Posted in Eleanor Cawley

Pushing the Birds out of the Nest

Leaving the nest copyThese opinions are my own based on my personal school-based experiences and recent postings from other therapists on social media 

When is it time to discharge?

This is always one of the biggest questions when it comes down to CSE Meetings and whether or not to recommend services for students next year. Of course, in a school-based setting, the big ‘money makers’ are handwriting and now keyboarding. Before making that decision, I think that it is important to look at the student’s level of function in a particular environment. I feel that when we report progress a rubric is very important but so is the environment or context in which the skill is performed. When I look at either handwriting or keyboarding I look at the following:

  1. Can the student perform the task automatically with my assistance in a therapy room?
  2. Can the student perform the task automatically in the therapy room without my assistance?
  3. Can the student perform the task automatically in a classroom with my assistance?
  4. Can the student perform the task automatically in a classroom without my assistance?

This is an important factor that is left out of documentation on goal progress. Anyone that knows about me, knows that I love to use rubrics. I love documentation to be clear and concise, understood without my being there to explain. So I often base my documentation on the level of self-sufficiency-does the student have the power to perform the task over a wide range of activities and settings. In other words, is the handwriting or keyboarding at the level of being automatic? The DeCoste Writing Protocol is an evidence-based tool with some very good research supporting its development. Based on this research, both handwriting and keyboarding should be at the level of automaticity. If these skills are not automatic, then the focus in on the motor components of the task and therefore the student cannot meet the cognitive demands of the writing task. Basically, we will not know what the student has absorbed because he or she cannot get it on paper.

I remember hearing somewhere that in order to do your best on a test, you should take the test in the same location that the teaching or learning took place. Could that mean that a student may hand write better if he or she is in the room where they actually learned the skill? It is certainly an interesting point and possibly one for a good research study. Our goal is to have the student generalize the skills to all handwriting or keyboarding tasks-to become proficient. The Written Language Production Standards provides us with what is expected of a student with regard to handwriting and keyboarding at a particular grade level. Does your student meet those standards? Do you think that your student is capable of meeting those standards? Why or why not? Is the student capable of meeting those standards in a variety of settings without your support? Why or why not? I feel that I am not doing my job well, if I can’t answer these questions, my student is not performing as expected within the classroom and I have not offered alternatives.

There is also something else to consider and that is the student’s expectations and preferences. Is this student so overwhelmed with handwriting or keyboarding that they have just given up? I use The Student Interview to explore the student’s preferences and understanding of their own skills, i.e., what the student thinks they can do to what the parent thinks they can to and compare that to what I and the teacher see them do. The level of anxiety and frustration that a student experiences with not being able to express themselves on paper should be considered.

So while I would always like to think that OT RULES and I have all the answers, I don’t. What I do know is this, keep the student involved with determining goal progress, assess the skill across settings and keep the student in mind when determining where to go next, if anywhere. If you think that you can discharge a student when they can type 10 words a minute and they are in the 4th grade or above, think again. That student is not ready to handle the keyboard in the classroom.

Posted in Eleanor Cawley, M.S., OTR/L

So Why Should Occupational Therapists Bother to Write Rubrics?

Mostly, therapists read my posts on social media and then move on. Some comment positively and others, not at all. But then there are those times when there  is that one person who challenges you. I must say, that one person tends to get my fight on! I feel that I have to prove my work all over again. But I really love the debate. To those of you who feel that rubrics are not necessary, that’s okay. However, I feel they are.
Rubrics have been around for a very long time. During my research for my book, “Using Rubrics to Monitor Outcomes in Occupational Therapy“I found that rubrics actually began not in the educational field but in the medical field, decades ago. I feel that rubrics were lost in the shuffle in part due to the changes in the provider/client relationship, moving from power over to power with and ultimately to power through our clients. Now that we are searching for ways to become more ‘client-centered’ as a profession, I feel that transparent, understandable documentation is the key.

It has always been our premise, as occupational therapists, to have our clients engaged in purposeful activity. With the increasing intrusion of third-party payment systems into what we do with our clients and the struggle to become ‘client-centered’ having a method of recording progress becomes increasingly important. Yes, of course, we need to get paid for our work but we also have an obligation to our clients, any one receiving our services.

We all have those people, who question what we do.  I am sure that each and every one of us has had this experience.  Sometimes we can explain what is going on, through statements based on clinical knowledge, but then there are other times that we need real data.  Some challengers will accept the “+” or “-” system of data collection [“+” yes the client was able to perform the task or “-” no the client was not able to perform the task]  while

 

My Book Cover2
Enter a caption

others want more information.

So rubrics offer us a method of documenting some of our thought processing with regard to critical thinking, clinical reasoning and judgment. Sharing rubrics with clients and caregivers provides them with a tool to engage them in the treatment process in a way that is greater than just sharing goals.  By encouraging clients to monitor their own progress they become more vested, more engaged and more accountable to themselves and to us, their service providers, ultimately leading to greater gains.

Rubrics may be initially time-consuming to learn and to write, just like any other skill, the experienced therapist will soon be developing rubrics a lightening speed and have at their disposal a wealth of data and documentation supporting our services.  In my humble opinion, if a therapist chooses to use or not to use rubrics, it is okay, it’s their decision.  I choose to use rubrics, engage my clients in progress monitoring, and have data specifically highlighting the client’s progress.  In my opinion, how can I expect my clients to make the best progress if I do not share my expectations with them. I feel that I empower my clients through the use of rubrics, because I want to, not because I have to.

 

 

Posted in Eleanor Cawley, M.S., OTR/L

Revisiting The Student Interview

The Student Interview CoverAI have worked with middle and high school students most often.  At this age, a student’s frustrations increase proportionally to the workload.  They are aware of what works and what does not work for them.  When frustrations run so high and parents begin to panic, it is at this time other professionals, advocate and lawyers, become involved.

The Student Interview was developed because of a number of school-based cases that I had been involved in were quite intense.  Every small detail of the case was explored in depth.  I felt that it was imperative that the student have a voice and that I had a document that asked all the right questions. While it is very sad to see the state of the educational system, as it is right now, I feel that the educational system is in transition.  There are always ups and downs when experiencing a transition.

Over the last few years, I have used this interview with many students.  Since this is a form to complete, it is good experience for a student in the transition process.  There is a variety of questions, relevant to the student’s educational, vocational and self-care needs.  Some questions require a yes or no response, while others are open-ended and call for more detail.  The Student Interview serves its intended purpose quite nicely. Since using The Student Interview, I have not had that “uh oh” moment when something comes up that I should be aware of.  At least nothing that I have not at least asked and have a response to.

I really love a student’s surprise when he or she is asked to complete the satisfaction survey.  This is often the very first time a student is asked for his or her opinion on services.  I, now, provide each student with this interview.  I find it an invaluable tool not only as written documentation but also as a basis for a deeper conversation regarding a student’s skills, and their perceptions of themselves.

 

Posted in Occupational Therapy

To all the Lefties Out There! Yes, Our President is a Lefty!

Check out the President's position.  His paper is set up for a right-handed writer.
Check out the President’s position. His paper is set up for a right-handed writer.

 

Recently we celebrated Left-Handers Day.  There were a number of articles written about those who write with their left hand.  Some articles talked about the psychological differences between lefties and righties.  Other articles discussed the statistics of lefties vs. righties. BUT what about the functional aspects of handwriting for lefties?  This is really a world made for righties!  Just look at notebooks and binders.  The rings of a binder and the spiral of a notebook are all on the left side of the book.  The left handed writer must learn to navigate around and through these obstacles.  Do you see how this young woman is attempting to write in a binder awkwardly navigating her hand through the rings of the binder?

Lefty with binder

There are a few ways to solve this problem without having to torture your students:

  • Flip the binder around so that the rings are on the right side (upside down to a righty).  You will be writing on the backside of the righty page (front side for a lefty).
  • OR Take a page or two out of the binder to write on then replace them when you are done.  Some times it helps the quality of the handwriting by having a page or two under the one that you are writing on.
  • OR Use a loose-leaf pad for notes and (easier to carry than a binder) then place the notes in the binder at the end of the day.

If you must use a notebook, you can use the following tips:

  • Start at the back of the notebook instead of the front.  Particularly if you use one of those wire spiral bound notebooks.
  • Use a notebook that has the spiral at the top instead of down the side.

Spiral on the top Notebook

 

Stay organized.  Keep your binder neat and tidy so that you can use it as a slant board.  A slant board will help extend that wrist a bit.  By extending that wrist, you can prevent smudges and fatigue from that lefty flexed wrist.

lefty on a slant board

 

Lastly, if you are a lefty, elevate the corner of that paper.  This may also help you extend that wrist a bit.

Lefty paper position

 

Happy Belated Left-Hander’s Day!

 

Posted in Eleanor Cawley, M.S., OTR/L

The Can of Worms is Open!-Building Blocks Missing

I am, in many ways, so grateful for this past year.  I have gone from a caterpillar to a butterfly, so to speak.  I have been so grateful for having the opportunity to collaborate with occupational therapists from all over the world and learn so much.  I am excited about the possibilities for learning from social media and currently sad to see the state it is in.

I was communicating with Katherine [Handwriting with Katherine] and we were discussing my last blog, ‘Does Backpack Safety Awareness go far Enough?’  I really just expressed a lot of my own opinions, but isn’t that one of the privileges of having a blog? In my opinion, one of the major issues, understanding the importance of developing all the blocks before constructing the building.  One of my pet projects, as if you didn’t know, is taking notes.  There is often a recommendation for assistive technology when what is really needed is more building blocks.  As occupational therapists know, good handwriting is built on quite a number of those building blocks; posture, visual perceptual/motor skills, functional pencil grip, enough muscle strength and endurance to maintain the writing task for as long as is needed, integration of primitive reflexes, etc.  All of these skills are building blocks that lead to good handwriting, and there are many more.

I am often amazed at how a student could come to me in the 7th grade with poor handwriting skills but missing vital building blocks.  The response often is to get him to take notes on the computer.  The first thing that comes to my mind is, “Well if he can’t take handwritten notes, what makes you think he can miraculously take notes on a keyboard?”  Posture, visual tracking, listening, responding to prompts, formatting the page, keyboarding, etc are all part of taking notes.   I am thinking of one student in particular, 12 years old, in OT since early intervention, who still did not have legible handwriting.  I observed this student in class and in the therapy room [or should I say therapy closet].  I was shocked beyond belief!  What I saw was the residual Asymmetric Tonic Neck Reflex [ATNR] in all its glory.  Of course, I could report my findings, but not make a recommendation to visit a neurologist [district policy].  Any way, this student exhibited classic signs of a residual ATNR.  He was right handed, but left foot and eye dominant.  He tested positive for an ATNR in quadruped. When hand writing, he sat on his left leg with his left arm flexed with his head tilted tilted slightly downward and turned to the right. Basically, reading with his left eye. Using a thumb wrap pencil grasp, he was able to write, but as he moved away from midline, he had difficulty retaining his grip on the pencil.  His grip was so tight, I could not pull the pencil from his hand without having him topple over.  He was so involved in maintaining control of his body that he failed to learn the listening skills, visual tracking skills, and all the other skills needed for effective note-taking.

Teachers have been complaining for years about his handwriting.  He was able to type with both elbows tight against his body but unable to type and read from copy placed to either side as any slight head turn would trigger the ATNR.  Any visual tracking to left or right of midline triggered the response. Was he aware of what was happening to him? Did anyone teach him different strategies? One of the first things that I did with him was to encourage him to write with the paper placed in landscape rather than portrait.  This way he was always writing at midline.   He was asked to sit further back in the classroom so that he did not have to turn his head to see the board.  He was asked to work this way as we continued to work on integrating the ATNR. Here is a link to Lisa Fass, OTR/L and her videos on using Yoga to integrate the ATNR   [Yoga Poses for Primitive Reflex Integration]. This student has made some progress in improving his handwriting and in integrating the ATNR.

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Every baby is born with primitive reflexes which are often integrated in the first few months of life.   I chose this picture of the ATNR because it shows both the upper and lower extremity responses to head turning. As you can see, the arm and the leg on the side to which the head is turned are outstretched.  The opposite arm and leg are bent-a sword fighting position.    Some babies, when pushing down on the foot of bent leg and reaching with the arm on the same side, it can help the baby learn to roll from supine [on his or her back] to prone [on his or her tummy].  Again, this is why tummy time is so important to development.  Lisa’s video of integrating the ATNR is working in prone [tummy time].

Some therapist’s feel that once a child gets past the age of nine and the age of rapid changes in neuroplasticity, no amount of therapy will address integration of primitive reflexes.  So maybe the jury is still out on this one.  What I do know is this:  therapists working is school districts need more than a closet to address many of the needs of their students; good mats and equipment should be provided by the school district; therapists need to be able to spot all the signs for deficits in handwriting; therapists need to be able to make recommendations “from one parent to another” or “personally, I would…”  I am not sure how this went on for so long.  But it did and now this student is stuck in limbo with poor handwriting, just learning about why his handwriting is so poor and what he can do for himself.

Posted in Eleanor Cawley, M.S., OTR/L

-Daily Task Worksheets

When working in schools, there is a constant need to collect and analyze data.  In doing so, I also feel the need to constantly evaluate my students’ skills in other areas as well.  I always try to assess or reassess skill(s) during each session.  I began creating Daily Task Worksheets.  I typically work with an older population [middle and high school] so that vocational skills also enter into the therapy session.  My thought was to get my students used to using and finishing a checklist in a timely fashion.  I now keep my forms in Microsoft OneNote so that my students’ work was organized and they can use technology while completing a number of tasks assigned on any given day.  Students were assigned to one of my computers [they all had names] and asked to open their own notebook.  Since many of my students are seen in groups at this age, it is important to create an individualized plan for each student that encompasses their goals and promotes a sense of independence.  My students love working on daily task worksheets.

Daily Task Worksheet 5

Daily Task Worksheet 5 pg2

My students were able to complete tasks independently or with very little assistance.  At the same time, I would be assessing activities of daily living [tie your left shoe], left-right discrimination, handwriting, following written directions, and any other number of skills.  Since each of the worksheets were created for individual students, I could easily include activities that would measure goal progress and, of course, explore daily progress on anything related to those darn standardized assessments.  If the worksheet is completed on a tablet, a stylus is offered to the student for handwriting.  Sometimes that portion of the worksheet was printed so that the student could complete it on paper.  I always worked on a student’s signature, whether or not is was a goal and had them sign in daily [this just supported my billing].  It was the very first part of the therapy session.  Students were required to keep an agenda for school, so I used that agenda to further increase their independence by applying a label for OT, which they applied to the correct date and added a period #.  I found that students with transition issues were able to get so much more work accomplished than when they did not have a worksheet.

 

Posted in Eleanor Cawley, M.S., OTR/L

-Taking Notes from an Occupational Therapist’s Perspective

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http://1stopbrainshop.com/study-skills/making-notes-on-books-or-handouts/951/

Taking notes is a very complex skill rooted in abilities developed in infancy.  While sitting in a classroom, a student is expected to have appropriate cognitive and motor responses to the teacher providing the lecture.  That is easier said than done!

As an infant, we are supposed to alert to a sound, respond to that sound with head turning in that direction, differentiate pleasant sounds from unpleasant sound and learn to express pleasure or displeasure.  Visually, we are expected to respond in a similar way: alert to a visual stimulus, respond by following that stimulus by turning our head to follow it, differentiate pleasurable from displeasing.  Infants are expected to demonstrate a motor response to the stimulus, i.e., eye opening, finger splaying, and activation of limbs.

Just as an infant is expected to display a motor response to stimuli, a student is also expected to respond motorically to stimuli provided by the teacher.  Students learn to respond to certain cues, i.e., “This is important,” “Conversely,” repetition of the information, etc.  It is very difficult for student to respond if he or she lacks the prerequisite skills.  Alternatives for taking notes should be offered to the student.  The least invasive is to have the student copy notes from the board (far point).  Some students have difficulty with visual skills such as pursuits and saccades (visual tracking and changing fixation from one target to another) making this difficult.  First a slant board (often a binder) can be used to address this issue.  If that doesn’t work then maybe copying from near point will work.

The next more invasive intervention might be providing the student with some form of prepared notes, i.e., Cloze Notes.  Cloze notes are fill-in the blank notes.  Students are only required to add one or two words to a statement rather than copy the entire statement.  The next level might be providing the student with a copy of teacher generated notes prior to the class for the student to highlight during class.  The next level might be having the student attempt whatever he or she is able then giving a copy of notes to the student, usually a copy from another student who takes very good notes.

Another strategy is to use on-line notes for a site like www.studyblue.com.  You may be lucky enough to find course notes similar to class notes with flash cards.  Kno.com is a site where you can buy electronic textbooks (usually at a reduced cost), this site also provides lecture (from the book), study materials and social networking for studying.  Kno.com is iPad friendly.  Along with programs like Evernote with Penultimate, this maybe all the student needs to be in class.  A student could photograph handouts and never have to carry another piece of paper.  Assignments could be entered into Everstudent (a digital assignment book/agenda).

One of the last options would be to type notes on a laptop or a computer.  If the student lacks the prerequisite skills for note taking, they cannot be expected to be successful if you give them something to type on even though they can type at a good speed with good accuracy.  A sixth grader is expected to type at a speed of 25-30 words per minute with 93% accuracy.  If a student has only handwriting concerns, is able to meet all the prerequisite skills for note taking, can type 25-30 words per minute with 93% accuracy then maybe the option for using a keyboard or laptop is the answer.