People are often confused about why a child would qualify in one setting but not the other, or why therapy looks so different in the two settings. Although occupational therapists are trained to help “people participate in the things they want and need to do through therapeutic use of everyday activities (occupations)” the goal or mission of the school or clinic setting is different, thus different models are used to deliver services. Private clinics use a Medical Model where the primary goal is to address medical conditions and to help a child realize their full potential. Schools use an Educational Model where the primary goal is to support engagement and participation in the curriculum and school setting.
In both settings a child must have a recognized disability or disorder that affects their performance. Both require initial evaluation to determine the need for service and continuous monitoring of the intervention plan once service is started. The intervention plan must document a student’s strengths as well as the limitations along with setting goals to help improve performance.
In the Medical Model, the interventions will address skills needed for tasks across a variety of settings: home, community and school. The overall goal is to help the child function to the best of their potential in all environments.
A doctor’s referral for services is required here in Illinois, while it is not always needed in the school setting.
A doctor can refer because of a specific disability or because of an apparent delay in development that needs to be addressed.
Children with mild, moderate and severe disabilities may benefit.
Therapy can address movement and regulation quality as well as function.
Therapy is usually delivered in a one to one setting.
Activities can address underlying deficits in order to improve higher skill ability.
Insurance may or may not pay for therapy services depending on the individual insurance policy.
Therapy often looks like play, as a therapist scaffolds difficulty in games and tasks to allow for development and progress toward the goals.
In the Educational Model, the interventions address skills needed in the school environment. The focus is on independence and functionality. The goal for services is that a child achieve within the average range of performance as same age peers or has functional alternatives rather than fulfill their best potential.
Direct Occupational Therapy services in the school are a related service, meaning the student must qualify for special education services due to academic concerns; a student can not qualify for direct OT services without an accompanying academic delay.
Schools often need to prove a percentage of delay from expected age norms, meaning the performance is below the average range, not necessarily just below the median or 50th %tile.
In other words, a child who does not perform to what may be his/her full potential but functions adequately, would not qualify for school based services.
An occupational therapist may consult with a team for a child who has a 504 plan, or a medical condition which does not affect academic performance but limits a students access to the building or curriculum. Consultation would include accommodations needed in the classroom, environmental changes that would allow for greater access, and strategies for staff to use.
Consultation with teachers and teams may also be provided during the Multi-tiered System of Support (MTSS) to help keep a student within the average range of functioning so that special education services are not needed.
Therapy is often delivered in a group, within the natural context of the classroom.
Therapy services are provided by the school district.
Goals are directly related to the functional activities/skills that are targeted for intervention, underlying foundational skills are not the focus of therapy sessions.
Often times children qualify and receive therapy in both settings. A child may have delays at school and need occupational therapy to enhance their participation in the approved curriculum, as well as have delays in daily functioning within the family and community. Often school therapists will work on handwriting and fine motor skills development, while the clinical therapist will work on social skills, regulation and many of the underlying foundational skills. In these situations it is best when the therapists from each setting can talk with each other, sharing insights about the child as well as what the goals are and how the child is progressing toward accomplishing those goals.
There are many reasons why a child would need clinical OT services even though they are receiving it at school. The foundational skills needed for holding a pencil to write are the same foundational skills needed to hold and use eating utensils or a paintbrush or sidewalk chalk. Visual scanning is necessary for reading as well as scanning a room to locate a specific toy or a second sock while getting dressed. A child may have attention/regulation issues in school that interfere with learning, while in the home parents need strategies to get through the morning routine and out the door in time for school. There also may be times a child has room for improvement in fine and visual motor skill development necessary for handwriting, cutting and reading; but not qualify for services in the school. In all of these instances, private clinic based services can help a child reach their fullest potential.
Having worked in both settings, I fully understand the limitations of the Educational Model – therapy in that setting is for a different purpose than providing private occupational therapy. Therapy in the school setting is not meant to be a replacement for clinical therapy. Students who need therapy in the school setting often have disorders that affect life outside the school as well, and private therapy is there in a more expansive manner to help a child navigate all aspects of life.