Beyond the Medical Model

Therapy services are provided in hospitals, clinics, homes and schools. But in the educational setting, therapy intervention is unique because it is controlled by the landmark education legislation called the Individuals with Disabilities Education Act (IDEA) and by the child’s Individualized Educational Program (IEP). In this setting, school-based therapy intervention focuses on the child and how he/she interacts with the school environment and curriculum. The IEP lays out a set of goals and collaborations for engaging and working with a child with disabilities. We refer to this approach as the educational model, to distinguish it from the clinical or medical model.

The Educational Model vs. the Medical Model

So how different are these two models? School-based therapy provided under an IEP must relate specific educational outcomes to the interventions recommended by the therapists. Therapy provided under the medical model tends to focus on discipline-specific goals that may not have a direct relationship to educational performance. For example, a clinically based physical therapist (PT) may have lower extremity strengthening as the ultimate goal for a child who exhibits weakness. But improving muscle strength does not have a direct link to educational performance. Although physical and occupational therapists who work in educational environments remain concerned about the underlying components of a child’s motor disability, they must (under the law) be able to describe how these limitations affect the child within the context of the school environment.

More specifically, school therapists must articulate how a limitation in fine or gross motor function inhibits a child’s ability to benefit from special education. This is the principle of determining educational relevance. If the therapist believes that a child’s need for therapy extends beyond the child’s educational goals, the therapist has a professional obligation to inform the parents or legal care providers so that medically (or clinically) based therapy can be provided through another funding source.

Therapists must extend the application of particular therapeutic techniques (for example, neurodevelopment therapy (NDT) or the sensory integration (SI) model) beyond the traditional medical model approach and adapt them to meet the needs of the child within the context of the school environment. The focus of intervention is directed away from achieving isolated motor skills that are practiced in one-on-one therapy away from the classroom and directed toward achieving functional tasks required to participate and benefit from special education placement (Dunn, Brown, & Duigan, 1994). For example, an OT may recommend specific techniques for improving hand dexterity with the educational outcome being improved handwriting legibility. In the same vein, a physical therapist may recommend specific use of a piece of adaptive equipment that would allow more independent mobility within the school environment. Without these stated educational outcomes, the intervention would be more medically based.

Providing educationally relevant intervention extends beyond academic performance to the larger school environment. School-based therapists should recognize that educational performance for young children also includes self-help skills, mobility in the classroom and on the playground and physical education. For older children, this may include activities that occur after school hours such as accessing the bleachers for football games or the gymnasium for school dances.

Occupational and Physical Therapy in Schools

So how do IEP teams make decisions about when and how to provide OT or PT? In making a decision to provide either occupational or physical therapy within the school environment, IEP teams must ask the following questions:

• What does the child need to learn?
• Which strategies facilitate this learning?
• Does the child require the expertise of an OT or PT to achieve the educational outcome through the implementation of these strategies?
• How should intervention be provided (i.e., direct or consultative model)?

(Hanft & Place, 1996.)

Many times, physicians and other service providers who have worked with the child make specific recommendations for therapy. These recommendations need to be considered, but decisions must be made in the context of the child’s educational needs. Therefore, the IEP may not always reflect the amount of services recommended if some of these are not related to the child’s educational needs.

Using information available in the diagnostic summary, IEP teams need to decide what services and level of services are needed. Many routine classroom activities directed by teachers and paraprofessionals help develop a young child’s fine and gross motor skills (cutting with scissors, playing games with balls or bean bags, drawing, etc.). Sometimes these routine activities, without the aid of a therapist, may be sufficient to meet the child’s needs. In some cases, the team may determine that a therapist may need to provide consultation so that a teacher or paraprofessional can more effectively implement strategies to improve the child’s motor skills that relate to the educational needs. Sometimes COTAs or PTAs, working under the supervision of a therapist, may be able to address the individual child’s IEP needs.

In other cases, the team may determine that a child’s needs are such that he/she really needs direct therapy from an OT or a PT because of the level of expertise required. If direct OT or PT is shown as the service on the IEP, it needs to be provided by that professional. Also, the code of ethics for each of these professions needs to be followed in terms of roles and levels of supervision. Whatever the IEP team decides, it is very important that the student’s IEP clearly indicates how services will be provided, (consultation, group, individual) so that the parents and all members of the team know who will be doing what. This can be summarized in a narrative fashion or by specifically listing these types of related services.

Determining the Level of Services

One concern we tend to hear often is, if the therapist is providing services in a consultative model, will the child receive less intervention from the therapist? One of the myths of consultation is that it will automatically decrease the level of services that the child is receiving. It will decrease the amount of time that the therapist pulls the child away from the natural setting of the classroom, but it may, in fact, increase the opportunities for the child to practice teacher/therapist-designed strategies throughout the school day. The consultation model, if applied correctly, asks that teachers and therapists truly collaborate to develop more effective, functional strategies that all the staff facilitates during the course of a child’s day.

References

Dunn, W., Brown, C., & Duigan, A. (1994). The ecology of human performance: A framework for considering the effect of context. American Journal of Occupational Therapy, 48(7).

Hanks, B., & Place, P. (1996). The consulting therapist: A guide for occupational and physical therapists in schools. San Antonio, TX: Therapy Skill Builders.

The major content of this article was provided by Kim Nevins, Registered Physical Therapist, and Columbia Public Schools.

Additional Resources

APTA Section on Pediatrics: Dosage Considerations: Recommending School-based Physical Therapy Intervention Under IDEA Resource Manual.

APTA Section on Pediatrics, Fact Sheet: Providing Physical Therapy in Schools Under IDEA 2004

APTA Section on Pediatrics, Fact Sheet: Physical Therapy for Educational Benefit.

APTA Section on Pediatrics, Fact Sheet: The Role of School-based Physical Therapy: Successful Participation for All Students.

McEwen, I. IDEA: Providing Physical Therapy Services Under Parts B & C of Individuals With Disabilities Education Act, 2nd Edition. 2009: APTA Section on Pediatrics.

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