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 Front Cover
 Preface
 Table of Contents
 Introduction
 Background
 Occupational therapy
 School-based occupational...
 Tables
 Conclusion
 Reference






Title: Occupational therapy : effective school-based practices within a policy context
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Table of Contents
    Front Cover
        Page 1
    Preface
        Page 2
    Table of Contents
        Page 3
    Introduction
        Page 4
    Background
        Page 5
    Occupational therapy
        Page 6
        Page 7
        Page 8
    School-based occupational therapy
        Page 9
        Page 10
        Page 11
        Page 12
    Tables
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
        Page 26
    Conclusion
        Page 27
        Page 28
    Reference
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
Full Text








Occupational Therapy: Effective School-Based
Practices within a Policy Context
Prepared for the Center on Personnel Studies in Special Education






by
Yvonne Swinth
University of Puget Sound
Karen C. Spencer
Colorado State University
Leslie L. Jackson
Easter Seals, Inc.





June 2007
COPSSE Document No. OP-3


Center on Personnel Studies in


UNIVERSITY OF FLORIDA


http://www.copsse.org










CENTER ON PERSONNEL STUDIES IN SPECIAL EDUCATION


UNIVERSITY OF FLORIDA

JOHNS HOPKINS UNIVERSITY

VANDERBILT UNIVERSITY

UNIVERSITY OF COLORADO BOULDER

INSTRUCTIONAL RESEARCH GROUP, LONG BEACH, CA

COPSSE research is focused on the preparation of special education professionals and its
impact on beginning teacher quality and student outcomes. Our research is intended to inform
scholars and policymakers about advantages and disadvantages of preparation alternatives and
the effective use of public funds in addressing personnel shortages.

In addition to our authors and reviewers, many individuals and organizations have contributed
substantially to our efforts, including Drs. Erling Boe of the University of Pennsylvania and
Elaine Carlson of WESTAT. We also have benefited greatly from collaboration with the National
Clearinghouse for the Professions in Special Education, the Policymakers Partnership, and their
parent organizations, the Council for Exceptional Children and the National Association of State
Directors of Special Education.


The Center on Personnel Studies in Special Education, H325Q000002, is a cooperative
agreement between the University of Florida and the Office of Special Education Programs of
the U. S. Department of Education. The contents of this document do not necessarily reflect the
views or policies of the Department of Education, nor does mention of other organizations imply
endorsement by them.
Recommended citation:
Swinth, Y., Spencer, K. C., Jackson, L. L. (2007). Occupational therapy: Effective school-based
practices within a policy context. (COPSSE Document Number OP-3). Gainesville, FL:
University of Florida, Center on Personnel Studies in Special Education.


IDEAs
thatWork
U. S. Office of Special
Education Programs


Additional Copies may be obtained from:
COPSSE Project
P.O. Box 117050
University of Florida
Gainesville, FL 32611
352-392-0701
352-392-2655 (Fax)

There are no copyright restrictions on this document; however,
please credit the source and support of the federal funds when
copying all or part of this document.









CONTENTS


Introduction...... .............. ........................................................ ........ .......... .......... 4

Background........................................ ........................ ... ... ...... .................5

Occupational Therapy..................................... ................. .................................. 6

School-Based Occupational Therapy.............................. ................................. 9

C o nclus io ns ...................................................................................................... 27

REFERENCES.................................. ..................... ......................................... 29

TABLES

Table 1. Summary of CEBM Levels of Evidence.....................................................13

Table 2. Databases Used.................................... ............... .............................14

Table 3. Search Term s.................................................... ....................... .........15

Table 4. Evidence for Occupational Therapy in the Schools..................................16









INTRODUCTION

The Individuals with Disabilities Education Act [IDEA] (2004) and the Individuals with
Disabilities Education Improvement Act [IDEIA] (2004) require schools and early intervention
programs to use appropriately qualified personnel to provide special education, related services,
and early intervention services. These services are designed to help meet the academic,
developmental, and functional needs of eligible children with disabilities. In the 2004
reauthorization of IDEA (P.L. 108-446), Congress determined that children's education could be
more effective by

... supporting high-quality, intensive preservice preparation and professional development
for all personnel who work with children with disabilities in order to ensure that such
personnel have the skills and knowledge necessary to improve the academic achievement
and functional performance of children with disabilities, including the use of
scientifically based instructional practices, to the maximum extent possible...
(601(c)(5)(E)).

Under the auspices of the federally funded Center on Personnel Studies in Special Education
[COPSSE], the authors for this report were charged with the task of reviewing the research to
identify evidence-based and effective practices for school-based occupational therapy [OT].
The purpose of this report, therefore, is to provide an overview of current research and evidence
that supports OT practices in schools, specifically children serviced under Part B of IDEA. While
Part C is equally important to address, this was not included in the charge for this report.
School-based occupational therapists, addressing the needs of students in preschool through high
school, are the primary audience for this report as are institutions of higher education that
prepare occupational therapists for school-based practice, school administrators who hire and
supervise occupational therapists, and the students and families who receive special education
and related services.









BACKGROUND

COPSSE examined personnel preparation as well as personnel competency and recruitment in
special education. The project's primary focus on special education teachers and administrators
was supplemented with a secondary focus on related service personnel in OT, physical therapy,
school psychology, speech language pathology/audiology, and school counseling. For each
participating discipline, reports were developed to clarify the current status of personnel
preparation, recruitment, and retention [For OT, see Swinth, Chandler, Hanft, Jackson, &
Shepherd (2003)]. Following completion of the reports, a research panel of related service
experts and researchers was convened to discuss the status of personnel preparation, competency,
and personnel recruitment in their respective fields. These experts were charged to develop a
comprehensive, interdisciplinary related service research agenda that identified a critical need for
scientifically based studies of the related service personnel practices and the impact on targeted
student outcomes (Rapport, 2004). Additionally, a consensus among panel members suggested
that related service professionals, in general, lacked needed competencies to use the available
research effectively to make everyday decisions regarding service planning and delivery.

Acting on the developed research agenda, the present report was prepared to help advance
evidence-based OT practice in schools and to facilitate occupational therapists' accountability
for targeted student outcomes, namely, educational participation to support academic
achievement and performance within the general curriculum and to include functional life skills
as required by IDEA and the No Child Left Behind Act. More specifically, this report describes
OT and then begins to identify effective OT practices and interventions.









OCCUPATIONAL THERAPY

This first section provides the reader with an understanding of the domain and scope of OT
services in educational settings. A basic understanding of OT therapy services in schools is
assumed. OT practice within educational settings enables students with disabilities or those at
risk for disability to engage in their everyday school occupations-comprised of many
overlapping and interrelated activities, including academic, social, extracurricular, and self-care
tasks.

In collaboration with other members of the education team, occupational therapists engage in
evaluation, intervention, and outcome processes when serving children and youth. OT services
always begin with the outcome in mind: What is it that the child and adolescent need or want to
do in order to be successful as a student? Student performance of education-related activities
based on access to and engagement in schooling represent the targeted outcomes for OT services.
Toward this end, occupational therapists may work to enhance: (1) student performance skills,
e.g., motor, process, communication/interaction skills; (2) performance patterns, e.g., needed or
important school habits, routines, roles; (3) the student's educational context, e.g., physical,
social, cultural, technology; (4) the student-activity match, e.g., space, objects, timing, student
function needed; and (5) individual student factors, e.g., body structures and functions.
(American Occupational Therapy Association [AOTA], 2002).

The majority of occupational therapists who work with children provide their services under the
auspices of the IDEA; and these services largely take place in schools and in early intervention
programs (Parts B and C of IDEA). According to Part B of the law (300.34(a)), OT is a
"related service" for eligible children aged 3-21 who require assistance to benefit from special
education and who have diagnosed disabilities that are physical, behavioral/psychosocial,
cognitive, or other delays that interfere with the child's ability to benefit from special education
(602(26)(A)). occupational therapists work not only with these children, but also with family
members, teachers and other school personnel, school administrators, and community healthcare
providers as needed. Education-related OT services may be provided in schools, early
intervention programs, homes, daycare programs, and community settings as appropriate.
Services are designed to enable students to access the general curriculum, perform educational
activities, and participate in their various student roles.

Evaluation

To achieve targeted performance outcomes and to design needed services, occupational
therapists start with an evaluation. Within an educational context, the evaluation uses
assessment tools and strategies that are educationally relevant and focused on what a student
currently does to participate in school activities and contexts. These assessment tools and
strategies examine the combined influence of individual characteristics, performance skills,
performance patterns (e.g., roles, routines); the educational context; and specific activity
demands. Subsequent OT intervention uses evaluation findings to help a student achieve
educational goals that have been established by the entire team, including family members
(Giangreco, 1995; IDEA, 2004). Educational goals may focus on academic and non-academic
(extracurricular) performance (Hanft & Place, 1996; IDEA, 2004).









Intervention


Occupational therapists working in educational settings with children from birth to age 21 use
their professional judgment (i.e., clinical reasoning); knowledge of the literature and research in
the field; findings from student evaluation processes; and team input before selecting an OT
intervention model (i.e., frame of reference or practice model) that has a theoretical and research
base. The intervention model or models determined to support optimally the student's
performance and participation in his or her education are selected. The occupational therapist
must also choose an intervention approach (i.e., how the services will be provided based on the
selected intervention model). Alternative approaches include promoting health,
remediation/restoration, maintaining or preserving current performance,
compensation/adaptation, or disability prevention (AOTA, 2002). An example of the
remediation/restoration approach is guiding a child's movement and posture on playground
equipment during recess for a child who is very unsteady. An example of the
compensation/adaptation approach involves analyzing the student's classroom environment with
the teacher to find a quiet work area for the child who overreacts to sensory input, e.g., sound,
visual stimuli.

According to the Occupational Therapy Practice Framework (AOTA, 2002), occupational
therapists may use four types of interventions. Each is briefly described here within an education
context. First, the "therapeutic use of self' includes the occupational therapist's strategic use of
his or her own personality, insights, or perceptions to affect the student's performance. It may
be used to form or maintain a motivating therapeutic alliance with the student, a group of
students, parent, or teacher. Second, occupational therapists may engage in the "therapeutic use
of occupations and activities." By engaging the student or groups of students in activities that
naturally occur within the educational context, the occupational therapist can provide
opportunities for students to become an active participant or to practice needed skills that will
enable full participation (in collaboration with teachers and other educational staff). Third,
occupational therapists may consult with the student, teachers, family members, or others by
collaborating with them to identify problems and potential solutions. Through collaboration with
other educational staff, the occupational therapist enables the "client" to solve identified
problems and is not solely responsible for the outcome. Fourth, occupational therapists may
provide education which includes sharing information and knowledge so that others may use it to
facilitate student performance and participation. For example, occupational therapists may
educate school staff about disability and its impact on student performance or conduct in-
services about child development. As with the intervention approach, specific type of OT
intervention should be described as part of the OT intervention plan, not within the IEP
document.

Outcomes

OT intervention must ultimately enable individuals, groups, or populations to engage in needed
and valued occupations. Such engagement can then facilitate participation in a variety of real-
life contexts (AOTA, 2002). Taken together, engagement and participation represent the desired
outcomes of the OT intervention process and are consistent with the educational outcome
expectations put forth by IDEA and NCLB.









In targeting engagement in occupation to support participation as the broad, overarching
outcome of the occupational therapy intervention process, the profession underscores its
belief that health and well-being are holistic and that they are developed and maintained
through active engagement in occupation. (AOTA, 2002).









SCHOOL-BASED OCCUPATIONAL THERAPY

Schools, which represent a major practice arena for occupational therapists, are also a critical
performance setting for children and youth in the U.S. Children may spend six or more hours a
day, five days a week in school-a sizable amount of time that carries with it high expectations
for learning and performance. In their student role, children and youth are expected to engage in
a wide variety of activities such as boarding and exiting the school bus, completing assignments
in math and language arts, playing kickball during recess, checking out library books,
participating in a school club or sport, taking standardized achievement tests, socializing with
peers at lunch or in the hallways, and managing personal care activities throughout the school
day. Successful access to educational activities by the student is obviously needed prior to
engaging in or "doing" the activity, and engagement is essential if the student is to participate in
the occupation of "student" at school (context). Meaningful student participation within the
educational context represents the desired outcome of OT services within a school setting. The
specific activities that comprise the "student role" are largely determined by teachers and other
members of the education team, not the occupational therapist. By collaborating with general
and special education teachers and participating as a member of the IEP team, occupational
therapists can help students access and engage in available education activities. For example, for
a kindergartener who is having difficulty manipulating classroom tools, e.g., pencil, ruler, or
scissors, the occupational therapist may work with the teacher to adapt the tools so the student
can complete classroom assignments and activities. For a third grader with autism who has
difficulty following classroom routines, the occupational therapist may work with the teacher to
help establish a picture schedule so the student can independently follow the routines. For a
Junior High student with cerebral palsy who is unable to participate in physical education [PE],
the occupational therapist may collaborate with the physical therapist and PE teacher to modify
and adapt the PE curriculum.

As part of providing OT services, as in the previous examples, the occupational therapist must
account for OT contribution to a student's education through measures or data that evaluate
activity access, engagement, participation, and ultimately student achievement within the general
curriculum. Occupational therapists' strategies to demonstrate positive student outcomes from
their efforts (e.g., data-based planning and decision-making strategies, effective use of
interventions based on evidence-based practice) will be discussed later.

Perspectives on Student Outcomes

Occupational therapists in the schools must consider outcomes within the context of the
environment and expectations their services are provided. In addition to the expectations of
parents, teachers, and students themselves, two federal education laws have established outcome
expectations for students with disabilities enrolled in public schools. The Individuals with
Disabilities Education Improvement Act of 2004 [IDEA] (P.L. 108-446) and earlier versions of
the law dating back to 1975 established clear outcome targets for children and youth with
disabilities receiving special education and related services in public schools. The Amendments
to the long-standing Elementary and Secondary Education Act, now entitled the No Child Left
Behind Act of 2001 [NCLB] (P.L. 107-110), specifies important educational outcome targets for
all students, including students who have disabilities. Educational outcome expectations based









on federal policy will be presented below and shown to be consistent with the OT profession's
view of appropriate student/client outcomes. It is critical for school-based occupational therapists
to have a good understanding of their professional domain of practice and expertise and to
understand the policy context within which they work. IDEA and NCLB laws and regulations
are essential reading for all school-based OT practitioners.

According to IDEA 2004, effective education for students with disabilities is based on high
expectations, participation, and progress in the general education curriculum alongside peers
without disabilities to the maximum extent possible. The law also expects students with
disabilities to ultimately exit school ready to assume productive and independent adult living
roles (601(c)(5)(A)). Measurable student progress within the general curriculum based on the
student's Individualized Education Program (IEP) is critical, but post-school performance
outcomes are the strongest indicators of the overall effectiveness of special education and related
services. Post-school engagement in paid employment, independent living, and post-secondary
education are among the post-high school outcome expectations for young adults with
disabilities as specified in IDEA (601(d)(1)(E)).

The importance of post-school outcomes as a measure of education effectiveness cannot be
overstated. After students with disabilities have received up to 19 years of publicly supported
instruction (general education, special education and related services), it is reasonable for
family members, general taxpayers, and policy makers to expect the vast majority of these
students to be prepared to assume productive and positive adult roles in their communities.
Even teachers and related service personnel who work with young children must hold high
expectations for these children to become productive and valued adults in their communities
eventually.

During high school and as students prepare to leave the public education system; the special
education team must increase its focus on preparing students to make the transition to post-
school roles and activities. By law, transition planning must begin when students are 16;
however, planning may begin earlier when needed. According to IDEA, transition is

... a coordinated set of activities for a child with a disability that-A) is designed to be
within a results-oriented process, that is focused on improving the academic and
functional achievement of the child with a disability to facilitate the child's movement
from school to post-school activities, including post-secondary education, vocational
education, integrated employment (including supported employment), continuing and
adult education, adult services, independent living, or community participation; (B) is
based on the individual child's needs, taking into account the child's strengths,
preferences, and interests; and (C) includes instruction, related services, community
experiences, the development of employment and other post-school adult living
objectives, and, when appropriate, acquisition of daily living skills and functional
vocational evaluation. (602(34)).

NCLB further reinforces IDEA's focus on student performance outcomes. Applicable to all
students, including students with disabilities, NCLB's call for accountability in the area of
educational achievement is one of the law's four main pillars; the others are greater freedom for









states and communities, a focus on using proven educational methods, and more choices for
parents. (http://www.ed.gov/nclb/overview/intro/4pillars.htm)

Educators and related services professionals are by now familiar with their own state's education
accountability system of written education standards and statewide testing of student
achievement. While controversial, accountability provisions in NCLB must be understood by all
personnel who work with students. Student outcomes-based state standards measured by state
tests (including approved alternative assessments for select students with disabilities) have
become a critical bottom line for schools and school districts. Education and related service
personnel who clearly contribute to this bottom line of student performance and achievement
within the general curriculum will be viewed as effective and valued team members. Related
service personnel may risk distancing themselves from responsibility for student performance on
NCLB accountability measures because they do not teach core academic subjects within the
general curriculum. These professionals are reminded that their job is to "assist a child with a
disability to benefit from special education" (IDEA, 602(26)(A)) and ensuring student "access
to the general education curriculum in the regular classroom, to the maximum extent possible"
(601(c)(5)(A)). Clearly, occupational therapists and other related service personnel share
responsibility with other members of the education team for student academic performance in
addition to developmental and life skill performances.

Research

Terminology and background. Different terms are used to refer to interventions supported
by research. In the education field, one sees the terms research-based intervention and
scientifically based research used interchangeably. In OT, one finds the term evidence-based
practice [EBP]. In general, all these terms refer to the central role that high-quality research
plays in determining which interventions are most likely to produce the targeted or desired
outcomes for students who have disabilities. There is, however, a difference between how the
education field and the OT profession view evidence.

This report uses the term evidence-based practice to mean practices that are well supported by
high-quality research. By comparison, the term effective practice describes practices that have
preliminary research support (including qualitative studies) or are "promising practices" based
on the systematic collection of student performance data and student participation outcomes.

In OT, evidence-based practice concepts are rooted in the field's early ties with healthcare and
medicine. OT has adopted the definition put forth by Sackett, Rosenburg, Gray, Haynes, and
Richardson (1996), who view EBP as the "conscientious, explicit and judicious use of current
best evidence in making decisions about the care of individual patients" (p. 71). Further, they
recognize that

...the practice of evidence based medicine means integrating individual clinical expertise
with the best available external clinical evidence from systematic research. By individual
clinical expertise we mean the proficiency and judgment that individual clinicians acquire
through clinical experience and clinical practice. Increased expertise is reflected in many
ways, but especially in more effective and efficient diagnosis and in the more thoughtful









identification and compassionate use of individual patients' predicaments, rights, and
preferences in making clinical decisions about their care. (pp. 71-72).

Thus AOTA recognizes that EBP is the integration of best research evidence with clinical
expertise and client values. When these three elements are integrated, clinicians and clients form
a diagnostic and therapeutic alliance that optimizes clinical outcomes and quality of life (Tickle-
Degen, 1999, 2000).

AOTA has made EBP a high priority within their national agenda. As a result, several years
have been spent developing evidence-based literature reviews related to OT outcomes. The over-
arching goal of AOTA's Evidence-Based Literature Review Project is to contribute to an
international effort to promote an outcome-based orientation among occupational therapists that
focuses on the effectiveness and cost of providing quality services to a broad range of clients in a
broader range of settings (Lieberman & Scheer, 2002).

The AOTA project conducts its own topic-specific research reviews (i.e., handwriting, children's
behavior, neurodegenerative diseases, autism) using a Critical Appraisal of Topics (CATs)
format. Reviews have led to the development of Occupational Therapy Practice Guidelines,
online evidence briefs for AOTA members, and articles published in peer-reviewed journals. An
evidence-based resource center is now available for members on the AOTA website that includes
the evidence reviews and other resources (www.aota.org). Some of these reviews and resources
are relevant to school-based OT.

For each research article review, AOTA defines each study's interventions and outcomes using
the International Classification of Functioning, Disability and Health (World Health
Organization, 2001) and the Occupational Therapy Practice Framework (AOTA, 2002). All
reviews emphasize the available Level I and II research studies that have been ranked using the
hierarchy developed by the Centre for Evidence Based Medicine [CEBM] in Oxford, England
(2006) Thus, a medical framework is used for interpreting and summarizing data from the
reviewed studies.

Scientifically based practice. IDEA states that "the use of scientifically based instructional
practices, to the maximum extent possible" will be done by qualified educational personnel and
that scientifically based research "...means research that involves the application of rigorous,
systematic, and objective procedures to obtain reliable and valid knowledge relevant to education
activities and programs" (9101(37)(A)). According to Whitehurst (2002), evidence-based
education is the preferred term, which is defined as "the integration of professional wisdom with
the best available empirical evidence in making decisions about how to deliver instruction"
(Whitehurst, 2002).

Considering the previous EBP and policy concepts, many research studies were reviewed for this
report. Research quality was examined using evidence hierarchies developed by the CEBM
(2006) and the American Academy of Cerebral Palsy and Developmental Medicine [AACPDM]
(2002). AOTA currently uses the CEBM framework for all evidence reviews completed by the
Association. The CEBM framework has been accepted by the Institute for Educational Sciences
within the U.S. Department of Education [USDOE], which is responsible for supporting high-
quality efficacy research in special education. This report also uses the CEBM framework;


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however, in some ways, the framework developed by AACPDM may be more applicable to the
needs of the student population typically served by occupational therapists in the schools. While
these hierarchies can help occupational therapy practitioners make decisions regarding the
credibility, reliability, and generalizability of a specific intervention or outcome, it should be
noted that some scholars question this hierarchical approach to evidence-based decision making
and whether it reflects the actual practice of OT (Hammel, 2001; Hyde, 2001; Tomlin, in press).

CEBM levels are defined based on the research methodologies used to examine an intervention
and its effect or outcome. These five levels of evidence help a reader decide how much
confidence to place in a particular study's findings. Randomized control trials are the "gold
standard" at Level I of the hierarchy. Expert opinion about intervention methods and associated
outcomes, e.g., an opinion presented at a workshop, is ranked as the lowest, Level V.
Descriptions of the types of studies considered within each level are detailed in Table 1.

Table 1. Summary of Levels of Evidence
LEVEL DESCRIPTION
Level I Large randomized controlled trials, producing results with a high probability of
certainty.
Level II Small randomized trials, producing uncertain results, outcomes research, or
ecological studies
Level III Non-randomized prospective studies of concurrent treatment and control
groups; cohort groups
Level IV Non-randomized historical cohort comparisons; case series with controls
Level V Case series without controls; expert opinion, anecdotal, and qualitative research


Use of EBP. With this increasing emphasis in school-based practice on the use of the best
research available, competent therapists find themselves asking what evidence is available.
Competency (Ilott, 2004; Law, Pollock, & Stewart, 2004; Muhlenhaupt, 2003) is the
practitioner's ability to make informed decisions about OT service provision using available
research-based evidence; professional judgment; the client's (e.g., student, teacher, parent)
values and preferences; and effectiveness data collected systematically and evaluated against
targeted student outcomes. However, a recent study by Hess (2003) found that many school-
based occupational therapists developed competency on the job and used in-services and
continuing education to maintain competency. Less frequently, they reported using published
materials; but it is unknown from these data the extent to which these published materials were
research-based.

Do school-based occupational therapists practice evidence-based education and use scientifically
based research? Some studies are beginning to answer this question. A recent survey by
Spencer, Turkett, Vaughan, and Koenig (2006) found that occupational therapists in Colorado
more frequently delivered therapy services in a pullout treatment area (61%), contrary to
evidence that supports the use of inclusive service delivery. Previous studies have found similar
results on both state and national levels (Case-Smith, 1997; Case-Smith & Cable, 1996). In a
survey (Cooley, 2006), a large number of school-based occupational therapists who were
members of the School Systems Special Interest Section [SSSIS] reported using research to


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support their interventions, e.g. American Journal of Occupational Therapy and Occupational
Therapy Advance, to inform their interventions. While the former is a peer-reviewed journal, the
latter is not peer-reviewed and thus conclusions may have limited validity and reliability when
generalized to everyday practice. Most encouraging about this study were the school-based
therapists (90%) who were aware of the principles of EBP and reported attempting to use
research to inform practice.

While there is not an extensive literature addressing EBP in school-based OT, a number of
studies address the OT profession and the use of research to support practice. A Critically
Appraised Topic [CAT] completed by Cooley (2005) addressed the question: "What are the
current supports and/or barriers that impact effective evidence-based practice methods [EBP]
among occupational therapy practitioners?" and found that

The majority of studies reviewed were at a 'III' level of evidence; no studies were found
at a 'I or II' level. Rather than utilizing research-based evidence to guide their practice,
many therapists (more often veteran therapists) rely on their clinical experience,
consultation with colleagues, continuing education, and the monitoring of their patients'
progress when selecting treatment interventions. This supports two of the three prongs of
evidence-based research; but practice may be further enhanced if all three prongs
(research evidence in addition to clinical expertise and data) are considered during
decision making. Only a handful of occupational therapists read books and attended
workshops related to EBP; a larger number of therapists read journal articles and utilize
low level evidence to guide their practice (between 1-5 x's per year).
Common barriers OTs encountered in the workplaces were shortages of time, limited
ability to find and understand research articles, high caseloads, high turnover and staff
shortages, lack of computer skills and/or access to computers, limited evidence to support
OT practice, difficulty generalizing evidence into therapeutic intervention, and the
growing costs of continuing education. (p. 5).

Cooley (2005) also reviewed several Level IV and qualitative studies with similar findings,
concluding generally that the OT profession is still learning how to apply EBP as part of
everyday decision making.

Research review. This review began with a search of the literature that utilized a variety of
databases (see Table 2) and various combinations of search terms found in Table 3.

Table 2. Databases Used
OTSeeker
ERIC: Education Resources Education Center
Ebsco
EBP Resources at www.aota.org
OTSearch
library.ups.edu/simon/summit
CINAHL
Medline
PubMed









Table 3. Search Terms
PRIMARY SECONDARY
school-based OT effective practices
intervention sensory integration
decision-making ball chairs
assessment evidence-based practice in OT
efficacy in school-based OT handwriting
collaboration consultation
schools transition
data collection


An emphasis was placed on finding any research that directly addressed the impact of OT
services on student outcomes in the schools that provided Level I or II evidence. Also
emphasized were practices unique to OT or that represented a cost-effective and good use of the
unique skills and expertise of an OT. After an exhaustive search, a limited number of Level I or
II research that may help inform school-based OT services were found. These included two
systematic reviews completed as part of AOTA's EBP project addressing psychosocial needs of
children and school-based interventions, including a number of articles on handwriting
interventions.

The published literature currently contains limited Level I and II research that supports or refutes
interventions utilized by school-based therapists. However, several CATs of Level III, IV, and V
evidence were useful. Also some evidence reviews that summarized Level I and II evidence
from other practice areas were also relevant to the services occupational therapists provide in the
schools.

A summary of the results of the search are provided in Table 4. The research is organized
according to the main steps in the OT intervention process: evaluation, intervention, and
outcomes as identified by the Occupational Therapy Framework (AOTA, 2002). This table is
not an exhaustive summary of all research found. It includes key research with an emphasis on
the relevant summaries and CATs. In some cases, a research website is referenced.













Table 4. Evidence for Occupational Therapy in the Schools
EVALUATION
OT Practice Question Type of Evidence Evidence Summary Reference
Is there evidence that the School CAT (Level III only) Valid assessment of social skills in Lopez, M. (21 14). Is there evidence that the School
Function Assessment and the children and adolescents with Function Assessment and the Vineland Adaptive
Vineland Adaptive Behavior Scales disabilities can be achieved with the Behavior Scales are valid measures of social skills
are valid measures of social skills use of the SFA & the VABS; for children and adolescents? UPS Evidence-Based
for children and adolescents? assessment could also include Practice Symposium, retrieved 4/6/2006 from
observation & interview. www.ups.edu/-ot
The SFA correlates with the VABS
in all sections except
communication.
What assessments are most Website (Levels II, A variety of summaries, reports, and lihp \ \ \ .canchild.ca
appropriate to support effective III, IV, and V) links to published research that
decision-making in the schools? addresses assessments such as the
Gross Motor Function Measure
[GMFM], Peabody Developmental
Motor Scales, CAPE, PAC, PEGS,
and Canadian Occupational
Performance Measure (COPM)













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION
OT Practice Question Type of Evidence Evidence Summary Reference


What techniques or programs other
than 1:1 therapy have proven
effective for helping children with
Asperger syndrome achieve age-
appropriate social and
emotional skills?


CAT (Levels I
through V)


* The computer program, Emotion
Trainer, is effective in improving a
person's ability to recognize and
predict emotions in others.
* Parent training programs are
effective in helping parents manage
their child, increase their feelings of
competence, decrease problem
behaviors, and increase the parents'
satisfaction in how they handle
behaviors.
* Social skills training groups are
effective in teaching a person to read
nonverbal communication,
improving their ability to read both
adult and child facial expressions.
Social skills training groups are also
effective in improving skills in
greeting, conversation, and play,
helping establish and maintain
friendships and improving
perceptions of social support.
* Social stories can be effective in
managing behaviors and social
difficulties.
* Social skills training groups can
increase a person's confidence in
social skills as well as help in
developing skills to make
friendships in and outside of the
group.


Savage, A. (2005). What techniques or programs
other than 1:1 therapy have proven effective for
helping children with Asperger syndrome achieve
age-appropriate social and emotional skills?
UPS Evidence-Based Practice Symposium, retrieved
4/6/2006 from www.ups.edu/-ot













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION (cont.)
OT Practice Question Type of Evidence Evidence Summary Reference
Circle of friends, social skills
training groups, and social story
interventions seem to work best in
improving social skills and
supporting inclusion in the
mainstream setting.
Do children with disabilities who CAT (Level III only) Several strategies increased the Hoss, S. (21I 14). Do children with disabilities, who
are included in the general education likelihood of increased student are included in the general education classroom, have
classroom have better academic performance. These included: better academic achievement than children in special
achievement than children in special Collaboration with school personnel education classrooms? UPS Evidence-Based Practice
education classrooms? in order to provide each student the Symposium, retrieved 4/6/2006 from
best opportunity. www.ups.edu/-ot
Adequate adaptations implemented.
Increased awareness of OT skills
and expertise
**OTs may want to consider these
factors when working in general
education settings
Does auditory training result in CAT (Levels I, II, Most studies showed improvements Peters, K. (2i'14). Does auditory training result in
improved attention, expressive and III) in sound sensitivity, behavior improved attention, expressive language and a
language, and a reduction of problems, language, comprehension, reduction of behavior problems for children with
behavior problems for children with and attention, autism? UPS Evidence-Based Practice Symposium,
autism? Behavior improvements could be retrieved 4/6/2006 from www.ups.edu/-ot
due to better attentiveness to one's
surroundings, which leads to
decrease in confusion, stress, and
anxiety.
No significant relationships were
found between behavioral
improvement and age, degree of
sound sensitivity, and amount of
variability in the pre-AIT
audiogram.













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION (cont.)
OT Practice Question Type of Evidence Evidence Summary Reference
What is the effectiveness of family- Research summaries Family-centered services have many www.canchild.ca
centered services? and briefs advantages and should be utilized.
What interventions are most Research Summary The OT in the schools is primarily a Missiuna, C. (2003). Children with developmental
effective when working with a child (Level V) consultant when working with a child coordination disorder: At home and in the classroom.
with developmental coordination with developmental coordination (5th Ed.) [Booklet]. McMaster University, Hamilton,
disorder in the schools? disorder and helps the child develop ON: CanChild Centre for Childhood Disability
strategies to practice motor skills that Research. Also available at
need to be learned. www.fhs.mcmaster.ca/canchild/
Is direct service or collaborative Level II Both service delivery models were Dunn, W. (1990). A comparison of service provision
consultation more effective in the equally effective in regard to student models in school-based occupational therapy
schools? goal achievement. However, teachers services: A pilot study. The Occupational Therapy
from the collaborative consultation Journal ofResearch, 10, 300-320
group reported more positive
interactions.
What are effective methods of Level II The consultation group improved Palisano, R. J. (1989). Comparison of two methods of
serving school children with significantly more in motor skills than service delivery for students with learning
disabilities: Large-group therapy the therapist-directed group. disabilities. Physical and Occupational Therapy in
combined with small-group therapy, The therapist-directed group improved Pediatrics, 9, 79-100.
and large group more in visual-perceptual skills than
therapy combined with consultation the consultation group, but the
with classroom teacher? improvement was not statistically
significant.
Should school-based OTs address Research Summary CAT indicates that it may be Jackson, L., & Arbesman, M. (2005). Children With
psychosocial skills through activity- (Levels I through V) appropriate and there is a high Behavioral and Psychosocial Needs: Occupational
based interventions for children with likelihood that addressing psychosocial Therapy Practice Guidelines. AOTA, Bethesda, MD
disabilities? skills through activity-based
interventions may lead to increased
student performance and student
outcomes in this area













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION (cont.)
OT Practice Question Type of Evidence Evidence Summary Reference
What is the best treatment for the CAT (Levels I BTA is a useful adjunctive therapy Feller, A (2005). What is the best treatment for the
management of upper extremity through V) to OT in the treatment of children management of upper extremity spasticity in children
spasticity in children with cerebral with cerebral palsy (i.e., decrease with cerebral palsy? UPS Evidence-Based Practice
palsy? spasticity with BTA & acquire fine Symposium, retrieved 4/6/2006 from
motor skills through OT www.ups.edu/-ot
intervention).
SPR can have a positive effect on
UE function & trunk control &
should be evaluated pre- & post-
surgery.
BPDR is effective in decreasing UE
spasticity & improving UE function
for at least 15 months post-
procedure.
Conflicting evidence supporting the
effectiveness of UE weight-bearing
to reduce muscle tone & improve
UE function.
What performance components and Level V The influence of play on therapy Case-Smith, J. (2000). Effects of Occupational
variables in OT intervention outcomes suggests that a focus on Therapy Services on Fine Motor and Functional
influenced fine motor and functional play in intervention activities can Performance in Preschool Children. American
outcomes in preschool children? enhance fine motor and visual motor Journal of Occupational Therapy, 54(4), 372-380.
performance.
What is the effect of school-based Level IV Students who received OT services Case-Smith, J. (2002). Effectiveness of school-based
OT on handwriting? demonstrated improved letter OT intervention on handwriting. American Journal of
legibility, but speed and numeral Occupational Therapy, 56(1), 17-25.
legibility did not demonstrate
positive intervention effects.
Will preschool children who receive Level IV The results of this study demonstrate Dankert, H. L., Davies, P. L., & Gavin, W. J. (2003).
OT demonstrate improvement in that intervention, including OT, can OT effects on visual-motor skills in preschool
their visual-motor skills? effectively improve visual-motor children. American Journal of Occupational Therapy,
skills in preschool-aged children. 57(5), 542-549.













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION (cont.)
OT Practice Question Type of Evidence Evidence Summary Reference
What is the effect of sensorimotor Level III Therapeutic practice was more Denton, P. L., Cope, S., & Moser, C. (2006). The
and therapeutic practice on effective than sensorimotor-based effects of sensorimotor-based intervention versus
handwriting? intervention at improving therapeutic practice on improving handwriting
handwriting performance. The performance in 6- to 11-year-old children. American
study included random assignment Journal of Occupational Therapy, 60(1), 16-27.
and a control group.
Can nonproficient handwriters be Level IV Nonproficient handwriting is a work Rosenblum, S., Goldstand, S., & Parush, S. (2006).
distinguished by biomechanical activity often characterized by Relationships among biomechanical ergonomic
ergonomic factors as well as by inferior biomechanical ergonomics, factors, handwriting product quality, handwriting
measures of handwriting handwriting quality, efficiency, and efficiency, and computerized handwriting process
proficiency? significantly different handwriting measures in children with and without handwriting
process measures, difficulties. American Journal of Occupational
Therapy, 60, 28-39.
Should an OT include typical peers Level IV An OT working with a preschool Tanta, K. J., Deitz, J. C., White, O., & Billingsley, F.
when working on play schools with child with play delays and wanting (2005). The effects of peer-play level on initiations
preschool children? to facilitate the child's initiation and and responses of preschool children with delayed
response in play situations should play skills. American Journal of Occupational
consider pairing the child with play Therapy, 59, 437-445.
delays with a child who has higher
play skills.
Is the dynamic tripod grasp the most CAT (Levels II and Researchers agree, for the most part, Cooley, C. (i"' 1 4) Is the dynamic tripod grasp the
functional grip for handwriting? III) that the dynamic tripod grasp is not most functional grip for handwriting? UPS Evidence-
the only functional pencil grip Based Practice Symposium, retrieved 4/6/2006 from
utilized in handwriting activities. www.ups.edu/-ot
The lateral tripod grasp was
considered in more than one study to
be equal to the dynamic tripod grasp
for functional writing capability.
The lateral/dynamic quadrupod and
four-finger pencil grasps were found
to be as functional as the dynamic
tripod and lateral tripod pencil grasp
in one study.











Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION (cont.)
OT Practice Question Type of Evidence Evidence Summary Reference
Grasp alone may not significantly
impact overall handwriting
performance.
Are sensory-based interventions for CAT (Levels II, III, Using sensory modalities has Goldenburg, C. (211114). Are Sensory-based
children with selective eating and IV) positive effects on infants born Intervention for Children With Selective Eating
problems effective? preterm, and/or transitioning off of Problems Effective? UPS Evidence-Based Practice
tube feedings. Symposium, retrieved 4/6/2006 from
Feeding can have multiple etiologies www.ups.edu/~ot
and requires a team approach.
The use of sensory input as a
reinforcer in behavior modifications
is common practice.
Sensory analysis of food textures
can improve tolerance to more
varied food.
For school-aged children diagnosed CAT (Levels II, III, Allen, H. (2003). For school aged children, diagnosed
with Attention Deficit Hyperactive and V) with Attention Deficit Hyperactive Disorder, does the
Disorder, does the use of therapy use of therapy balls or inflatable discs as classroom
balls or inflatable discs as classroom seating increase attention within the classroom? UPS
seating increase attention within the Evidence-Based Practice Symposium, retrieved
classroom? 4/6/2006 from www.ups.edu/-ot

Are therapy balls an effective form CAT (Level IV) There is insufficient evidence to Holman. (2005). www.otcats.com/topics/CAT-
of alternate seating compared to support or refute the use of therapy KHolman2005.html
typical classroom chairs in balls as an alternate form of seating for
improving in-class behavior and improved classroom behavior of
attention of children with children with autistic/ behavioral
autistic/behavioral disorders? disorders













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
INTERVENTION (cont.)
OT Practice Question Type of Evidence Evidence Summary Reference
Do weighted vests increase on-task CAT (Levels III and Overall, there was general support for Straw, A. (i '114). Do weighted vests increase on-task
behavior in the classroom for IV) wearing of weighted vests in the behavior in the classroom for children and
children and adolescents with classroom to increase on-task adolescents with developmental disorders? UPS
developmental disorders? behaviors of children with Evidence-Based Practice Symposium, retrieved
developmental disorders. However, 4/6/2006 from www.ups.edu/-ot
there is a lack of generalizability in the
findings within research literature to
support or refute the effectiveness of
weighted vest intervention, due to
small sample sizes, age ranges studied,
and lack of representation within all
diagnostic developmental disorder
categories.

Is Sensory Integration [SI] Therapy Summary of The results are mixed. Some studies ERIC Digest, 2003
an appropriate intervention in the Research articles are addressing traditional Ayres http://ericec.org/faq/sensinte.html
schools? (Levels 3, 4, and 5) approach to SI while others are
addressing a sensory processing Vargas, S., & Camilli, G. (1999). A meta-analysis of
Meta-analysis approach. research on sensory integration treatment. American
When comparing SI to a no-treatment Journal of Occupational Therapy, 53, 189-198.
control group, there were no significant
effects. When SI has been compared to
alternative treatments, e.g., such as
perceptual motor therapy and academic
tutoring, there has been no difference
in effect.













Table 4. Evidence for Occupational Therapy in the Schools (cont.)
OUTCOMES
OT Practice Question Type of Evidence Evidence Summary Reference
What impact can OT services have Research summaries OT can support outcomes such as www.canchild.ca
on quality of life, health, and well- and reports participation, self-esteem, transition to
being adulthood, and other childhood
occupations
What is the role of OT in increasing Research summaries This main area of CanChild research www.canchild.ca
the participation of children with and reports explores the participation of children
disabilities? and youth with disabilities and their
families, with a focus on community
and family activities, and on
environments that support or limit
participation. This link will take you to
studies, reports and resources on this
topic. Related terms include:
accessibility, barriers, and
environmental factors.
What is the importance of Multiple methods, NLTS2 is: hup "\ i\ .nlts2.org/gindex.html
community-based experience for longitudinal,
high school kids? Importance of retrospective, Focusing on a wide range of What Works
employment during high school as randomly selected important topics, such as high
predictor of post school national sample school coursework, extracurricular lhp \ \ \ .ncset.org/publications/viewdesc.asp?id=7
employment, etc. activities, academic performance, 14
postsecondary education and
training, employment, independent
living, and community participation.
SProducing information of interest to
many audiences, including state and
local education agencies, the U.S.
Congress, USDOE, parents,
teachers, researchers, advocates, and
policy makers.

http://www.nlts2.org/gindex.html








Summary of effective practices. The preceding evidence review revealed a lack of high-
level research-based evidence due to the few Level I and II studies available to guide school-
based OT services. Despite this finding, a growing body of Level III, IV, and V literature does
exist along with qualitative studies. Thus, currently, occupational therapists must rely more on
effective or promising practices, clinical expertise, and client values as well as systematically
collected data when delivering effective practices.

Additionally, the literature in general reveals that the OT profession strongly supports EBP. This
is reflected in AOTA documents (American Occupational Therapy Foundation [AOTF], 2004),
the premier U.S. journals in the OT field (American Journal of Occupational Therapy, OTJR:
Occupation, Participation, and Health), available research funding for efficacy research
(AOTF, 2006; Institute for Educational Sciences [IES], 2006); the national standards for OT
education programs (Accreditation Council for Occupational Therapy Education, 2006); and
repeated calls by OT scholars for the expansion of high-level research activities (Holm, 2001;
Law, Baum & Dunn, 2005; Tickle-Degnen & Bedell, 2003).

Third, it is clear that school-based OT practices are, at times, based more on policy than on
research. For example, education policy reflects the nation's widely held beliefs regarding equal
opportunity and the rights of students with disabilities and their parents (the IEP process, due
process, and student access to the general curriculum). Policy in these cases is most often tested
in the courts and not through research. IDEA promotes specific practices that are believed to be
beneficial but may lack empirical support, such as calls for inter-professional collaboration on
behalf of students with disabilities (614(d)(1)(B); 636(a)(1); 652(b)(1); 653(b); 654(a)
(1)(C)); the use of whole-school interventions (636(a)(1)); and education within the regular
classroom based on the concept of least restrictive environment (20 U.S.C. 1412(a)(5)(B);
601(c)(1); 614(d)(1)(A)). Even without high-level research evidence, these policy-driven
practices have become a part of the mainstream public education culture, in part, because of our
nation's inclusive values (Lipsky & Gartner, 1997). However, data are emerging that indicate
some of these policies, such as collaborative practices, may be effective (Friend & Cook, 2003;
Snell & Janney, 2005; Thousand & Villa, 2000; Villa, Thousand, Nevin, & Malgeri, 1996;
Walther-Thomas, Korinek, McLaughlin, & Williams, 2002).

Given the state of the literature, providing effective (versus evidence-based) OT services may be
the only realistic option when Level I and II studies are not available to guide intervention
decisions. Interventions based on a careful reading of Level III, IV, or V studies combined with
the systematic collection of individual student performance and outcome data can allow students
to achieve targeted outcomes. In fact, the Institute for Educational Sciences [IES] with USDOE
calls this student-focused accountability process an "individual student growth model" and is
supporting research in this area. Of interest to IES is the model's potential to offer special
education professionals with a valid and reliable way to account for student progress based on
IDEA and NCLB requirements (retrieved 7/19/2006, www.http:/ies.ed.gov/ncser/funding/
accountability. asp).

Regardless of the research "holes" that currently exist for school-based occupational therapists,
the expectation remains for them to use effectively the best available research combined with
their professional expertise and an understanding of client values. To accomplish this, the
school-based OT can benefit from thinking like a researcher who strives to answer the following
questions about OT intervention and then by using systematically collected data throughout
intervention and at its conclusion:







What was the impact of the OT intervention on the student's performance of
educational activities?
To what extent was the student's participation within the education context affected
by the OT intervention?

To move toward addressing these questions as an effective practitioner, the occupational
therapist must be able to draw on the available research related to the student's focus problem
and alternative intervention approaches. Using the Occupational Therapy Framework as a guide
(AOTA, 2002), the occupational therapist must also collaborate with the student and the
education team to identify a specific behavior or outcome that the student is expected to perform
with OT support (e.g., complete written English assignments; appropriate social interactions
during recess). By starting with a student outcome in mind, student evaluation and subsequent
intervention planning will be focused and efficient. Following a contextual evaluation of student
performance in the classroom, the occupational therapist must select an intervention approach,
such as using occupation-based activity (e.g., engaging the student in using computer technology
to complete English assignments); collaborative consultation (e.g., working with the teacher to
identify technology accommodation strategies that could be implemented by the teacher within
the classroom); or education of members on the student's IEP team (e.g., teaching
paraprofessionals how to support student performance without "over-helping"). Data collection
can begin after specification of an intervention protocol (what the occupational therapist will do,
when, and where) and when outcome measures are selected (e.g., teacher evaluations of writing
quality and quantity, number of written paragraphs, number of words typed per minute, etc).
The occupational therapist must develop a systematic way to document the OT intervention plan,
its implementation, and student performance data. With this evidence in hand, the occupational
therapist is equipped to work with the team to make well-informed decisions about continuation,
discontinuation, or modification of OT services.

At the risk of oversimplification, the previous example demonstrates how occupational therapists
can think like researchers in a systematic manner to provide effective school-based OT services.
The preceding example may assist occupational therapists, school administrators, and other
members of the education team to understand how occupational therapists can support students
with disabilities to gain educational access, perform according to curriculum and IEP
expectations, and ultimately participate in the school community as a student. Additionally,
when OT services are designed to be outcome-oriented, it is possible for occupational therapists
to account for changes in student performance and participation, thus meeting accountability
expectations outlined by IDEA and NCLB.

Finally, when reading any research article or CAT summarizing the research, school-based
occupational therapists need to review the data carefully based on the skills and expertise of an
occupational therapist. Some data may indicate that a particular intervention results in a specific
outcome but that the skills and expertise of an occupational therapist are not required in order to
implement the intervention.








CONCLUSIONS

The purpose of this paper was to summarize the research regarding effective OT practice in the
schools. The public school is identified by more than one-third of the members of the AOTA as
their primary work setting (AOTA, 2005a). This percentage underscores the need for school-
based practice to be an integral part of initial OT preparation programs and ongoing professional
development offerings (Swinth, 2002).

The Occupational Therapy Code of Ethics states, "Occupational therapy personnel shall critically
examine available evidence so they may perform their duties on the basis of current information"
(AOTA, 2005b, p. 4). Thus, it is crucial that school-based occupational therapists keep abreast of
current evidence regarding the intervention strategies they choose. However, due to the fact that
Level I and II research is limited, school-based occupational therapists need to use systematic
data-based decision making to help inform their interventions. "Research findings do not replace
or supersede clinical experience, but rather they support and shape services so that the most
effective and efficient strategies are considered" (Kellegrew, 2005, p. 12).

OT may be termed a "research emergent" profession (Ilott, 2004). For that reason, at times the
profession lacks sufficient research-based evidence to declare which specific practices and
interventions are most effective. As a result, the competent school-based occupational therapist
must think about "effective practice" and engage in systematic data collection related to desired
student outcomes. At all times, the therapist must utilize student/client evaluation and
intervention activities to collect and document student performance (outcomes) that justify
ongoing decisions about OT service continuation, modification, or discontinuation.

Accountability for special education and related services is directly tied to the educational
performance outcomes achieved by students. When occupational therapists understand the
outcomes targeted by our education system, OT intervention effectiveness questions can begin to
be answered. In other words, occupational therapists must first know where they are going in
order to evaluate whether or not they actually got there.

Concurrently, school-based OT needs a strong research agenda to help shape future practice.
This research agenda should not only study current practice strategies (e.g., use of sensory
principles in the classroom, best use of the skills and expertise of an occupational therapist to
address handwriting) but should also address the current assumptions of school-based OT service
delivery (e.g., therapy in a therapy room versus in the classroom, collaborative service delivery).
High-level experimental and quasi-experimental studies addressing the effectiveness of specific
OT practices on students' educational access, participation, and performance (outcome
measures) are also needed. Additional research should include:

Further development of valid and reliable outcome measures that can be used in OT
efficacy studies-which ones have promise?
Rigorous and trustworthy qualitative studies focused on intervention impacts that
identify promising practices worthy of further study
Research that matches the OT interventions to subgroups of students (age, diagnosis,
current performance levels)
Research that helps to inform OT service delivery decisions in the schools, for
example, variables influencing collaborative practices versus 1:1 "hands-on" services

IN -7







* Systematic data collection on school- based OT practice based on clear, measurable
goals
* Identification of preservice and ongoing professional development strategies for
personnel preparation that improve evidence-based, practice-related behaviors among
school-based occupational therapists.








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