to explain that role to others.

46

r --''I)

10. Ability to present inservice training on therapyrelated topics to parents, teachers and other supportpersonnel.

47

SAMPLE JOB DESCRIPTIONPHYSICAL THERAPY ASSISTANT

Statement Provide occupational therapy services to handicappedof Duties: students. These services are assessment, direct

individual and group therapy and indirect therapy in theform of consultation and monitoring. Therapy servicesmay include:



3. Activities of daily living and independent living,e.g., feeding, dressing, toileting, home livingskills, working, and keyboarding to enhancefunctional ability.

4. Monitor the use of splints and other adaptivedevices designed to enhance independence in theeducation setting, e.g., writing, typing, feedingand positioning.

Supervision Educational supervision to be provided by a certifiedReceived: educational administrator and clinical supervision by a

Licensed Physical Therapist (LPT)

Performance. 1. Assist in essessing students' level of functioningResponsi- and need for therapy.bilities:

2. Assist in developing an Individual EducationalPrograms (IEP) for each student dnd participate inIEP meetings with parents at the direction of theLPT.

3. Implement therapy programs to meet IEP goals.

4. Teach parents, teachers or aides and otherappropriate personnel to implement motor programs asprescribed by the LPT.


6. Monitor therapy programs using observation, dataand/or pre-post testing.


48








15. Perform such other educationally related duties asassigned by the supervisor.

Qualifica- 1. Knowledge of etiology, characteristics andtions: prognosis of major handicapping conditions.


3. Ability to interpret physical therapy evaluationreports.


5. Ability to work as part of a multidisciplinary team.

6. Graduation from a physical therapy assistant schoolapproved by the Council on Medical Education of theAmerican Medical Association in collaboration withthe American Physical Therapy Association.

7. Must hold or be eligible for an Oregon Statephysical therapy assistant license.

8. Experience in a pediatric physical therapy assistantsetting is desirable.

9. Knowledge of the role of an assistant and th,ability to explain that role to others.

49

Statementof Duties:

SAMPLE JOB DESCRIPTIONOCCUPATIONAL THERAPY ASSISTANT

Provide occupational therapy services to handicappedstudents. These services are assessment, directindividual and group therapy and indirect therapy in theform of consultation and monitoring. Therapy servicesmay include:



3. Activities of daily living and independent living,e.g., feeding, dressing, toileting, home livingskills, working, and keyboarding to enhancefunctional ability.

4. Monitor the use of splints and other adaptivedevices designed to enhance independence in theeducation setting, e.g., writing, typing, feedingand positioning.

Supervision Educational supervision to be provided by a certifiedReceived: educational administrator and clinical supervision by a

Certified Occupational Therapist.


1. Assist in assessing student's level of functioningand need for therapy.

2. Assist in developing an Individual EducationalProgram (IEP for each qualified student andparticipate in IEP meeting with parents, at thedirection of the OTR.

3. Implement therapy programs to meet IEP goals.

4. Teach parents, teachers or aides and otherappropriate personnel to implement motor programs asprescribed by the OTR.


6. Monitor therapy programs using observation, dataand/or pre-post testing.


50





12. Attend staff meetings and serve on committees asdire,ted.



15. Perform such other educationally related dutires asassigned by the supervisor.



3. Ability to conduct and interpret occupationaltherapy evaluations.


5. Ability to work as part of a multidisciplinary team,consult with education staff, and direct a licensedCOTA, if necessary.

6. Graduation from an occupational therapy schoolapproved by the AMA and the American OccupationalTherapy Association.

7. Hold or be eligible for an Oregon State OccupationalTherapy license.

8. Experience in a pediat-ic :uyational therapysetting is desirable.

9. 11/4. -ledge of the role of an occupational therapista . the ability to explain that role to others.

51

C4)

APPENDIX B

EXCERPTS FROM PL 94-142

Occupational and physical therapy services as part of publicschool education are governed by Part B of the Education of AllHandicapped Children Act of 1975, Public Law 94-142. The intent of thelaw is expressed in its statement of purpose: "It is the purpose ofthis Act to assure that all handicapped children have available tothem, within the time periods specified, a free and appropriate publiceducation which emphasizes special education and related servicesdesigned to meet their unique needs." (P.L. 94-142, 1975, Sec. 3, c.)

Legal Definitions - Federal Code.

1. Handicapped - "The term 'handicapped children' means mentallyretarded, hard of hearing, deaf, speech impaired, visuallyhandicapped, seriously emotionally disturbed, orthopedicallyimpaired, or other health impaired children, or children withspecific learning disabilities, who by reason thereof requirespecial education and related services." (emphasis supplied)[20 U.S.C. 1401(1)].

The implementing regulation, 34 C.F.R. 8, further defines"handicapped children": "As used in this part, the term'handicapped children' mean those children evaluated in accordancewith Reqs. 300.530-300.534 as being mentally retarded, hard ofhearing, doaf, speech impaired, visually handicapped, seriouslyemotionally disturbed, orthopedically impaired, other healthimpaired, deaf-blind, multi-handicapped, or as havinr specificlearning disabilities, who because of those impairments needspecial education and related services."

2. Special Education - "The term 'special education' means speciallxdesigned instruction, at no cost to parents or guardians, to meetthe unique needs of a handicapped child, including classroominstruction, instruction in physical education, home instruction,and instruction in hospitals and institutions." (emphasissupplied)

3. Related Services - The term "related services" is defined at20 U.S.C. 1401(17): "The term 'related services' meanstransportation, and such developmental, corrective, and othersupportive services (including speech pathology and audiology,psychological services, physical and occupational therapy,recreation, and medical and counseling services, except that suchmedical services shall be for diagnostic and evaluation purposesonly) ast_ss.._22_Iandicaedthildtobeneffrom special education, and includes the early identification andassessment of handicapping conditions in children." (emphasissupplied)

52

C

An awareness of these definitions is crucial to understanding achild's entitlement of physical and e,:uupational therapy under the lawsgoverning special education programs. is the United States Departmentof Education specifically noted in 'ts comment immediately followingthe definition of special education found at 34 C.F.R. 300.14:

"Comment. (1) The definition of 'special education' is aparticularly important one under these regulations; since a childis not handicapped unless he or she needs special education. (See

the definition of 'handicapped children' in section 300.5.) Thedefinition of 'related services' (section 300.13) also depends onthis definition, since a related service must be necessary for achild to benefit from special education. Therefore, if a childdoes matmeg.12221112(112111911, there can be no 'relatedservices ' and the child (because not 'handicapped') is notcovered under the Act.'(emphasis supplied)

Under the law, children are not considered to be handicappedunless they actually need specially designed instruction or are foundto have a physical, mental, etc., disability which adversely affectstheir ability to learn. Supportive services such as physical andoccupational therapy are "related services," not specially designedinstruction. Federal law specifically provides that "related services"are to be provided to those children defined as "handicapped" under thelaw when such related services are required for the child in questionto benefit from the child's program of specially designed instruction.

Even when a child is handicapped (because the child needsspecially designed instruction), the child does not automaticallyreceive related services. Rather the child is entitled to receive

are required for the child to benefit from theprogram of specially deasigned instruction. Physical and occupationaltherapy services covered under P.L. 94-142 are only those serviceswhich enable the child to benefit from special education.

such related services as

The term "related services" means transportation, and suchdevelopmental, corrective, and other supportive services (includingspeech pathology and audiology, psychological services, physical andoccupational therapy, recreation, and medical and counseling services,except that such medical services shall be for diagnostic andevaluation purposes only) as may be required to assist a handicappedchild to benefit from special education, and includes the earlyidentification and assessment of handicapping conditions in children.[20 U.S.C. 1401(17)]

If it is determined through assessment/evaluation that the childis eligible for education related physical or occupational therapyservices, the IEP should note that physical and/or occupational therapyis the related services to be provided. Implementation strategies suchas Neurodevelopmental Treatment or sensory integration therapy are NOTidentified as related services and should NOT be listed as such. The

53

methods of implementation are to be determined by the provider of thatservice and may be reflected in the goals anu objectives of the IEP.(Education Due Process Reporter, 1981)

The IEP coals and objectives for physical and occupational therapyshould be directed to the identified educational needs of the studentand should be stated in such a way that they reflect that relationship,i.e., how will physical and occupational therapy assist the student tobenefit from his special education program. Documentation of thecomplete process is essential and should be written in aformat/language that is compatible with other educational documents.

Those students not identified as having exceptional educationalneeds as well as those students identified as having exceptionaleducational needs but who do not require physical and occupationaltherapy to benefit from their program of specially designed instructionare not eligible for related services.

Some examples of children who are not eligible to receive therapyas a related service are:

1. Students with a temporary disability such as a fractured leg,muscle injury, etc.

2. Students with a disability or a handicapping condition whichdoes not require the provision of specially designedinstruction. Examples of disabilities which may or may notconstitute hanicapping conditions are clumsiness, scoliosis,traumatic injury to nerves/muscle of the hand, mild cerebralpalsy, etc.

3. An amputee who is independent in the use of his or herprosthesis.

4. Any child who has reached maximum benefit from the therapysuch that direct therapy, monitoring and consultation is nolonger needed.

"'Nothing in the Act or the regulations prohibits the use of Site,local, Federal, and private sources of support, including insuranceproceeds, to pay for services that may be provided to a child....'(300.111 [d] [1]), as long as the parents are not changed." (FromFOCUS, A Review of Special Education and the Law, Volume 2, Number 4,September, 1982)

54

APPENDIX C

OREGON REVISED STATUTES

OCCUPATIONAL THERAPY

"Occupational therapy" means the analysis and use of purposefulactivity with individuals who are limited by physical injury orillness, developmental or learning disabilities, psychosocialdysfunctions or the aging process in order to maximize independence,prevent disability and maintain health. The practice of occupationaltherapy encompassees evaluation, treatment and consultation. Specificoccupational therapy services includes but is not limited to:Activities of daily living (ADL); perceptual motor and sensoryintegrated activity; development of work and leisure skills; thedesign, fabrication or application of selected orthotics or prostheticdevices; the use of specifically designed crafts; guidance in theselection and use of adaptive equipment; exercises to enhancefunctional performance; prevocational evaluation and training;performing and interpreting manual muscle and range of motion tests;and appraisal and adaptation of environments for the handicapped. Theservices are provided individually, in groups, or through socialsystems.

"Occupational Therapy assistant" means a person licensed to assistin the practice of occupational therapy under the supervision of, orwith the consultation of, an occupational therapist.

Qualifications for licensing occupational therapist. (1) Exceptas provided in subsection (2) of this section or in ORS 675.270, eachapplicant for licensure under ORS 675.210 to 675.340 as an occupationaltherapist shall:

(a) Have successfully completed an educational program inoccupational therapy recognized by the board, with concentration inbiological or physical science, psychology and sociology, and witheducation in selected manual skills.

(b) Pass to the satisfaction of the board an examinationconducted or adopted by the board to determine the fitness of theapplicant for practice as an occupational therapist or be entitled tobe licensed as provided in ORS 675.270.

(c) Have successfully completed at least six months of supervisedfield work that complies with rules adopted by the board.

Qualifications for licensing as occupational therapy assistant.Except as provided in ORS 675.270, an applicant for licensure under ORS675.210 to 675.340 as an occupational therapy assistant shall:

(1) Be at least 18 years of age.

55

(2) Have successfully completed the academic requirements of aneducational program for occupational therapy assistants recognized bythe board.

(3) Pass an examination conducted or approved by the board todetermine the fitness of the applicant for practice as an occupationaltherapy assistant.

(4) Have successfully completed at least two months of supervisedfield work that complies with rules adopted by the board. [1977 c.858S6; 1981 c.250 S4]

Definitions

"Supervision". as it is used in ORS 675.210(4). means ongoing, directionand instruction to establish and maintain an occupational therapyprogram service combined with observations and evaluation ofperformance of the occupational therapy assistant's services withoutthe necessity of the occupational therapist being physically present atall times when services are being conducted.

"Consultation". as it is used in ORS 675.210(4). means conferencesbetween the occupational therapy assistant and occupational therapistat least on a monthly basis to implement, discuss and observe patientactivity and maintenance programs.

Contact the Occupational Therapy Licensing Board for furtherinformation about laws governing the practice of occupational therapy.

Occupational Therapy Licensing Board908 State Office Building1400 SW 5th AvenuePortland, Oregon 97201

Peggy SmithExecutive Secretary229-5139

56

APPENDIX D

OREGON REVISED STATUTES

PHYSICAL THERAPY

"Physical therapy" means treatment of a human being by the use ofexercise, massage, heat or cold, air, light, water, electricity orsound for the purpose of correcting or alleviating any physical ormental condition or preventing the development of any physical ormental disability, or the performance of tests as an aid to thediagnosis or treatment of a human being. Physical therapy shall notinclude radiology or electro-surguery.

"Licensed physical therapist" means a professional physicaltherapist licensed as provided in ORS 688.010 to 688.220.

"Physical therapist assistant" means a person who assists alicensed physical therapist in the administration of physical therapy.[1959 c.461 S1; 1965 c.314 §1; 1969 c.339 Si; 1971 c.585 Si; 1975 c.111

Si]

License required to practice physical therapy or use designation.(1) Unless a person is a licensed physical therapist ir holds a permitissued under ORS 688.110, a person shall not:

(a) Practice physical therapy; or

(b) Use in connection with the name of the person the wards orletters, "P.T.", "R.P.T.", "L.P.T.", "physical therapist","physiotherapist" or any other letters, words, abbreviations orinsignia indicating that the person is a physical therapist, orpurports to be a physical therapist.

(2) Unless a person holds a license as a physical therapistassistant, a person shall not:

(a) Practice as a physical therapist assistant; or

(b) Use in connection with the name of the person the words orletters, "L.P.T.A.", "P.T.A.", "physical therapist assistant","licensed physical therapist assistant", or any other letters, words,abbreviations or insignia indicating that the person is a physicaltherapist assistant or purports to be a physical therapist assistant.[1959 c.461 S2; 1965 c.314 S2; 1969 c.339 52; 1971 c.585 S2; 1975 c.111

§2]

57

(Licensing)

Licensing procedure. Any person desiring to be a licensedphysical therapist or physical therapist assistant shall apply inwriting to the board, upon such form and in such manner as shall beprovided by the board. Each application shall include or beaccompanied by evidence, under oath or affirmation and satisfactory tothe board, that the applicant possess the qualifications prescribed byORS 688.050 (1) to (3) for applicants for licensing as a physicaltherapist and ORS 688.055 for applicants for licensing as a physicaltherapist assistant. [1959 c.461 §6; 1969 c.399 S3; 1971 c585 §3; 1975c.111 §4]

Qualifications of physical therapist; exam' Each applicantfor licensing under ORS 688.010 to 688.220 as physical therapist shall:


(2) Be of good moral character.

(3) Be a graduate of a school of physical therapy approved by theboard.

(4) Pass to the satisfaction of the board an examinationconducted by the board to determine the fitness of the applicant forlicensing as a physical therapist, or be entitled to be licensed asprovided in ORS 688.06041959 c.461 S5; 1971 c.585 §4; 1973 c.827 §73]

Qualifications of physical therapist assistant; examination. Anapplicant for a license under ORS 688.010 to 688.220 as a physicaltherapist assistant shall:


(2) Be of good moral character.

(3) Have completed to the satisfaction of the board a course forphysical therapist assistants approved by the board.

(4) Pass to the satisfaction of the board an examinationconducted by the board to determine the fitness of the (.pplicant forpractice as a physical therapist assistant, or be entitled to belicensed as provided in ORS 688.080.[1969 c.339 S5; 1971 c.585 §5; 1973c.827 §74; 1975 c.111 S5]

Temporary Permit. The Board, in its discretion, my issue withoutexamination a Temporary Permit to a person to practice physical therapyor as a physical therapy assistant in this State if the person files anapplication'for a license by examination as provided in Section 10-015or by endorsement as provided in Section 10-020 or 10-025 and pays tothe Board at the time of filing of such application the nonrefundablefiling fee set forth in Section 10-015 (2), 10-020 (1), and 10-025 (1)

58

as the case may be, and provides written proof that such person hasgraduated from an approved school and will be working under thedirection of a Licensed Physical Therapist. A person holding aTemporary Permit may practice physical therapy only under the directionof a Licensed Physical Therapist. Temporary Perm',: may be granted toendorsement candidates, pending receipt of examine Am scores, reportedfrom tia Interstate Reporting Service, provided all other applicationmaterials have been received by the Board Executive Secretary.Candidates for Oregon State Licensure by examination, who file acompleted application form may be granted a temporary permit until theresults of the next regularly scheduled examination are available tothe Board, who shall determine whether a permanent license shall beissued. A temporary permit shall not be issued to a previouslyunlicensed person who has failed any examination required under theserules or who has failed a similar examination in another state.Temporary Permits shall be granted for a period of not to exceed three(3) months and may be renewed by the Board at its discretion for anadditional three (3) months, but no longer.

Physical Therapy Licensing Board1011 State Office Building1400 SW 5th AvenuePortland, Oregon 97201

Lynn ChaseExecutive Secretary229-5043

59

APPENDIX E

ACRONYMS USED IN SPECIAL EDUCATION

APE Adaptive Physical Education

CCD Crippled Children's Division

COTA Certified Occupational Therapy Assistant

CSD Children Services Division

DD Developmentally Delayed (or) Developmentally Disabled

DRAC District and Regional Assessment Center Education,administered by Portland Public School District

ESD Educational Service District (such as the Lane CountyEducational Service District, most counties have an ESD)

IEP Individual Educational Plan

IFP Individual Family Plan

IPP Individual Pupil Plail

LD Learning Disabled

LEA Local Education Agency (or district such as the Salem PublicSchool District)

LPTA Licensed Physical Therapy Assistant

MDT Multidisciplinary Team

MR Mental Retardation (or) Mentally Retarded

MR/DD Mental Retardation/Developmental Disabilities

NDT Neurodevelopmental Treatment

ODE Oregon Department of Education

OT Occupational Therapist (or) Occupational Therapy

PT Physical Therapist (or) Physical Therapy

ROM Range of Motion

RSOI Regional Services for Students with Orthopedic Impairments

6;3 4

SEA State Education Agency (such as the Oregon Department ofEducation)

SED Severely Emotionally Disturbed

S/LP Speech/Language Pathologist

SOI Severely Orthopedically Impaired

61

APPENDIX F

DIRECTORY OF DIRECT SERVICE PROVIDERS

Crippled Children's Division (CCM.Regional Services Center

(Eugene) Clinical Services Building901 E. 18thEugene, Oregon 97340

686-35751-800-637-0700

P.O. Box 574(Portland) 707 SW Gaines

Portland, Oregon 97207

225-80951-800-452-3563

District and Regional Assessment Center DRAC)4620 SE Powell BoulevardPortland, Oregon 97206

280-5757

Emanuel Hospital and Health CenterChild Development Program2801 N. Gantenbein AvenuePortland, Oregon 97227

280-4505

Holladay Center2600 SE 71stPortland, Oregon 972:4

777-4505

Rehabilitation Insti.'ute of OregonGood Samaritin Hospital and Medical Center1040 NW 23rdPortland, Oregon 97210

229-7311

Shriners Hospital for Crippled Children3101 SW Sam Jackson Park RoadPortland, Oregon 97207

241-5090

62

APPENDIX G

RELATED SERVICES AND MEDICAL SERVICES REQUIREMENTSUNDER CURRENT LEGAL STANDARDS

Problems in the delivery of "related services" under P.L. 94-142continue as a major factor in educating handicapped children. Muchrecent publicity has focused on the attempt it California to reduce theprovision of occupational therapy in separate programs, and thelitigation which ultimately resulted in a requirement thatcatheterization be provided a child with spina bifida to enable her toattend her regular school classroom. (Reference: #1) Thesepublicised instances represent, to use the cliche, just the tip of theiceberg. The provision of related services by public educationalagencies everywhere scattered, haphazard, and problematic.

There is also general agreement among educational administratorsas to why this is the case. Many of the federally defined "relatedservices" have traditionally been available from community servicedelivery systems other than the schools. School staff have rarely beenqualified or trained to deliver such services. The problems ofinteragency coordination have too often been compounded in many statesby the withdrawal of other state agencies from providing these -- giventhat educational agencies are presumed to have primary respons ±bilityunder comprehensive special education statutes (whether P.L. 94-142 orsimilar state legislation). Related service requirements thus involvethe schools in novel areas of activity and relationships. Finally,such services inevitably are costly, putting pressure on local schoolbudgets which has been only partially alleviated by federal and statereimbursements or supplements.

It is not surprising that educators have tried to protect theirlimited resources by searching for the appropriate limits upon relatedservices. This course generally seeks to define various relatedservices as not being related at all -- that is, to assert that aparticular service is not of "educational" significance, but ratherarises from conditions which are not "educationally" related. Primaryvariants of this argument are the assertions that particular servicesare "medical" or "health" related, involve "life supports," or arisefrom "emotional," "family," or "social," rather than "educational"needs.

The following comments are intended as a review of the basic legalhistory which has resulted in current related services requirements atthe federal level. The extent of, and the limits upon, relatedservices has been the subject of critical judicial decisions.

I. Public Law 94-142

The related services requirements of P.L. 94-142 and itsregulations are familiar. As a general matter:

63

a 1.4

"The term 'related services' means transportation, and suchdevelopmental, corrective, and other supportive services . .

as may be req.,Ared to assist a handicapped child to benefitfrom special education ." [P.L. 94-142, Section 602(171)].

The regulations list many specifically required services, such as:

Moreover:

". . . speech pathology and audiology, psychologicalservices, physical and occupational therapy, recreation,early identification and assessment of disabilities inchildren, counseling services, and medical services fordiagnostic or evaluation purposes . . . school healthservices, social work services in schools, and parentcounseling and training." (P.L. 94-142 regulations,34 C.F.R. 300.13).

"The list of related services is not exhaustive and may,include other developmental, corrective or supportiveservices if they are required to assist a handicappedchild to benefit from special education." (300.13, Comment,emphasis added).

These are intentionally broad requirements. Realistically thereare only two limitations upon their scope:

1. if a service is not "required to assist a handicapped childto benefit from special education," and,

2. if, although a service is required in such a way, it is alsoa "medical" service for other than diagnostic or evaluationpurposes.

II. To Benefit from Special Education Only?

Many handicapped children, and particularly those with physicalhandicaps, may require supplemental services but in every other respectmay participate in the regular course of instruction. That is, theymay not need "special education" (defined in P.L. 94-142 as "speciallydesigned instruction . . . to meet the unique the needs of ahandicapped child" [Section 602 (16)], but might need a service such ascatheteriz&-ion or mobility assistance in order to remain in theregular classroom.

Stringing these provisions together literally, some educationalofficials have questioned their responsibility to provide supplementalservices to such handicapped children, given the lack of relationshipto "special education." Current legal requirements emphaticallyreject this attempt to limit service provision.

64

1.';1.1

The federal courts have emphasized that handicapped children mustbe afforded the opportunity to attend school, and to suffer noexclusion from school solely because of their handicap. Secondly,handicapped children should be educated in the "least restrictiveenvironment" (LRE) -- that is, to the maximum extent appropriate withnonhandicapped children, and in the regular classroom wheneverpossible. These more fundamental principles supercede any technicalinterpretations which might be discovered in the definitional nuancesof P.L. 94-142.

The federal courts have already considered these particularsituations. alndicapped children, who require assistance such ascatheterization, but who otherwise would attend the regular classroom(with no "special" education) must be provided those services. Onecourt found that such services were directly required by bothSection 504 and P.L. 94-142 to conform to the least restrictiveprovisions, and because failure to provide such services would amountto the illegal exclusion of the child from school. (Reference: #2)

More recently, a federal court of appeals confirmed thatcatheterization in such circumstances falls

"within a literal interpretation of the . . . (P.L. 94-142). . definition of related services. Quite simply but,without the provision of . . . (catheterization, the child). . . cannot be present in the classroom at all."(Reference: #1)

III. Related to "Educational" Needs

It is apparent, therefore that the courts will require delivery ofservices related to educational (whether "regular" or "special") needsof handicapped children. This linkage to "education" has oftendeveloped into consideration of just what the term education shouldencompass.

Traditionally, public schools have focused upon academic subjectsand skills -- those related to mental development or cognition. In

conformity to this tradition, many educators would suggest that many ofthe presumed "related services" are in fact not required foreducational purposes at all. Physical therapy is more properly"developmental" assistance, with no relation to academic achievement.Catheterization is in the nature of a "life support," and mental healthservices deal with emotional or social adjustment, not education.

The most notable impact of judicial developments is the expansionof the term "education" to encompass areas such as these which areimportant to handicapped children. Many of the basic skills which comeeasily to nonhandicapped -- walking, talking, basic self-care -- mayrepresent a high level of achievement for some handicapped children.Thus the federal courts have emphasized that "education" forhandicapped children may be directed at achieving "self-sufficiency . .

65

[or] . . . some degree of self-care." (Reference: #4)

As summarized by one commentator:

. . . education is concerned with much more than simply the'three R's': the definition would include instruction toteach one to dress oneself, toilet training, eating skills,and other self-help skills." (Reference: #5)

Similarly, what may be "related" to this broad objective isdefined expansively. Services are related whenever:

(a) "required to assist a handicapped child to benefit fromspecial education" [P.L. 94-142, Section 602 (17)];

(b) requred to meet the needs of handicapped children asadequately as the nonhandicapped [504 regulations,34 C.F.R. 104.33 (b)];

(c) required to enable the handloapped child to be in a regulareducational environment (34 C.F.R. 104.34);

(d) a service "arises from," or has a "connection to," the effortto educate or to equal educational opportunity(Reference: #1A) or;

(e) the service might be seen as a "prerequisite" to learning.(Reference: #6).

The net result is that the federal laws, eN'anded by federal courtdecisions, have adopted broad definitions of both "education" and"relatedness." In this context, tho effort to find substantial limitsupon the extent of related services runs counter to most legalprecedent.

IV. Judicial Responses to Specific Services

The strength of this legal precedent is manifest as one considersthe more common related services in detail. Consider the requirementsfor the delivery of the following specific services:

(1) Occupational Therapy.

Occupational therapy is specifically listed in the P.L. 94-142regulations (300.13), a status given some confirmation in a recentjudicial decree. (Reference: #7)

(2) Physical Therapy.

Physical therapy, like occupation& therapy, is listed in the P.L.94-142 regulations (300.13), and included in the recent consent decree.(Reference: #7)

(3) Catheterization.

Thought by many to represent a service on the boundary of related

6 66

services because of obvious "medical" aspects and "life support"characteristics, catheterization has been clearly designated a relatedservice by the courts. (Reference: #1,2)

(4) Mental Health Services -- Psychotherapy or PsychologicalCounseling.

It is extremely difficult ever to state categorically that mentalhealth services are not required for "social" or "emotional" reasons.But it is equally true that emotional problems will inevitably affectthe educational progress of a child. Whatever their cause, the effectsof emotional problems will generally simultaneously be "educational,"and "social," and "emotional." A broad concept of education virtuallyguarantees that emotional or psychological needs will generateeducational aspects.

And in fact this has been the basic judicial response whenconfronted with the issue. In one recent decision (Reference: #8), amultiply-handicapped child (with epilep'/, an emotional distrubance,and a learning disability) sought placement in a residential facility.That facility would simultaneously provide medical supervision,psychological support and special education. The court decided that"all oof these needs are so intemately intertwined that realistically itis not possible . . . to perform the Solomon-like task of separatingthem." (Reference #8) The local educational agency was required topay for all of the services. Another court in a similar situation(Reference: #9) simply decided that "psychological" services werespecifically listed within P.L. 94-142 [Section 602 (17)] and held thelocal educational agency fully responsible for their cost.

This simple summary of present lemal interpretations of relatedservices .ts that the most common areas of dispute have already beenconsidered in the courts, and the concept of related services has notbeen limited in any significant way.

V. "Medical" Services Limited?

P.L. 94-142 will not require a "medical" service (unless fordiagnostic or evaluation purposes), even if that service is in otherrespe.s related to educational needs. At first glance, this appearsto create a major limitation upon the extent of related servicesrequirements.

Many educational officials have argued that the specific servicesdescribed above (occupational therapy, physical therapy,catheterization, mental health services), as well as others, such asthe treatment of learning disabilities in a clinic, or administrationof drugs by school nurses, should p.operly be considered "medical" innature. By common experience and understanding, such services arefrequently delivered by "medical" staff (therapists, nurses, doctors .

.), in medical settings (clinics, hospitals . . ,) or with medicalequipment or rocedures (catheters, sanitary conditions . . .).

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But "medical services" is a very specific legal term inP.L. 94-142. Despite common usage of the word " medical," P.L. 94-142includes mlx services which are "provided by a licensed physician"[Regulations, 300.13 (b)(4)]. Thus any service which is otherwise arelated service, and which is provided by a nonphysician (includingtherapists, nurses, counselors, psychologists, audiologists . . .), isnot a "medical" service under P.L. 94-142 and thus may be aneducational responsibility.

It is worth noting that the cause generating the need for such aservice may be medical. Bladder problems (catheterization), or motordifficulties (physical therapy) may create the service need. But ifthat need can be met by nonphysicians, the service (if "educational")will generally be "related" under the law. This result is to beexpected. Most handicapping conditions can be described as "medical"in their origin, but the effect, and their amelioration, is ofteneducational, particularly so under a broad concept of education.

It is worth noting too that many services which in the abstractmight arguably be "medical" are specifically listed, for P.L. 94-142definitions, are "related." In addition to those mentioned already(0.T., P.T. . . .), one could add audiology, and school healthservices.

VI. Summary

It is apparent that the "related services" concept is extremelybroad and that it has been expanded, rather than limited, by mostjudicial interpretations. This result is not entirely attributable tothe passage of 94-142. Given an expanded school clientele, judicialconcepts of education, and educational opportunity, related servicesare merely those services inevitably associated with assisting childrenin reaching basic objectives such as walking, talking, socializing, orotherwise becoming prepared for life.

The judicial impact shculd not be disregarded. P.L. 94-142established more extensive federal involvement, funding, andcoordination of special education. services. But P.L. 94-142 cannot besaid to have created rights and obligations which otherwise would notexist. As the legislative history clearly demonstrates, P.L. 94-142"followed a series of landmark court cases establishing in law theright to an education for all handicapped children." (Reference:#10). It was those cases (Reference: #3, 11) which first solidifiedan expanded notion of "education" and the inevitable corollary andsupplemental services.

Similarly, judicial involvement in the existing context has bee.expansive. In part because catheterization is so clearly required forregular classroom attendance, while being so easy to administer, thecourts have refused to be diverted by technical applications ofP.L. 94-142 or the alleged potential of unlimited educationalinvolvement in "medical" or "life support" issues. Nor will the courts

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lam; rr

readily allow the child caught in the middle of interagency squabblesover the "educational" or "emotional" origins of his difficulties to gowithout services (Reference: #8).

VII. Implications

Expanded obligations will inevitably tax existing resources. Butas a legal, and perhaps even more importantly, as an eminentlypractical matter, the efforts to limit "related services" concepts seempeculilarly destined to fail.

It is indesputable that past efforts to access more resources haveencountered great difficulty. Coordination of diverse serviceagencies, which often have conflicting priorities, has been especiallyfrustrating. Nevertheless, there are many resources in mostcommunities which might cooperate in providing related services --under contract and frequently at low cost.

In light of the especially strong impetus to designate the schoolsas a lead agency, the efforts to minimize legal interpretations ofrelated services run counter to expanding concepts of educationentitlement. The better use of precious energy appears to be inoptimizing interagency cooperation, developing more efficient systems,reallocating existing funds and resources, and generating additionalresources whenever possible. These efforts will be required in anyevent, and are best commenced now rather than later.

References: Related Services, Focus, Vol. 1, #2, March 1981

1. Tatro v. State of Texas, 625 F 2d. 557, 5 Cir. (1980).1A. Tatra v. State of Texas, 481 F. Supp. 1224. N.D. Texas (1980).2. Hcirston v. Drosick, 423 F. Supp. 1980. S.D. W. Va. (1976).3. Pennsylvania Association for Retarded Children v. Commonwealth of

Pennsylvania, 343 F. Supp. 279. E.D. Pa. (1972).4, Fialkowski v. Shapp, 405 F. Supp. 946. E.D. Pa. (1975).5. R. burgdorf, Jr., The Legal Rights of Handicapped Persons

(Paul H. Brookes, Publisher), (1980), p. 187.6. nary B. v. Cronin, No 79-05383, N.D. Illinois (1980).7. ,iley v. Anne Arundel County Board of Education, No. K-79-2211,

U.S.D.C., Maryland (1980).8. North v. District of Columbia Board of Education, 471 F. supp.

136, D.C. D.C. (1979).9. In the Matter of the "A" Family, 602 P. 2d. 157. S.Ct., Montana.

(1979).

10. U.S. Congress, House of Representatives, Report 94-332. (June 26,1975, p. 3).

11. Mills v. Board of Education of the District of Columbia, 348 F.Supp. 866, D.C. D.C. (1972).

From Related Services in the Public Schools, Office of IndependentStudy, Division of Continuing Education, Colorado State University,Elnora Gritfoyle, editor, printed in Focus, Vol. 1, #2, March 1981.

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