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 Assistive Technology, Occupational Therapy

The Challenge of Moving Toward Self-Sufficiency with or without Assistive Technology

This blog is concurrently posted on Handwriting With Katherine.  Check out Katherine for some excellent resources.  She is the Handwriting GURU!

As school districts begin to think about transitioning students with disabilities out of school and onto the next phase of life, the idea of becoming as independent or self-sufficient as possible comes to mind. I prefer to use the term self-sufficient as this term implies a sense of power and strength in addition to not requiring assistance from others.  At the age of 14 years, school districts are required to begin developing a transition plan.  Educators, therapists and parents investigate vocational as well as, social and self-care tasks.  In many high schools, Life Skills Programs concentrating on just this effort are charged with the task of fostering self-sufficiency.

Collectively, we explore both basic [BADLs] and instrumental activities of daily living [IADLs]. BADLs include basic self-care tasks, such as feeding, toileting [including maintaining continence], dressing [donning/doffing and selecting clothes], grooming/bathing, walking and transfers (such as from bed to wheelchair). These are the skills that we have begun to develop since birth. IADLs are more complex skills that we are taught as our thinking skills become more developed and include things like money management, driving/using public transportation, shopping, meal prep, communication using a telephone, computer or tablet, managing medications, housework and basic home maintenance.  The IADL and vocational skills are the focus of the Life Skills Programs.

What happens, though, if despite our collective very best efforts, an individual is unable to complete these tasks without some type of assistance? We begin to explore compensatory strategies and levels of assistance that are needed to increase the individual’s ability to become self-sufficient. Assistive technology is a huge area of practice that can be considered and includes both low and high tech devices. Low tech generally means that the strategy or item is simple and generally does not require any type of power source like batteries.  Low tech items can include things like a pencil grip or hand-held grabber to a paper calendar or checklist.  High tech usually involves a technology device with apps [a computer, cell phone or tablet]. Adaptive technology is another term that is used. Adaptive technology is developed specifically for persons with disabilities and is rarely used by a non-disabled person.  Adaptive technology is electronic and includes things like a personal emergency response system [PERS]. A fall detector is a good example of PERS.  The purpose of all these technologies is to help the individual develop or maintain their ability to give the individual the power to be independent for as long as possible. Without these technologies, persons with disabilities would be dependent on others to meet many of their needs.

Each and every day, we are challenged with the task of identifying ways for these students to become self-sufficient.  There are always budgetary concerns and so we begin with the least restrictive strategy. Let’s use Marty, a life skills student, as an example.  Marty is 16 years old and is exploring vocational options.  He is enrolled in a retail work experience program through his school with a job coach.  We begin to explore his work readiness skills.  Is Marty capable of completing all BADL and IADL skills to get him ready to go to and then to get him to work? We look at Marty as he comes to school each day.

Marty comes to school neat and cleanly shaved with hair combed and appears to be well organized. We interview his parents, we may learn some things about Marty that we did not know.

  • Is Marty able to prepare for school each morning?
  • Can he bathe and dress himself?
  • Does he choose his own clothing? Tie his shoes?
  • Can he groom himself?
  • Can he pack his backpack?
  • Make his own lunch or remember to bring money to buy lunch?
  • Does he require any sort of assistance?
  • If he requires assistance, how much and what type?
  • Is there anything that can be done to improve his ability to get ready for school without help from his parents?

Marty is able to shave himself using an electric razor.  Initially, he had some difficulty and shaved off part of his eye brows. Marty’s dad worked with him and helped him learn the correct way to shave.  He is able to pick out clothing appropriate for the weather but his clothing is not always coordinated in color and patterns.  Marty’s mom hangs coordinating clothes on a hanger to help him appear well dressed.  It seems that Marty’s parents have many strategies already in hand to deal with his deficits.  Marty is able to make his favorite salami sandwich, taking two slices of bread, spreading mustard and adding salami without help.  He is able to place and seal his sandwich in a plastic reusable container, add 2 napkins, a cold drink, a piece of fruit and a packaged snack in his insulated lunch bag.  Mom checks his backpack before Marty gets on the bus to make sure that he has everything that he needs to get through his day.  At the end of the day, Marty is able to empty his backpack and lunch bag.  He places the reusable container into the dishwasher and removes any trash that he did not do so when in the cafeteria.  All of this shows us that Marty is capable of following a well-established routine with just supervision.

What about taking on new and variable tasks, like those required for his work experience program? In his retail work experience, Marty has a number of tasks to complete on any one day.  He needs to take inventory, stock shelves with new merchandise, re-stock shelves when merchandise is sold, organize that merchandise [i.e., matching pairs of shoes in color, size and style] and decide which merchandise needs to be returned.  Can Marty perform all these tasks with just a verbal directive?  Can he remember the steps to each task? Can he remember when to take lunch? Can he focus on each of the tasks and complete each, meeting the demands of his job?  We explore his abilities and begin to develop strategies beginning with the least restrictive.

  • Completing job tasks with without supervision requiring only simple verbal directives and a demonstration
  • Use a checklist to complete tasks
  • Use distant supervision, requiring only someone to monitor his job performance from a distance?
  • Use close supervision, requiring someone working in the same area and prompt him to follow his checklist and to complete tasks

Once we get to the level of close supervision, we look at how many tasks is Marty capable of completing?  How much of the task is he capable of completing? Does he need to focus on only one task at a time?  For example, does Marty need to focus on only matching pairs of shoes and then go back to put the shoes in the correct location?

Here is where we begin to look at low tech strategies. Will a checklist work? Will picture prompts work? Should Marty be partnered with another worker in the store? Finally, we may arrive at high tech solutions, such as needing a tablet with a picture schedule and video modelling to help Marty complete his work with the least amount of assistance from another worker or job coach.  At this point, we need to collect data on what Marty is capable of doing, how much assistance is required and what supports have been put in place and failed to get us to the determination that a device is warranted.

Hopefully, at this point, everyone is also focusing on Marty’s abilities to complete IADL skills.

  • Is he capable of handling money? Can he create a shopping list? Does he know what a recipe is? Can he differentiate a recipe from a shopping list and can he develop a shopping list by looking at the recipe, determine what he already has in the pantry or refrigerator and what he needs?
  • Does Marty take medication? Is Marty able to remember what medication he takes and when he needs to take it consistently? Does Marty know when he needs to order new medication? Does he know when he has to return to the doctor to get a new prescription? Can Marty keep track of his doctor’s appointments? Can he arrange transportation to get to the doctor’s office? Does Marty need a medication reminder?
  • Is Marty capable of making plans to organize his schedule? Does he know when others are available to drive him or accompany him on public transportation? Is Marty capable of using a cell phone and Google to navigate from one location to the next? Does Marty need to review a family or group schedule to figure out if, when and who is available to help him?

Many of the questions asked above can be addressed using simple, free or low cost and easily available apps that are available on either Apple or Android devices.  Highly structure training and data collection is required to determine if Marty will be capable of using this technology to become self-sufficient.  If it were not for technology, Marty may be dependent on others for all his needs and be independent in none.

For more information, please feel free to contact me.

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

Cost Effective School-Based Assistive Technology Programs

By now, almost every school district has an Assistive Technology Program. Many students have access to graphic organizer, text to speech and word prediction software within their classrooms or at least in a computer lab. But, that is a BIG BUT, does the district have to provide computers for home use?  Not in my opinion!

School districts are switching over to Google and Google Apps for students to use while at school.  This allows the student to have a school-based e-mail with access to Google Drive.  Documents created in school with Google Apps can then be opened and worked on at home.

Companies, licensing assistive technology software to districts, provide a number of options for sharing this programming for the students to use at home.  This may come in the form of a web based version or an actual disc or thumb drive that a parent can use to load the software onto their home computer.

If students can access work from school at home and then have the assistive technology software available on their home computers, there is no reason for students to have a device to carry back and forth from home to school.

It is my belief that students should have two e-mail addresses to access between home and school.  One, of course, should be their g-mail account through Google and the other should be an Outlook account through Outlook.com.  One might think that a g-mail account would suffice.  It might if the student has no executive function issues and is very well organized. However, that Microsoft Office Suite that we know and have grown to love, has the best digital notebook program EVER!  Yes I mean, EVER!  Microsoft OneNote comes with every version of the Microsoft Office Suite.  If you have the Microsoft Office Suite, you have OneNote. School districts have had this programming forever and never knew it!

If you create an Outlook account, you have OneNote!  There is a modified version within your Outlook account, along with Word, PowerPoint and Excel. What is not to like?  Then the absolute best thing is to download the the free OneNote App.  Yes, that’s right, I said free!  With this app, a student can have access to his or her notes anywhere there is an internet connection!

The absolute best case scenario is to have the Microsoft Office Suite on your home computer.  Create your notebooks at home and store them within your Outlook account.  When you create your notebook, choose the web option as the location to store your notebook.  Under web location, log in with your Outlook log on and password.  You will use the same log on and password to open your notebook within the app on your iPad or Android device.

Setting up your notebooks from your home computer through the Microsoft Office Suite provides many more options, with my favorite option being the template feature.  This saves oodles of time.  Just add the template to your notebooks from your home computer and their will magically appear on your other devices. You can scan handouts and homework assignments into the notebook at home or photograph them with your tablet or phone when in school or in the community.  The best part about this program is IT IS AN AUTOSAVE PROGRAM!  If you forget to save something, no big deal, once you put it in a notebook, it is there until you take it out.

Microsoft OneNote is a life saver.

  • Parents never again will have to run to school with a forgotten assignment, as long as, the student put the assignment in their OneNote Notebook.
  • Is it time for a notebook review by your teacher?  Share the notebook with your teacher!
  • Left your notes in school and you have a test tomorrow?  Access your notes anywhere there is an internet connection.
  • Organize your OneNote Notebooks just like you would your paper notebooks or binders.  You can easily add tabs for sections and add new pages to each section.

I like my OneNote notebooks better than Evernote. There are organizational features in OneNote that Evernote cannot match. OneNote is easy to use. Open your notebook to where you need to add a new assignment then either use a scanner (if your at home) or take a photo of the assignment. It will go right to the place that you have open. Nothing could be easier.

So going back to the original topic of cost effective assistive technology, with the availability of a number of free options that work across platforms (PC or Mac), there is really no reason to provide each student with a device to take home. Students are entitled to a free and appropriate education but not necessarily a free computer.  If assistive technology is needed, then absolutely provide it. Send home the software but not a device.

Of course we all worry about where our tax dollars are being spent and in my opinion, sending home devices with students can be a huge waste of our tax dollars. There is an easy solution and we should take advantage of it. Yes, there are homes without internet or even a computer. Recently, many local libraries have begun distributing free wireless devices for internet access to families in need. Netbooks are a reasonable option, for those students requiring assistive technology, and who are without computers in the home. The netbook can be left at home and returned to the district at the end of the school year.  While there may be some normal wear and tear on the netbooks, there should not be damaged from transporting the devices repeatedly to and from school.

In my opinion, internet should be free and accessible to everyone.  If you need something faster than what is a free connection, then go ahead and pay for the faster service.

With the onset of a new technological age, where technology is the norm rather than the exception, we need to be just as careful about our money as we are about educating our students.

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

All About Me- The Student Interview & Patient-Centered Interview

Dr. Anne Zachary recently posted “6 Ways Your Child with Special Needs Can Get the Most out of Occupational Therapy.”  She is so right on to suggest an “All About Me” binder that a parent creates for his or her child.  This binder, as suggested by Dr. Zachary, should include relevant information, service providers, favorite toys, and any other info that the parent feels appropriate.  Dr. Zachary calls this the “Ice Breaker!”  This binder is the beginning of a patient-centered interview.  It is the initial collection of psychosocial data that is so important to improving clinical outcomes.

As parents and clinicians, we are charged with encouraging our children to be assertive and responsible.  As school-based therapists, we evaluate, collect data and make many of our judgments through standardized testing and analysis of work samples.  All of this data that we collect has little to do with the feelings or actual function of our students. In my opinion, we need to go a step further.  Our students need guidance to initiate conversation that will lead to information gathering specifically related to a student’s needs.  “The Student Interview” becomes my “ice breaker.”

I recently read an article, Evidence-Based Patient-Centered Interviewing, by Swiss Lyles, et al.  This article describes the basis for Patient-Centered Interview which includes: The Student Interview CoverA

  1. Gathering personal and psychosocial data
  2. Competency in interviewing skills
  3. Relationship building skills that nurture confidence and human understanding

In essence, being in the moment with the patient, focusing on his or her needs which is the basis for ‘therapeutic use of self.’ As therapists, one of the first terms that we learn is ‘therapeutic use of self.’ This term refers to using yourself as a therapeutic tool in the evaluation and treatment process.  It includes being focused in the moment and on your patient.  As a school-based therapist, this is not often easy to do.  There are so many students, assessments, reports and evaluations to conduct that we can easily fail to concentrate our focus on the student.

Interviewing a student may not always be an easy task.  Providing a student the freedom to discuss whatever they choose may actually be a luxury.  So how do we get to a patient-centered interview?  Since our students are still quite young, we still need to guide them through the interview process.  We must encourage them to discuss their needs but guide them to discuss their needs within the realm of occupational therapy.  As some one who has worked in middle and high schools, my focus has been to meet the student’s needs and discharge.  I have sat in many meetings where someone says, “but he has so many deficits.”  It has often been the result of a committee decision to continue therapy and not my opinion. Often, the student has had no input at all.  It is my belief that I need to train my students to be appropriately assertive and give him or her a voice in the process.  My students are emerging into adulthood.

Research has indicated that when physicians encourage a patient to participate in his or her care by asking questions during appointments showed improvement in blood pressure, blood glucose levels and functional status. It is this giving and receiving of information that shapes how a patient feels about their disease or disability giving them control over how their disability impacts on their lives. This creates a sense of commitment to the treatment process. The “Ice Breaker” becomes a tool to promote familiarity and engagement.  I created “The Student Interview” to have the very same effect with my students.  Using “The Student Interview” allows me to learn about a student’s likes/dislikes, what worked or has not worked, what they feel comfortable with, leisure activities, self-care activities, what they think their abilities are.  It is a guided interview with checklists leading to open-ended questions which my students can use to focus attention on their treatment needs.  In my opinion, The Student Interview not only provides a structure to help a student express their opinions and needs but helps to train them to become assertive and not feel as if they have no control.  Using a patient-centered interview has been shown to increase patient satisfaction and compliance with treatment.

I began using The Student Interview a few years ago.  Yes, I did start to develop this resource out of frustration due to numerous challenges brought by unhappy parents. I know that all they really wanted was to focus on their child’s specific needs. What I saw was an over tested and overwhelmed student becoming increasingly frustrated because no one asked them what was important and what worked for them. They did not know how to respond or how to contribute. They were frightened to raise their voices to be heard. The Student Interview allows a student to do just that.

 

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

Creating Digital Notebooks

Reduce frustration for you and your child

Organization Group NewsIt is difficult for some students to get through school well organized.  Parents, teacher and even students become frustrated with missing homework assignments, notes out of order torn or even missing altogether.  When frustration ensues, it is easy to become argumentative, which is counter-productive to getting work done.

It is my goal to support your efforts to help your child by taking that task over. Creating digital notebooks with your child, there is little worry about losing important work.

Children with Executive Function Disorder have difficulty performing “activities such as planning, organizing, strategizing, paying attention to and remembering details, and managing time and space. ”

Using technology I can help your child manage all that paperwork and not feel so frustrated.  Just think, once a document is loaded into the correct digital notebook, it will never be lost.  If your child loses a paper document that has been uploaded, all he or she needs to do is print out the document.

When teachers request that the student present a notebook, the notebook can be e-mailed to the teacher.  If the teacher will not accept a digital form of this notebook, the notebook can be printed.

Notebooks will be available, in real-time, on the web allowing access in any location with an internet connection by simply using a log-on and password.

Less frustration for all makes home and school life smoother. Please feel free to call for further information.  631-629-4699

 

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
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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.