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.


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.


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 Occupational Therapy

-Using Rubrics to Measure Patient Progress in All Practice Areas

Taken from the handout "Putting on Socks with One Hand" from Ohio State's Wexner Medical Center
Taken from the handout “Putting on Socks with One Hand” from Ohio State’s Wexner Medical Center

The following example of using a rubric in a rehab setting was developed from the handout “Putting on Socks with One Hand” available on Ohio State’s Wexner Medical Center site.   The rubric contained in this post was developed from this handout so that the directions that are provided to the patient match the expectations of the therapist as set forth in the assessment rubric.  If you have read my book, “Using Rubrics to Monitor Outcomes in Occupational Therapy”,  you would know:

 “Various dictionaries define a rubric as a set of rules.  In this case, rules that are used to make a judgment regarding a student’s level of performance.  Rubrics identify the standard of performance.  It is a way of communicating what is expected, describing a level of performance and the associated quality.”

So now we can see how the handout becomes a rubric and how a rubric is more clear and more transparent as a method of documenting patient progress than any other.

The rubric contains not only the steps to follow [listed as criteria] but also contains descriptors [as a graded judgment of attainment].  In this example, level of attainment or goal progress is assessed through the number of trials [red].  This method of documenting goal progress can be monitored and judged by any other therapist working with the patient when the primary therapist is not present.  The criteria is measurable and can be measured.  This meets the IDEA criteria.  By outlining the rules for judgement, consistency between raters [therapists] is possible.  Does each therapist [measuring progress] find the same areas of deficit?  More than likely, yes.  The potential for inconsistency can come from the therapeutic activities conducted prior to the task.  For example, did the primary therapist apply heat, but the covering therapist did not?  Did the primary therapist perform stretching exercises differently than the covering therapist?  While there are many variables between therapists, a consensus in deficit areas should be judged to be similar.  Please keep in mind that the rubric contained in this post is an assessment rubric [a standard based on the handout provided to the patient].  Once the patient’s deficits or limitations have been identified, the rubric will need to be modified to meet the individual needs of the patient.  Initially, developing a rubric can be time consuming.  However, once you have developed your rubric and saved it to use again, it can easily be modified for each individual patient.

If you would like a copy of this assessment rubric, please follow my blog and send your e-mail address to

One Hand Sock Data Sheet