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Any school-based occupational therapist can attest to the popularity of tracing worksheets as a classroom tool to aid developing writers and struggling writers. But how effective is tracing, really? We know that learning to write is a complex task. Children have to use their visual skills to recognize that a drawing or symbol represents a letter, recognize that letter in its many different forms in text, create a mental picture of the letter in their memory, make a motor plan of how to form it themselves, and coordinate their brains and hands to execute that motor plan. Recent studies have used functional magnetic resonance imaging (fMRI) to better understand which parts of the brain are most used during a specific task. Studies that have looked at tasks related to reading or writing indicate clear differences in brain activation. Specifically, studies have used fMRI to study what is occurring in the brain when children see, type, or trace a letter, compared to when they free write a letter. When children free write letters, the areas of the brain responsible for reading and writing are highly activated (lit up). In contrast, when children see, type, or trace letters, these areas are not activated. When tracing, children tend to focus on the individual letter segments and on their ability to adhere to the lines, instead of focusing on the letter as a whole. They often start tracing at different points on the letter, and may not start at the same place each time. For these reasons, the act of tracing does not help children develop a mental representation of a letter, or develop form constancy, which is the understanding that a letter stays the same, even when it changes size, font, or case, in the way that free writing does. When free writing, children learn that their letter “A" may not look exactly alike each time they write it, and may not look exactly like the model, but it is still an “A." Furthermore, tracing a letter does not allow a child to develop a motor plan for the letter as a whole, which is important for writing with automaticity and fluency. Most children can overcome the limitations of tracing and learn to write fluently; however, children with poor visual-motor skills are likely to struggle, and may produce letters that are slow and labored, choppy, and drawn with various starting points. Finally, tracing worksheets are generally used as independent work activities; however, research indicates that learning handwriting should not be an independent process. Effective teaching includes guided practice that incorporates feedback from the teacher as well as the child's self-assessment. There are several compelling reasons for occupational therapists and teachers to abandon tracing activities in lieu of other, more effective methods of learning to write. Children benefit from explicit instruction in how to form letters along with guidance and feedback provided as they practice free writing. Children should be given frequent opportunities to practice writing letters and words in an environment that favors process over product. Here are a few resources on tracing that may be helpful! The effects of handwriting experience on functional brain development in pre-literate children (iu.edu) Why tracing is a very bad idea | Skills for Action To Trace or Not to Trace? - The Learning Professor
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| By Janine Calmes, PT, MS and Amy Collins, OTR, MOT
At TxSpot, we receive a lot of questions about dismissing a student from occupational therapy or physical therapy services in the school setting. So…let's look at some of the questions and answers about this topic! Is a reevaluation required to dismiss a student from occupational therapy or physical therapy services in Texas? Texas school districts are responsible for developing their own policies
that align with legal mandates. Many Texas school attorneys are currently
advising districts to evaluate students prior to dismissing a service, such as
occupational or physical therapy, and therefore, some districts have developed
local policy that requires a re-evaluation before dismissal. Therapists should
always follow the policies and procedures of the school districts in which they
work.
That being said, there is nothing in the Individuals with Disabilities Education Improvement Act (IDEA), the Texas Education Code, Texas occupational therapy or physical therapy licensure, or Texas Education Agency (TEA) guidance that stipulates a re-evaluation in order to discontinue a related service in the school setting. The decision to discontinue services is made by the ARD/IEP committee and must be based on current data regarding the unique educational needs of the student, but that data does not have to include a re-evaluation. Acceptable data could be a graphic representation of performance showing progress, work samples, parent information, outside evaluations, information from PLAAFP, etc. Some districts have created a form that prompts the provider to document the various sources of data used to make the recommendation to discontinue services. This helps make clear to all what data was utilized to make the decision. The form is often referred to as a Dismissal Summary; however, some caution that this might be viewed as predetermination of the outcome.
Texas physical therapists must be aware that a discharge summary is required by Texas Physical Therapy licensure rules before a client can be dismissed from service: The PT must provide final documentation for discharge of a patient, including patient response to treatment at the time of discharge and any necessary follow-up plan. A PTA may participate in the discharge summary by providing subjective and objective patient information to the supervising physical therapist. Texas Board of Physical Therapy Examiners RULES March 2022 §322.1.(e)(4)
Can a student be dismissed from services at an annual ARD/IEP meeting or only at a REED or 3-year reevaluation meeting? The decision to dismiss services for a student can be made in any convened ARD/IEP meeting. What are some considerations for dismissing a student from occupational therapy or physical therapy services at school? When considering if a student is ready for dismissal from OT or PT services, it is your responsibility to understand the purpose of occupational therapy or physical therapy as a related service under IDEA, to collect and assess current data about a student's participation and performance, and to use your professional reasoning to determine if a student continues to NEED your service in order to benefit from his/her Individualized Education Program (IEP).Some guidelines for considering dismissal of services: - Base your recommendation on current data from a variety of resources (parent, student, and teacher input, data collection, progress reports, observations). Make certain the data on which you are basing your recommendation are accurate.
- Determine if there are any areas where a student needs MORE than the other supports in his/her IEP or if the student is not anticipated to make continued progress without your service. If so, you may need to continue to provide support rather than dismissing the student.
- Some common reasons to consider discontinuing therapy services include:
- The student is able to participate in his/her educational program without additional support (there are no longer any goals/objectives that require support by OT / PT).
- The needed supports have been successfully integrated into the student's program so that ongoing involvement by OT / PT is no longer necessary.
- OT / PT has exhausted all supports/interventions with no positive impact.
- Seek to understand the concerns of parents or other IEP committee members, and address them with understanding and diplomacy.
- Be consistent with your professional reasoning - apply the same standards to each student.
- Remember that your job is to provide the IEP committee with your recommendation; the committee can always decide something different.
- Ask the IEP committee to document your recommendation in the paperwork, even if they choose not to follow it.
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| (Updated Article)
by Denice Tucker, OTR & Amy Collins, MOT, OTR
Manager, School-Based Therapy Services, HCDE
- Print a map of the district from the district website to locate schools.
- Print a school calendar and make note of grading periods.
- Collect your student "folders" so you have needed information about each of your students, including previous progress notes and evaluations. These may be digital folders. Or if your district still uses paper (“soft") folders, collect them and find out where they are securely stored.
- Review ARD/IEP information (confirm that a current evaluation and goals and objectives are in place, review accommodations/modifications, look for other valuable information such as a Behavior Improvement Plan, Individualized Transition Plan, or Autism Supplement.
- Review ARDed service (time, frequency, duration) and check to make sure service time in your records matches that on the service page in the IEP.
- If you are a PT, check to make sure the medical referrals for your students are current.
- Meet principals, office staff, diagnosticians, and ARD chairperson at your schools and provide them with your contact information.
- Meet/e-mail teachers and find out their schedules; find out when the student is doing he activity that the IEP goal is addressing; give them your contact information.
- Organize a personal system to manage documentation, such as a notebook with student attendance, progress notes, and data on IEP objectives or create electronic folders on your computer to organize by campus, student, and school year.
- Locate resources and test materials in your district.
- Observe your assigned students in the classroom.
- Think through intervention strategies and decide how to serve students in context by embedding strategies; write an intervention plan. If needed, write a plan for your OTA or PTA.
- Pick up referrals that pertain to your schools and know the process to proceed.
- Identify district procedures for securing parent consent.
- Ask about the flow of documentation in your district.
- Determine how and where to obtain needed equipment.
- Find places to work (office space for working on documentation, responding to e-mails, etc.)
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The American Occupational Therapy Association is offering COVID-19 & OT courses for free to members and to non-members through the AOTA Store, including the following: From Onsite to Online: Addressing Students' Needs Through a Telehealth Service Delivery Model.
Online Continuing Education Series AOTA is also offering an online continuing education series. Participants can earn up to 1.5 contact hours per session. Webinars will be live-tweeted using #COVID19andOT and available on the AOTA Store within 24 hours of the live event. Registration for the series is now open! Check AOTA's COVID-19 & OT Online CE Series page for detailed information and updates. COVID-19 & OT | An Online CE Series Update on the Coronavirus Aid, Relief, and Economic Security (CARES) Act
Wednesday, April 8 • 12:30 p.m.–2:00 p.m. ET
FREE Shortening the Distance: A Panel Discussion on Telehealth and Occupational Therapy with Children, Youth, and Adults Thursday, April 9 • 12:30 p.m.–2:00 p.m. ET FREE #OTatHome Friday, April 10 • 2:00 p.m.–3:00 p.m. ET FREE Providing Pediatric Outpatient OT Using Telehealth Technologies: Case Study of a Hospital-Based Institution Monday, April 13 • 1:00 p.m.–2:30 p.m. ET FREE State Advocacy Update: Ensuring Access to OT During a Pandemic
Tuesday, April 14 • 11:00 a.m.–12:30 p.m. ET FREE Earn up to 1.5 contact hours per session. Webinars will be live-tweeted using #COVID19andOT and available on the AOTA Store within 24 hours of the live event. Registration now open! Check AOTA's COVID-19 & OT Online CE Series page for updates.
Other OT Resources for COVID-19
New Telehealth Resources on the AOTA Coronavirus Resource Center include a free webinar focused on Telehealth Resources for Occupational Therapy hosted by the American Congress of Rehabilitative Medicine featuring AOTA Member Tammy Richmond and AOTA's Monica Wright, and the “Delivering Services Through Telehealth" chapter of The Occupational Therapy Manager (6th ed.) ($19.95 for members, $24.95 for nonmembers). Also available is the Telehealth Demystified CE, focused on the benefits of telehealth and how to incorporate it into an existing practice.
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| “There is no defined or correct method to adequately and equitably meet the need s of all students in an unprecedented event such as the current COVID 19 pandemic response. LEAs need to be flexible and consider employing a variety of delivery options as they make reasonable efforts to provide services to students with disabilities." (from TEA, https://tea.texas.gov/sites/default/files/covid19_special_education_qa_updated_march_20.pdf) School districts will each determine how to best provide education to all students during this confusing and rapidly changing climate. There is probably no option that does not come with advantages and disadvantages. Districts must consider access to instruction, equality, efficiency, competence with technology and more; many will want to follow the guidance of their attorney. It has been made clear that as soon as districts begin to provide instruction to students, all the mandates from the Individuals with Disabilities Education Act (IDEA) are in effect, including timelines for initial evaluations and implementation of Individual Education Programs (IEPs). As related service providers, school-based occupational therapists and physical therapists need to work closely with district leaders to determine how to assist the district to meet its obligations. In many districts, this will be your Special Ed Director or Coordinator. As you move forward, here are some things you'll want to consider: - How is your school district planning to deliver instruction to students?
- How is your school district planning to individualize instruction to students wit
- h an IEP?
- How can you gain access to instruction being provided to students you are serving?
- How can you contact teachers to collaborate and provide support?
- If instruction is being provided through an online platform, can you schedule to participate in order to provide needed support?
- If your district is asking you to provide services through telehealth, are you versed in your discipline's licensure rules related to telehealth?
- What technology support will you need to provide services?
- How will you communicate with parents who do not speak English?
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| As many school districts are scrambling to problem-solve how to deliver educationally-relevant related services to students, there has been much discussion around the use of telehealth services. There are many things OTs and PTs should consider when planning to use telehealth as a service delivery model. Therapists must be informed on what their state licensure rules say, as well as ethical considerations, FERPA compliance, access, reimbursement, and logistics. Here is what Texas OT and PT Rules require, along with some helpful resources.
OT RULES (December 2019) §362.1. Definitions. (39) Telehealth--A mode of service delivery for the provision of occupational therapy services delivered by an occupational therapy practitioner to a client at a different physical location using telecommunications or information technology. Telehealth refers only to the practice of occupational therapy by occupational therapy practitioners who are licensed by this Board with clients who are located in Texas at the time of the provision of occupational therapy services. Also may be known as other terms including but not limited to telepractice, telecare, telerehabilitation, and e-health services. (e) Evaluation. (3) The occupational therapist is responsible for determining whether any aspect of the evaluation may be conducted via telehealth or must be conducted in person. (4) The occupational therapist must have contact with the client during the evaluation via telehealth using synchronous audiovisual technology or in person. Other Texas Board of Occupational Therapy Examiners December 2019 37 telecommunications or information technology may be used to aid in the evaluation but may not be the primary means of contact or communication. (f) Plan of Care. (7) Except where otherwise restricted by rule, the occupational therapy practitioner is responsible for determining whether any aspect of the intervention session may be conducted via telehealth or must be conducted in person. (8) The occupational therapy practitioners must have contact with the client during the intervention session via telehealth using synchronous audiovisual technology or in person. Other telecommunications or information technology may be used to aid in the intervention session but may not be the primary means of contact or communication. (9) Devices that are in sustained skin contact with the client (including but not limited to wheelchair positioning devices, splints, hot/cold packs, or therapeutic tape) require the on-site and attending presence of the occupational therapy practitioner for any initial applications. The occupational therapy practitioner is responsible for determining the need to be on-site and attending for subsequent applications or modifications. (10) Except where otherwise restricted by rule, the supervising occupational therapist may only delegate to an occupational therapy assistant or temporary licensee tasks that they both agree are within the competency level of that occupational therapy assistant or temporary licensee.
PT RULES (March 2020) §322.5. Telehealth (a) When used in the rules of the Texas Board of Physical Therapy Examiners, telehealth is the use of telecommunications or information technology to provide physical therapy services to a patient who is physically located at a site in Texas other than the site where the physical therapist or physical therapist assistant is located, whether or not in Texas. (b) Physical therapy telehealth services must be provided by a physical therapist or physical therapist assistant under the supervision of the physical therapist who possesses a current: (1) unrestricted Texas license; or (2) Compact Privilege to practice in Texas. (c)The provision of physical therapy services via telehealth requires synchronous audiovisual or audio interaction between the physical therapist or physical therapist assistant and the patient/client, which may be accompanied by the use of asynchronous store and forward technology. (d) Standard of Care. A physical therapist or physical therapist assistant that provides telehealth services: (1) is subject to the same standard of care that would apply to the provision of the same physical therapy service in an in-person setting; and (2) the physical therapist is responsible for determining whether an evaluation or intervention may be conducted via telehealth or must be conducted in an in-person setting. (e) Informed Consent. A physical therapist that provides telehealth services must obtain and maintain the informed consent of the patient, or of another individual authorized to make health care treatment decisions for the patient, prior to the provision of telehealth services. (f) Confidentiality. A physical therapist or physical therapist assistant that provides telehealth services must ensure that the privacy and confidentiality of the patient's medical information is maintained during and following the provision of telehealth services, including compliance with HIPAA regulations and other federal and state law. (g) The failure of a physical therapist or physical therapist assistant to comply with this section shall constitute detrimental practice and could subject the licensee to disciplinary action by the Board. (h) Telehealth is a mode for providing one-on-one physical therapy services to a patient/client and is not a means for supervision of physical therapy aides. INFORMATION ON TELEHEALTH https://pediatricapta.org/news/#n1168 https://www.aota.org/Practice/Manage/telehealth/coronavirus.aspx https://www.aota.org/Practice/Manage/telehealth.aspx
https://ptot.texas.gov/wp-content/uploads/PTrules_2022.03.pdf (Chapter 322.5) https://ptot.texas.gov/faq/ (PT Practice FAQs - Telehealth)
https://ptot.texas.gov/wp-content/uploads/2022/06/OT-Rules-June-2022.pdf (Chapter 372.1) STUDENT PRIVACY AND ONLINE SERVICES
Respecting Student Privacy while using online educational services
VIDEO CONFERENCING PLATFORMS https://zoom.us/ (free to create account and time limit on free use waived currently)
ADVICE
The following are some words of wisdom from Laurie Ray, School-based Physical Therapy Special Interest Group of the Academy of Pediatric Physical Therapy: "While (these)* resources are provided for your information, EVERYONE must comply with their LEA, district, state and federal regulation, policy and directive! Please do not begin any practice without consideration of legal and ethical principles AND approval from your administration and supervisors! This is not a time to problem-solve on your own…lone rangers, dismount! Work within your school district/LEA and administrative structures to ensure compliant, thoughtful, reasoned action or inaction. Each student, IEP, situation and intervention must be thoughtfully considered with applied clinical reasoning, there is no single 'answer' to all."
Best regards and be well, Laurie Ray, PT, MPT, PhD *("These" resources does not refer to those listed in this article, but the thoughts apply.)
Return to Featured Article page
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To Consult or Not
to Consult: That is the Question.
Direct versus
indirect services. Which should I do? by Janine Calmes, PT, MS TxSpot has received many
questions about direct services versus consultation services.
First, it may be helpful to understand that neither the state of Texas nor the
Individuals with Disabilities Act (IDEA) use the term, “consultation.”
IDEA regulations state that
a student’s IEP must contain a statement of “special education and related
services and supplementary aids and services…to be provided to the child, on
behalf of the child, and…(through) program modifications and supports”
(IDEA Regulations, Part B, Section 300.230, italics added). The Texas Education Agency
(TEA) uses the terms, “direct” and “indirect” to describe services. The TEA
describes these two terms as follows: Direct services
usually refer to hands-on, face-to-face interactions between the related
services professional and the student. These interactions can take place in a
variety of settings, such as the classroom, gym, health office, resource room,
counseling office, or playground. Typically, the related service professional
analyzes student responses and uses specific techniques to develop or improve
particular skills. Indirect services
may involve teaching, consulting with, and/or directly supervising other
personnel (including paraprofessionals and parents) so that they can carry out
therapeutically-appropriate activities. …. (For example), a physical therapist
may serve as a consultant to a teacher and provide expertise to solve problems
regarding a student's access to instruction. Although the TEA defined
direct and indirect services in their 2009 FAQ, the terms were not meant to be
mutually exclusive since they describe methodologies that may both be needed to
best meet the student’s ongoing needs. Defining and limiting the methodologic
approach can result in unnecessary inflexibility that is unresponsive to student
needs. Instead of defining the
treatment approach as either direct or indirect, the evidence supports a blended
approach, sometimes called an integrated service model. This model stresses the
importance of working in context: interventions are applied in the environment
and to the task or activity where the student’s needs occur. Integrated services
include both direct and indirect services embedded into the natural environment
where the participation or performance issue occurs. Unfortunately,
some IEP management software is designed using a drop-down menu that requires a
forced choice of direct OR indirect. If so, there is sometimes a “work around”
that will allow designation of a blended approach. Further complicating the
matter is Medicaid reimbursement for services. Medicaid only reimburses for
direct service, that is, for service when the student is directly involved. For
example, time spent consulting or training staff or developing or modifying the
adaptive equipment is billable ONLY when the student actively takes part in the
activity. There are times when the
therapist may be pressured to provide only direct services. However, IDEA
indicates that the treatment approach is to be determined by the IEP committee
based on individual student needs. It should not be influenced by software
limitations, the student location (e.g. - school vs. homebound) or reimbursement
rules (Medicaid). It must be recognized that both direct and indirect services
are important in contributing to successful student outcomes and should be
included as part of integrated IEP service time. Some school districts
support the concept of “classroom support” in which generalized support or
consultation is offered to the teacher and other classroom personnel to provide
non-individualized strategies that apply to any student in the class. An example
would be an occupational therapist who describes the strategy of using a short
pencil or broken crayon to help students develop a tripod grasp for handwriting.
This is a general strategy that would be applicable to any or all students in
the class. This type of generalized support does not need to be
included as part of IEP service time. So, to the question, “Direct
versus indirect services: Which should I do?” the answer is…Both!
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|  from Harris County Department of Education -
School-based Therapy Services Thank you, PTs and PTAs,
for all you do to
help make students'
lives better! Check
out helpful links below:
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