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 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

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

Annual Review will be here before you know it–Create Balanced Assessments!

That’s right!  Annual review season will be here in just a few months.  You should start writing your annual reviews shortly.  During annual review, it is prudent to get a student’s feedback on what is working and what is not working.  Make sure that you have a way to gain that additional information.  An interview is always helpful to provide insight on a student’s ability to function not only in the classroom but also at home.  Parents so often paint a different picture of a student’s abilities at home.  Students can behave differently at home.

This is the time to put all your ‘ducks in a row.’  When assessing your students, make sure to have a balanced assessment with some type of real-life [authentic] assessment.  This often means having a rubric to demonstrate how a student’s progress has been judged and the data that supports the student’s progress.

Think about interviewing your student to learn about his or her insights into their skills. Did you ever think about providing your student with a satisfaction survey?  This is quite eye opening.  By developing a rapport with your students, you have the opportunity to create a report that is quite inclusive of all their skills and their opinions.  Listening to and including your student’s opinions leads to better goal development, better outcomes and improved compliance with recommended strategies.

Engage your students in every way possible to participate in collecting data and the development of their IEP.  You will go a long way in developing the respect and the trust of your students.