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PRE-REFERRAL OT CONSULTATION
Improving Student Outcomes and Teacher Perceptions Through Pre-Referral
Occupational Therapy Consultation
A Doctoral Capstone Project
Submitted to the School of Graduate Studies and Research
Department of Education
In Partial Fulfillment of the
Requirements for the Degree of
Doctor of Education
Jennifer Marie Curtis
Pennsylvania Western University
July 2023
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© Copyright by
Jennifer Marie Curtis
All Rights Reserved
July 2023
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Dedication
To my children, Abigail and Benjamin. Thank you for your love and inspiration. May you follow
your dreams and continue to grow and learn. I am proud of you both.
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Acknowledgment
Thank you to everyone who helped me to complete the Pennsylvania Western Doctor of
Education program. Thank you to my family, Daniel, Abigail, and Ben, for supporting me and
giving me the time to accomplish this goal. Thank you to my parents, Ken and Carol Harryn, for
supporting me throughout my education and encouraging me to pursue my doctorate.
Thank you to Dr. Mary Wolf, Faculty Capstone Committee Advisor, for your guidance
and support. Your suggestions and feedback were instrumental in allowing me to successfully
implement and complete my capstone project.
Thank you, Dr. Frank DeFelice, for serving as my external committee chair. I appreciate
your willingness to support me in this endeavor. I am grateful for your support and for providing
me with the opportunity to conduct this research project at Colonial Intermediate Unit 20.
Thank you to Dr. Jack Silva for allowing me to conduct my intervention within the
Bethlehem Area School District. Thank you to Jonathan Horvath, Principal of Asa Packer
Elementary School for participating and welcoming me into your building. Thank you to all the
teachers who participated in the study.
Thank you to my colleagues at Colonial Intermediate Unit 20 who supported me
throughout this process. Thank you, Allison Hubbs, Rebecca Miller, and Stephen Rupp for your
encouragement and feedback. I owe special thanks to Tiffany Smith for her participation as the
consulting therapist. Tiffany, without your willingness to participate and your ongoing
commitment, I could not have completed this project.
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Table of Contents
Dedication
iv
Acknowledgement
v
List of Tables
x
List of Figures
xi
Abstract
xii
CHAPTER I. Introduction
1
Capstone Focus
1
Background
1
Research Questions
4
Summary
5
CHAPTER II. Review of the Literature
6
IDEA and Related Services
6
Section 504 and School-Based Occupational Therapy
8
ESSA and School-Based Occupational Therapy
8
Occupational Therapy Licensing and Regulations
9
School-Based Occupational Therapy: Roles and Responsibilities
10
Medical Model Versus School-Based Occupational Therapy
13
Occupational Therapy Consultation for Identified Students
14
Handwriting Instruction and School-Based Occupational Therapy
16
IDEA and Early Intervening Services
17
Workload Versus Caseload Models
18
Occupational Therapy Referral Process
18
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Class Wide Interventions
19
Occupational Therapy as a Component of RTI
21
Examples of the Inclusion of OT in the RTI process
21
Therapist Perspectives on School-Based OT Services
25
Professional Development and School-Based OT Services
28
Teacher Perspectives on School-Based OT Services
29
Promoting Effective Consultation and Collaboration
31
Summary
32
CHAPTER III. Methodology
Purpose
Fiscal Considerations
Setting
33
33
35
37
Colonial Intermediate Unit 20 Occupational Therapy
37
Bethlehem Area School District
37
Asa Packer Elementary School
39
Governor Wolf Elementary School
40
Participants
41
Intervention/Research Plan
42
Research Design, Methods & Data Collection
44
Research Questions
44
Teacher Pre- and Post- Survey Statements
46
Occupational Therapist Interview Questions
47
Principal Interview Questions
48
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Validity
48
Summary
49
CHAPTER IV. Data Analysis and Results
51
Survey Data and Analysis
52
Analysis of Post Intervention Survey Responses
53
Analysis of Pre and Post Intervention Survey Responses between Groups
59
Analysis of Referral Data
59
Interview Data
62
Occupational Therapist Interview
62
Principal Interview
64
Analysis of Interview Responses
66
Discussion of the Data Analysis Process
68
Summary
68
CHAPTER V. Conclusion and Recommendations
Conclusion
69
69
Research Question One
69
Survey Responses
69
Occupational Therapist and Principal Interviews
72
Research Question Two
72
Survey Responses
72
Occupational Therapist and Principal Interviews
74
Research Question Three
Referral Data
75
75
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Interview Data
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76
Application to CIU20
77
Fiscal Implications
79
Limitations
79
Recommendations for Future Research
80
Summary
82
References
84
APPENDIX A. Teacher Survey Questions (pre- and post-)
93
APPENDIX B. Occupational Therapist Interview Questions
94
APPENDIX C. Principal Interview Questions
95
APPENDIX D. Teacher Consent Letter
96
APPENDIX E. Principal/Occupational Therapist Consent Letter
97
APPENDIX F. IRB Approval
100
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List of Tables
Table 1. Annual Cost of OT Services in Bethlehem Area School District
36
Table 2. Bethlehem Area School District Percent Enrollment by Race/Ethnicity
38
Table 3. Asa Packer Percent Enrollment by Race/Ethnicity
40
Table 4. Governor Wolf Percent Enrollment by Race/Ethnicity
41
Table 5. Post Intervention Survey Responses: Teacher Perceptions of Self-Competency
53
Table 6. Post Intervention Survey Responses: Value of IU OT Services
55
Table 7. Number of Referrals by School Year
61
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List of Figures
Figure 1. Control Group Pre- and Post- Survey Responses
57
Figure 2. Intervention Group Pre- and Post- Survey Responses
58
Figure 3. Control Versus Intervention Group Post- Survey Responses
59
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Abstract
Each year, Colonial Intermediate Unit 20 conducts a large number of at the request of school
districts. The current action research plan investigated the impact of providing professional
development and collaboration from an occupational therapist in the regular education setting.
Regular education teachers in the intervention group received classroom-based occupational
therapy consultation visits over five months. Participants in the intervention group and a control
group completed pre and post surveys to analyze their own perceptions of self-competency
related to addressing occupational therapy concerns in the regular education setting and the
teachers’ perceptions of the value of school-based occupational therapy services. The
occupational therapist and building principal participated in post-intervention interviews to
gather insight on their perceptions regarding the impact of OT services. In addition, referral data
was analyzed to determine whether the provision of pre-referral professional development and
class wide consultation could impact the number of initial referrals for kindergarten occupational
therapy evaluations. Overall, the survey data and interviews provided some support that the
provision of pre-referral professional development and class wide consultation can impact the
teachers’ perceptions of self-competency related to addressing occupational therapy concerns in
the regular education setting and the value of IU OT services. The results also showed that the
intervention was associated with a decrease in referrals for OT evaluations for the teachers in the
intervention groups when compared to the prior year.
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CHAPTER I
Introduction
Capstone Focus
Each year, Colonial Intermediate Unit 20 (CIU20) receives many referrals for
occupational therapy evaluations of regular education students, particularly kindergarten
students. District administrators have expressed concerns regarding the cost of related services
provided by the Intermediate Unit (IU) and are looking for ways to decrease costs while still
meeting the needs of all students. Because the IU Occupational Therapy (OT) staff only provide
services to students identified with a disability, there is often little collaboration between regular
education teachers and IU therapists regarding students in the general population. This lack of
collaboration may result in teachers being ill equipped with strategies to address issues prior to
moving to an occupational therapy evaluation. Increasing occupational therapists' presence and
involvement in pre-referral general education interventions would provide an opportunity to
intervene earlier to meet students' needs. Expanding these efforts could reduce the number of
special education referrals and equip regular education teachers to better address occupational
therapy issues in the regular education setting.
Background
CIU20 covers 1200 square miles in Northampton, Monroe, and Pike Counties. The IU
provides services for 13 school districts, three career centers, four charter schools and 65 nonpublic schools. CIU20 employs more than 1400 employees with annual budgets exceeding $226
million. Overall, the IU impacts over 86,000 public school students, which equals approximately
4.7% of the public-school students in the state. Over 9,000 students are served in IU programs.
CIU20 is the eighth largest IU based on the public-school student population served. As an
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intermediate unit, CIU20 serves a diverse student population with great variability in
demographics and socioeconomic variables across districts and counties.
CIU20’s mission statement is to develop and maintain positive relationships that support
student growth, are responsive to stakeholders’ crucial needs, and demonstrate effective results
through services and programs for students. CIU20’s vision is to be a vibrant, vital, influential,
and innovative child-centered organization serving children, families, and the people who serve
them wherever they might be and whatever they may need.
CIU20 provides some level of occupational therapy services for 13 school districts within
its geographical catchment area. Ten of the districts use the IU for all OT services provided to
students in both district and IU classrooms. Over the past several years, three districts have made
the decision to use outside agencies rather than the IU due to concerns with the cost of services.
During the 2020-2021 school year, the IU occupational therapy department conducted 544
evaluations of students across the kindergarten through twelfth grade continuum. The length of
time to complete an evaluation ranged from one hour to nine hours. The average amount of time
required to conduct an evaluation was 3.23 hours. Overall, 1,759 hours of therapist time were
devoted to the evaluation process for the 2020-2021 school year. During the 2021-2022 school
year, the IU occupational therapy department conducted 706 evaluations of students across the
K-12 continuum. The length of time to complete an evaluation ranged from one hour and ten
minutes to eight hours. The average amount of time required to conduct an evaluation was three
hours. Overall, 2,124 hours of therapist time were devoted to the evaluation process for the 20212022 school year. This time includes report writing, data analysis, and face to face evaluations.
Travel time, scheduling, and follow-up meetings are not included but require extra time from
each therapist.
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Multi-Tiered System of Support (MTSS) is a comprehensive framework that includes a
continuum of evidence-based supports and services to meet the needs of all students. Over half
of the school districts in Pennsylvania implement an MTSS system as a school improvement
measure. IDEA requires that schools provide students with appropriate instruction in the general
education settings. However, as independent service agency staff, Intermediate Unit
representatives are rarely involved in the MTSS process or general education intervention.
Currently, the main roles of school based Occupational Therapists are conducting evaluations to
determine eligibility for special education services and the provision of direct services to
identified students. Traditional MTSS models have not incorporated Occupational Therapists as a
pre-referral resource in providing regular education interventions. Increasing OT involvement in
the pre-referral intervention process has the potential to increase teacher competencies, decrease
wasted resources on unnecessary evaluations, and decrease the number of students requiring
higher levels of specialized intervention.
Research Questions
The following research questions will be explored through the implementation of the
proposed action research project:
1. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of self-competency related to addressing
occupational therapy concerns in the regular education setting?
2. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of the value of IU OT services?
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3. How does the provision of pre-referral professional development and class wide
consultation impact the number of initial referrals for kindergarten occupational therapy
evaluations?
Summary
Through the implementation of the proposed action research plan, the researcher hopes to
achieve several outcomes. First, providing more support from occupational therapists in the
regular education setting can decrease the number of referrals for occupational therapy
evaluations for kindergarten students. By providing professional development and collaboration
in regular education, teams can better meet the needs of students through the least restrictive
methods. Finally, increasing the involvement of IU therapists in pre-referral processes can create
more awareness of the CIU20’s occupational therapy department and improve collaboration and
communication with district partners. A review of the literature provides supporting evidence as
to the value of the involvement of occupational therapists in MTSS and the regular education
environment.
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CHAPTER II
Review of the Literature
Over the past 50 years, the role of the occupational therapist has continued to expand and
evolve in the school setting. Historically, school-based occupational therapy services have been
primarily accessible to students with disabilities. Students who exhibit weaknesses that impact
their ability to access the classroom environment and curriculum are frequently referred for
formal occupational therapy evaluations. Following a formal evaluation, eligible students
typically receive direct occupational therapy services, either individually or in a group, to target
identified areas of need. Based on this service model, a significant percentage of therapist time in
the educational setting is devoted to evaluations and the provision of direct services.
Although more recent legislation has supported the use of early intervening services for
non-identified students, occupational therapists have not had a significant role in these initiatives.
Expanding the role of the occupational therapist through consultation and collaboration with
general educators can provide effective ways to meet the needs of struggling students in the
general education setting.
IDEA and Related Services
The Education for All Handicapped Children Act (Public Law 94-142) was first signed
into effect in 1975 by President Gerald Ford. The act was considered a civil rights landmark and
opened the door for students with disabilities in public school settings. In 1990, the act was
reauthorized and officially renamed the Individuals with Disabilities Education Act, or IDEA.
IDEA mandated the right of students with disabilities to receive a free appropriate public
education (FAPE) in the least restrictive environment (LRE). Individuals who meet criteria under
the identified disability categories, and demonstrate the need for specially designed instruction,
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are eligible to receive special education services and related services. Legally, it is the IEP team's
decision on whether occupational therapy is needed as a component of the program to support
the student in attaining goals and objectives (U.S. Department of Education, 1990). While the
role of the occupational therapist in the school setting varies from state to state, therapists
generally work at the individual, classroom, and school level to address issues that impact a
student’s successful participation in the general education curriculum.
According to IDEA, a student’s IEP must outline the related services and supplementary
aids and services to be provided in order for a student to participate with nondisabled peers (U.S.
Department of Education, 1990). Related services include many services such as transportation
and other supportive services that are necessary to allow a student with a disability to benefit
from special education. These services include speech-language pathology and audiology
services, interpreting services, psychological services, physical therapy, and occupational therapy
(U.S. Department of Education, 1990).
IDEA further defines occupational therapy as the services provided by an occupational
therapist with appropriate credentials, with the goals of:
improving, developing, or restoring functions impaired or lost through illness, injury, or
deprivation; improving ability to perform tasks for independent functioning if functions
are impaired or lost; and preventing, through early intervention, initial or further
impairment or loss of function. (U.S. Department of Education, 1990, p. 10)
Within the school setting, practitioners work with the school team to evaluate a student’s
needs, determine what behaviors are expected within the school environment, and develop
interventions to address deficits. “As children with disabilities moved into public schools,
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occupational therapists were challenged with the task of developing alternatives to the medical
model of practice, a barrier experienced by many OTs today” (Ball, 2018, p. 264).
Section 504 and School-Based Occupational Therapy
In some cases, a student with a disability may not meet eligibility for special education
services under IDEA. Because schools receive federal funds, they must comply with both the
Americans with Disabilities Act (1990) and Section 504 of the Rehabilitation Act of 1973.
Section 504 provides another opportunity for certain students to receive school-based
occupational therapy services in the educational setting. Students with impairments which
severely limit major life activities may also be eligible for school-based occupational therapy.
The purpose of Section 504 is the protection of students with disabilities from discrimination.
Students who do not qualify for special education under IDEA may be eligible for protections
under Section 504. A 504 plan can provide students with reasonable accommodations that allow
them to benefit from and participate in the educational environment (U.S. Department of Labor,
n.d.). For some students, occupational therapy services are provided through a 504 plan. These
services can be provided individually or in a group setting and may include direct service and
consultation.
ESSA and School-Based Occupational Therapy
President Obama signed the Every Student Succeeds Act (ESSA) on December 10, 2015.
This act reauthorized the Elementary and Secondary Education Act (ESEA) and upheld the
nation’s longstanding commitment to equal opportunity for all students. ESSA replaced the
previous version of the law, the No Child Left Behind (NCLB) Act, which was enacted in 2002.
Primary focuses of ESSA were to close the achievement gap for disadvantaged or high-need
students and to increase accountability at the state and local levels.
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The terms "specialized instructional support personnel' and "related services" are defined
in the Every Student Succeeds Act (U.S. Department of Education, 2015). Instructional support
personnel include school counselors, school nurses, psychologists, school psychologists, social
workers, and school social workers; occupational and physical therapists; art, dance/movement,
and music therapists; and, speech language pathologists, and audiologists. ESSA requires that
state and local education agencies engage in meaningful consultation with specialized
instructional support personnel to best meet the needs of students in the educational setting.
Occupational Therapy Licensing and Regulations
The American Occupational Therapy Association (AOTA) is an organization that
represents over 230,000 occupational therapists and students throughout the United States. The
organization is dedicated to occupational therapy advancement with a focus on education and
research. The mission statement of the organization is to “advance occupational therapy practice,
education, and research through standard setting and advocacy on behalf of its members, the
profession, and the public” (American Occupation Therapy Association [AOTA], 2023, para.2).
The ability to practice as an occupational therapy is regulated by state law. All 50 states require
that both occupational therapists and occupational therapy assistants obtain licensure to practice
in both medical and educational settings. In Pennsylvania, the State Board of Occupational
Therapy governs the certification process for individuals seeking to obtain licensure. To be
licensed as a registered occupational therapist in Pennsylvania, an individual must complete a
four-year program in occupational therapy. In addition, all applicants must have successfully
completed a supervised fieldwork experience in an approved educational institute or training
program. Finally, applicants must obtain a passing score on an Occupational Therapist
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Registered (OTR) licensure examination or qualify for a waiver of the licensure examination
administered by the National Board for Certification in Occupational Therapy (NBCOT).
The Pennsylvania Department of State also oversees licensure for Certified Occupational
Therapy Assistants. This certification requires completion of a two-year degree program in
occupational therapy, completion of two months of supervised fieldwork experience, and a
passing score on the Certification Examination for Occupational Therapy Assistant prepared and
administered by the National Board for Certification in Occupational Therapy (NBCOT).
Maintenance of both OTR and Certified Occupational Therapy Assistant (COTA) licensure
requires ongoing professional development and documentation of continuing education credits.
School-Based Occupational Therapy: Roles and Responsibilities
According to the 2019 AOTA Workforce and Salary Survey, 18.8% of occupational
therapists and 15.4% of occupational therapy assistants work with students in school-based
environments in the United States (AOTA, 2020). AOTA developed several documents that
provide an overview of occupational therapy (OT) services in the school setting (AOTA, 2012).
Across all settings, occupational therapists assist individuals in meaningful activities in the
natural environment. Targeted activities may include education, work, play, socialization, and
activities of daily living. In a 2017 brochure developed for school administrators, AOTA further
clarified the continuum of services that occupational therapists can provide under the Individuals
with Disabilities Education Act (IDEA), Every Student Succeeds Act (ESSA), and Section 504
of the Rehabilitation Act of 1973. These activities include individualized special education
services, training for families and school personnel, participation on collaborative teams,
participating in district initiatives, and providing assistance for students who need additional
support in regular education. AOTA provides examples of early intervening services an
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occupational therapist can provide; these measures include periodic screenings, teacher training,
modeling whole classroom interventions, working with small groups, and assisting with team
problem solving.
For students who receive occupational therapy services as a component of an
Individualized Education Plan, services can be delivered directly or through a consultation
model. Hasselbusch and Penman (2008) interviewed teachers and occupational therapists to gain
insight into consultative practices used to support students with autism in regular education
environments. The researchers identified the development of relationships with school staff as a
key factor in the provision of successful consultation services in the school setting. Engagement
with the staff and developing a presence as a part of the school community required sufficient
time and varied across teachers and buildings. In addition, therapists who delivered effective
consultation were characterized by the ability to problem-solve on the spot and demonstrate
flexibility (Hasselbusch & Penman, 2008).
According to the American Occupational Therapy Association, the goal of occupational
therapy is to help an individual to achieve well-being and health, and to allow for participation
and engagement in occupation and life (AOTA, 2010). Although occupational therapy services
differ in certain settings, the evaluation process includes certain fundamental components
regardless of the environment. Through the evaluation process, the therapist determines the need
for service, identifies problems that need to be addressed, develops goals and interventions, and
develops a plan for assessment of progress (AOTA, 2010). Occupational therapy services in
schools can be delivered directly, indirectly, or through a consultation model. Direct service can
be provided in a separate environment or in the classroom but typically disrupts the student’s
participation in classroom activities. Indirect service involves a therapist teaching another adult a
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strategy which can then be implemented with a student. Consultation involves the identification
of strategies that can promote student success in the educational setting and focuses on
environmental changes that support student success (Villeneuve, 2009).
Benson (2013) conducted a study to better understand the views of school-based
therapists regarding conceptual models and current practice trends related to occupational
therapy. The researcher conducted interviews with 16 occupational therapists working in
educational settings with students across the K-12 continuum. Therapists reported working with
students using both pull-out and push-in methods. Pull-out instruction refers to working with
students outside of the classroom either individually or in small groups. Push-in instruction refers
to the provision of therapy within the naturally occurring classroom environment and routine.
“The relationship with the teacher often dictated the type of services. For example, some teachers
expect the child to be removed from the classroom, and others expect the support in the
classroom” (Benson, 2013, p. 169).
Therapists reported that they typically met informally with the teacher at the start of
sessions. Many therapists noted that they preferred push-in services as the best way to address
real-life issues in the natural environment. However, the therapists expressed some frustration
with the push-in model with certain individuals, and noted it was at times seen as a disruption to
the classroom routine. Overall, therapists reported better relationships and interactions with
special education teachers than general educators and expressed that the relationship with the
teacher was a critical factor in the successful implementation of services (Benson, 2013).
I enjoy it when I have a good working relationship with the teacher in the classroom. We
[OT and teacher] are working collaboratively…the teacher sees me as an asset rather than
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a nuisance. I have had teachers treat me both ways, so when something we do makes a
difference and the teacher notices [it’s a good thing]. Special educators are much more
educated in what we do and are much more open to our suggestions. Regular education
teachers have a much harder time. (Benson, 2013, pp. 171-172)
Medical Model Versus School-Based Occupational Therapy
In the school setting, occupational therapy's main goal is to allow a student to participate
in the school environment, including naturally occurring activities and routines. Therapists
consider the expectations across all school environments, including not just the classroom but all
educational settings. Transitioning in the hallways, accessing transportation, participating in
physical education, and eating in the cafeteria are examples of school-based activities that an
occupational therapist can consider when assessing a student’s needs (Cantu, 2003).
Occupational therapy services offered in the school setting differ from those offered
outside of school through a medical model. Private therapists may identify and target skill
deficits that do not impact a student’s ability to participate educationally. Due to these
differences, it is common for parents to question the differences between therapies offered in
outside medical settings. When parents do not understand these differences, it can create conflict
with school administrators regarding eligibility for school based occupational therapy. Unless a
student is found eligible as a child with a disability, he or she may not have access to
occupational therapy services in the school setting. Once a student is deemed eligible,
occupational therapy is only provided if it is determined necessary to meet identified goals and
objectives (Cantu, 2003).
Unlike occupational therapy services delivered through a medical model, school-based
services cannot be delivered in isolation. Best practice requires that school-based services be
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delivered through a collaborative, transdisciplinary approach. This approach necessitates
participation from general and special education teachers along with occupational therapists and
other related services providers such as speech therapists and physical therapists. Collaboration
on assessment, planning, and the implementation of interventions characterizes a truly
transdisciplinary model. A transdisciplinary model of service delivery has been associated with
improved student outcomes, positive teacher perceptions, and increased collaboration with
families (Mu & Royeen, 2004).
“Effective provision of services in schools is highly dependent upon the practitioner’s
ability to both collaborate interprofessionally and understand/plan for the provision of services in
the Least Restrictive Environment, per IDEA” (Friedman et al., 2022, p. 3).
Occupational Therapy Consultation for Identified Students
In the school setting, occupational therapy consultation is regularly provided for students
with special needs as a related service in IEPs or through a 504 plan. Wehrmann et al. (2006)
conducted a 2-year study to investigate the perceived benefit of school-based occupational
therapy for students with identified fine-motor issues. The consultation model of OT service
delivery was introduced in the 1990’s (Dunn, 1990). Since that time, this service delivery model
has grown in prevalence and acceptance. Occupational therapy consultation is typically based on
an identification of a student’s needs as determined through the evaluation process. The goal of
consultation is to educate the teacher and staff on how to best meet a student’s needs through
strategies and resources that can be implemented or accessed in the classroom setting. Through
this collaborative process, a classroom teacher can gain the skills to accommodate the needs of
diverse learners. The frequency of consultation visits is based on the student's needs but often
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occurs weekly or monthly. The results of the study supported OT consultation as a beneficial
intervention for identified students with fine motor difficulties (Wehrmann et al., 2006). This
result is consistent with findings of previous studies supporting occupational therapy
consultation as a preferred method of school-based service delivery (Dunn, 1990).
Villeneuve and Hutchinson (2015) examined the impact of collaboration between
occupational therapists and teachers on the outcomes of students with developmental disabilities.
The authors used two case studies to investigate the workplace practices that support
collaboration across educators and related services providers. The authors found that
collaboration could be facilitated through the focus of educational programming,
communication, and educational leadership. Occupational therapists’ collaboration on the
development of meaningful goals and demonstrations on integrating practices into a student’s
daily routine prepares teachers to effectively implement recommendations. Providing formal
opportunities for teachers and OTs to collaborate interactively is recommended to promote
meaningful multidisciplinary instruction. Leadership and accountability measures were also
identified as critical components necessary to support a collaborative multidisciplinary model.
Villeneuve (2009) synthesized literature on the use of collaborative consultation by
school-based occupational therapists. The review was guided by two main questions; first, how
consultation can contribute to meaningful outcomes for students with disabilities, and second,
what factors can influence the effectiveness of collaboration between therapists and teachers.
The findings of the literature review support two conditions that are essential in effective
collaboration between occupational therapists and teachers. First, all parties must have a clear
understanding of each member’s function. Teachers must clearly understand the roles and
responsibilities of the OT for the consultation process to be effective. In addition, therapists must
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be knowledgeable regarding the curriculum, classroom procedures, and school policies to ensure
the services they provide are educationally relevant.
Second, effective consultation and collaboration is dependent on sufficient time and
opportunities to work together and share information. Program administrators have a
responsibility to provide teachers and therapists with time within the school day to engage in
collaborative consultation to support students with disabilities in an inclusive setting (Villeneuve,
2009).
Handwriting Instruction and School-Based Occupational Therapy
Occupational therapy interventions for students with writing issues typically consist of
activities targeting the development of motor skills. A variety of fine-motor, visual perception,
visual motor, gross motor and postural strategies can be effective in improving handwriting.
Numerous studies have supported the use of occupational therapy to improve the legibility of
handwriting in the educational setting (Case-Smith, 2002; Feder & Majnemer, 2007).
Case-Smith (2002) studied the effectiveness of handwriting interventions delivered by
occupational therapists on the in-hand manipulation, visual-motor, visual-perception, speech, and
legibility of students between the ages of seven and ten. When compared to students who did not
receive direct service from an occupational therapist, the group showed significant improvements
in legibility. While the therapists in the study reported that they frequently collaborated with
teachers, there was no data collected on how the teacher carried over or supported the
interventions in the classroom setting (Case-Smith, 2002).
Taras et al. (2011) studied the effectiveness of a 14-week handwriting program
incorporating occupational therapy strategies on promoting handwriting skills with children in a
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general education kindergarten program. The program targeted hand skills, the awareness and
directionality of letter formation, and visual motor skills. The researchers reported that general
education kindergarten teachers were not implementing structured handwriting programs as class
wide interventions. In addition, teachers frequently referred students for occupational therapy
evaluations without having ever implemented interventions themselves (Taras et al., 2011). The
researchers conducted pre-and post-intervention handwriting assessments on students in 14
kindergarten classrooms. While students in the intervention received handwriting instruction
from occupational therapists, students in the control groups received handwriting intervention
from their general education teachers. The results of the study showed a significant difference in
post-test results between students receiving instruction incorporating occupational therapy
strategies and the control group (Taras et al., 2011). This study supports the use of occupational
therapy strategies in the general education environment and suggests that expanding the role of
the occupational therapist in the general education kindergarten setting can have positive
outcomes for all students while reducing referrals for OT evaluations in later years.
IDEA and Early Intervening Services
IDEA permits local education agencies to use a portion of funds to support the
development and implementation of services “for students in kindergarten through grade 12 who
are not currently identified as needing special education or related services, but who need
additional academic and behavioral support to succeed in a general education environment”
(U.S. Department of Education, 1990, p. 34). The 2016 IDEA regulations established mandatory
requirements for Comprehensive Coordinated Early Intervening Services (CCEIS). One such
requirement is the mandate that funds be used to identify and address issues that contribute to
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significant disproportionality. Early intervening activities should include professional
development, educational and behavioral evaluations, services, and supports.
Workload Versus Caseload Models
Seruya and Garfinkel (2020) analyzed trends in service delivery models related to schoolbased occupational therapy. Traditionally, occupational therapists have used a caseload model to
provide services in the school setting. This model is based solely on the number of students each
therapist treats. Conversely, a workload model considers all activities an individual engages in to
support students, either directly or indirectly. A caseload model, “provides more opportunities for
occupational therapy practitioners to implement occupation-based interventions in natural
environments” including “engagement in programs that promote positive student outcomes in the
larger community” (Seruya & Garfinkel, 2020, p. 76) such as multi-tiered systems of support
(MTSS). The researchers surveyed over 300 school-based occupational therapists and found that
while most students received OT services through an IEP or 504 plan, approximately 38% of
respondents reported participating in their school’s MTSS program.
Occupational Therapy Referral Process
Bolton and Plattner (2019) gathered survey data from teachers and occupational
therapists regarding the most common reasons for occupational therapy evaluation referrals. The
most common reasons for referrals identified were fine motor skills related to classroom
activities, handwriting, and sensory issues. Occupational therapy evaluations typically consist of
observation in the school setting, parent and teacher input and standardized assessment measures.
The Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery et al., 2010) is a
tool frequently used to determine eligibility for school-based occupational therapy services. The
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VMI assesses an individual’s integration of visual and motor skills and can help guide treatment
recommendations to assess areas of weakness. The VMI is a standardized norm-referenced
measure that can be used with individuals of all ages and has been shown to have high person
and content reliability (Pfeiffer et al., 2015).
The administration of the VMI involves the presentation of a developmental sequence of
geometric forms. Individuals are provided with verbal directions to copy each form using pen
and paper. The authors state that the VMI “can be used to identify, through early screening,
children who may need special assistance, to obtain needed services for them, to test the
effectiveness of educational and other interventions, and to advance research” (Beery et al.,
2010). The administration of the 30-item full form can typically be administered in 10 to 15
minutes (Beery et al., 2010).
Based on the results of standardized assessments, observation data, and input from team
members, the Occupational Therapist will make an eligibility determination regarding the need
for school-based services. In the event a student qualifies for service, an IEP or 504 plan will be
developed to incorporate identified goals, recommendations for accommodations and
modifications, and any other appropriate supports identified to assist the student in successfully
participating in the school setting. For students who do not qualify for services, the process may
result in recommendations that can be implemented in the regular education setting without
individualized intervention.
Class Wide Interventions
Research supports the use of class wide interventions to support regular education
students in a variety of ways. The use of class wide interventions has been shown to have a
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positive impact on student teacher interactions and promote learning and engagement (Conroy et
al., 2008).
RTI and other early childhood screening efforts in schools are very often limited to
reading and math assessments, such as assessments of phonemic awareness. Important as
such measures are, they are not sufficient. Schools need to attend to the whole child,
including physical and other factors that affect academics as well as other important
aspects of a child’s life. (Beery et al., 2010, p. 19)
Reeder et al. (2011) developed a case report of an elementary school in Texas that piloted
a Response to Intervention (RTI) program incorporating occupational and physical therapists. As
a component of the RTI process, OT’s conducted screenings, educated and supported teachers,
provided teachers with resources and strategies, and referred students to special education when
appropriate. The OTs reported that support most frequently requested by teachers were strategies
to address sensory regulation, posture, bilateral integration, pre-writing, and writing skills. The
OT’s provided intervention resources and ongoing class wide consultation and collaboration.
The researchers identified sufficient time for collaboration and to build trust as key components
to the success of the occupational therapist’s role in the RTI model. Through participation in the
RTI model, the therapists developed a flowchart to describe participation in each tier of the RTI
process.
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Occupational Therapy as a Component of RTI
School-based occupational therapists are in a unique position to integrate their profession
into all levels of a multi-tiered system of support. The AOTA developed a practice advisory
paper to address the inclusion of occupational therapy in a Response to Intervention Framework
(AOTA, 2012). The paper provides examples of services that may be provided by an
occupational therapist at each tier of the RTI model.one level, therapists can work to educate and
train teachers, conduct screenings, and implement a population-based approach in the general
education setting. A population-based approach involves interventions applied to an entire
classroom rather than with individual students. Examples of this could include professional
development on sensory processing, making recommendations on classroom management, or
assisting teachers to develop routines. At the tier two level, occupational therapists may review
student data to determine the need for more targeted interventions for struggling students.
Examples of tier two interventions may include interventions relating to seating for small groups
of students, targeted handwriting interventions, or recommendations for adapted materials.
Finally, tier three interventions are implemented with less than five percent of students who do
not respond to lower levels of intervention. For these students, therapists may recommend
individualized interventions, more frequent data collection, and consider the possibility of a
referral for formal evaluation (AOTA, 2012).
Examples of the Inclusion of OT in the RTI Process
Shifts in educational policy have led to higher expectations for kindergarten readiness
with increased demands related to fine motor skills and handwriting. To prepare students for
more structured, academic-focused kindergarten classrooms, occupational therapists have used
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collaborative approaches in the preschool setting to promote kindergarten readiness. Martino
and Lape (2020) piloted a six-week program to address fine motor and sensory issues with
students in a general education preschool program. The program was implemented with
typically developing students and included both fine-motor and sensory activities embedded into
the classroom routine. During the intervention, the occupational therapist developed and
implemented center-based activities multiple times per week. The classroom teachers carried
over the activities by implementing the centers on the days the therapists were not in the
classroom. Pre- and post-test measures were administered to determine the effectiveness of the
intervention. The results of the study supported the use of this collaborative integrated approach
to improve fine motor skills and kindergarten readiness for students in regular education
preschool (Martino & Lape, 2020).
Occupational therapists can play a vital role to increase awareness of the feasibility of
integrating occupational therapy services within preschool classrooms, collaborating with
teachers to help children improve fine motor and visual motor skills necessary for
participation in early literacy curricula. (Martino & Lape, 2020, p. 148)
Cahill and Lopez-Reyna (2013) conducted semi-structured interviews with occupational
therapists participating in problem solving teams through a Response to Intervention framework
in Illinois. The results of this study indicated school personnel lacked an understanding of the
scope of school based occupational therapy as well as the ways in which an OT might contribute
to the school team. Therapists reported that they were more frequently asked to informally
observe a student rather than participate in a problem-solving team process. The authors
identified collaborative consultation with active involvement from both the teacher and therapist
as a potentially effective RTI intervention in the school setting. To expand the role of the
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occupational therapist in the RTI model, it may be necessary to educate school teams on the role
of the occupational therapist and the support they can provide. Expanding the role of the
occupational therapist to include pre-referral collaboration and consultation could significantly
impact the performance of general education students (Cahill & Lopez-Reyna, 2013).
Hintz and Fletcher (2022) conducted a qualitative study to gather information on the
experience of teachers who received support from occupational therapists through a MTSS
framework. The researchers used surveys and semi-structured interviews to gain insight into the
experiences of 13 teachers employed in public schools within the United States. The results of
the study indicated teachers had positive experiences when collaborating with OTs through the
MTSS framework. Teachers reported that OTs provided consultation, recommended strategies
and that they felt the collaboration was an “efficient use of their time with effective solutions
which led to student progress” (Hintz & Fletcher, 2022). The study identified the lack of
documentation and the teachers’ lack of understanding regarding the role of the OT in the
schools setting. In addition, the teachers reported that high caseloads were one impediment to
increasing the role of the OT in the MTSS framework (Hintz & Fletcher, 2022).
For elementary students, handwriting is a critical skill that impacts a student's success
across all academic areas. Asher and Estes (2016) explored the implementation of handwriting
interventions through a Response to Intervention (RTI) framework. Asher and Estes (2016)
surveyed kindergarten through sixth grade teachers in a Midwestern school district to gather
information related to handwriting interventions in regular education classrooms. The results of
the survey indicated that teachers rarely sought out RTI supports for students solely due to
handwriting issues. Teachers reported that the occupational therapist was a valued resource in
the school community. The teachers identified the OT’s participation in RTI meetings,
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recommendations for intervention, and direct student service as the most meaningful
contributions. In addition, the teachers reported that there is a greater demand for OT support that
can be met due to the therapists’ availability. However, only 12% of the survey respondents
stated that they utilized occupational therapy support and services to address handwriting
concerns through the RTI process (Asher & Estes, 2016).
Asher and Estes (2016) also reported that while teachers had favorable views of OT
services, they did not always have a clear understanding of the tiers of support an occupational
therapist might provide through the RTI framework. In the general education classroom,
therapists can provide universal interventions to support effective handwriting instruction and
benefit the entire class. At a tier two level, therapists may offer more targeted interventions that
can be implemented and monitored by the regular education staff. Finally, if these efforts fail,
individualized interventions can be provided at the tier three level. Therapists can assist teachers
in better understanding this scope of practice to ensure appropriate interventions are available
across the continuum. Through the use of tier one and tier two interventions, teachers can
decrease the number of inappropriate or unnecessary referrals and help keep OT workloads at a
reasonable level (Asher, 2006). According to Asher and Estes (2016), “related to RTI programs,
therapists should educate school personnel about potential occupational therapy services related
to handwriting instruction, continue to contribute to problem-solving processes, and build their
roles as consultants.”
Ohl et al. (2013) conducted a study to determine the effectiveness of an RTI intervention
to address visual-motor integration and fine motor skills at the tier one level. The intervention
was implemented with over 100 general education kindergarten students across six elementary
schools. The primary research question investigated was whether the occupational therapy based
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RTI initiative would produce significant improvements in the fine motor and visual motor skills
of the participating kindergarten students. The students’ skills were assessed using several
standardized OT assessments prior to the intervention and following the 10-week period.
During the intervention phase, occupational therapists collaborated with the general
education kindergarten teachers to implement a program specifically developed for the study.
The program included direct intervention involving ten 30-minute weekly lessons delivered by
the OT along with the teacher, visual aids such as posters that were made available in the
classroom, skill modeling by both the teacher and therapist, the integration of a fine motor center
into the classroom routine, and ongoing consultation for struggling students (Ohl et al., 2013).
The results of the study indicated that the intervention group showed statistically
significant gains in both fine motor and visual-motor skills. Most of the teachers in the study
reported that they continued to implement components of the intervention following the
completion of the 10-week period. In addition, most teachers also reported they continued to
collaborate with the OT after the intervention was concluded. While the study did not
investigate the impact on occupational therapy referrals in the intervention group, the authors
listed this as a possible area for future exploration. Overall, the study supported the inclusion of
occupational therapy in an RTI framework and provided evidence that short-term, collaborative
class wide intervention can positively impact students’ pre-handwriting skills (Ohl et al., 2013).
Therapist Perspectives on School-Based OT Services
“Although there has been much discussion about the importance of collaboration between
professionals who work in inclusive classrooms, limited research is available on the actual
process of collaboration, particularly from the point of view of occupational therapists” (Bose &
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Hinojosa, 2008, p. 290). Bose and Hinojosa (2008) explored the perceptions of occupational
therapists regarding their interactions with early childhood educators in pre-kindergarten through
second grade classrooms in New York City. The researchers identified four major themes
through the analysis of interviews conducted with occupational therapists. The therapists had a
positive view of collaboration but provided few specific examples of the collaborative process or
resulting outcomes. The therapists identified the major barriers to effective collaboration as the
lack of time available to meet, a lack of support from administrators, and teachers’ receptiveness
to participating in the process.
The therapist’s perceived role in the school setting was another issue identified as a
contributing factor to successful collaboration. Several respondents indicated that teachers
frequently did not attend to their suggestions. In addition, whether the therapist was viewed as a
part of the school staff, or an outsider influenced their abilities to successfully collaborate with
teachers. Finally, the main activities therapists reported engaging in with teachers were not truly
collaborative in nature. Therapists viewed themselves as experts in their field, and this expert
role may have impeded their ability to participate as an equal team member in the collaborative
process with teachers (Bose & Hinojosa, 2008).
Cahill et al. (2014) surveyed 1,000 practitioners by randomly sampling individuals from
an AOTA database of early intervention and school-based therapists. The purpose of the survey
was to gather data on therapists’ involvement in the RTI process and attitudes towards that
involvement. Respondents indicated that over 75% of their school districts participated in an RTI
process. While most participants supported OT participation in the RTI process, they also
indicated the school personnel do not fully understand how OTs can contribute to it. While
practitioners reported participating in RTI across grade levels, most of the participation in RTI
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was reported at the K-3 level. Survey results indicated that participating in problem-solving
teams, coaching, consultation, and individual intervention were the activities therapists reported
to most frequently participate in.
While many therapists are open to participating in an RTI process, there can be
significant barriers impeding their involvement. Cahill et al. (2014) found that most surveyed
therapists identified limited resources, including time, personnel, and finances, as the main
barrier to their participation in RTI. In addition, they reported teachers' lack of understanding
regarding the scope of school-based occupational therapy, and the possible ways a therapist
might participate in class wide initiatives. Therapists also noted that there was often no precedent
within their districts for the participation of the OT in the RTI process.
Campbell et al. (2012) interviewed occupational therapists regarding their
implementation of collaborative classroom-based intervention. In this study, therapists
implemented Partnering for Change (P4C), a service delivery model that focuses on teacher and
therapist collaboration to enhance participation through environmental modifications and
adaptations. During the implementation phase, therapists spent one full day per week in the
school to allow for relationship building opportunities and consistent service delivery.
Within the P4C project, the therapists’ role included helping the teachers to recognize
children with motor difficulties and those at risk; making adaptations to classroom furniture,
work space, tools, and materials; working with the teacher to trial and monitor instructional
strategies; modeling strategies and techniques for a single student, for a group of students, or for
the whole class, sharing information and resources with families; providing brief “lunch-and-
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learn” in-services on topics chosen by teaching staff; liaising with school resource staff; and
acting as a bridge between the education and health care systems (Campbell et al., 2012, p. 53).
Professional Development and School-Based OT Services
Students with fine motor deficits can have trouble with common classroom activities
throughout the school day. “When performing these tasks, these students are often seen as being
sloppy with their work, unable to work independently, or lazy in getting the task completed”
(Chiu et al., 2008, p. 30). If not addressed, fine motor deficits can lead to secondary issues such
as academic problems, low self-esteem, and behavioral issues. Chiu et al. (2008) noted that a
lack of teacher awareness regarding occupational therapy can impede students’ access to
appropriate services. The provision of professional development is one method that can increase
awareness of how occupational therapy can improve student outcomes in educational settings.
General educators who participated in the workshops rated the areas in which they perceived the
most need for growth. Increasing awareness of factors that can lead to effective changes for
students, developing the ability to explain the needs of students with fine motor issues, and
understanding how to collaborate with OTs to promote student growth were the primary areas
identified for growth. The study's results provide evidence that improved awareness of fine
motor issues and occupational therapy can help teachers meet the needs of students in the general
education classroom. Collaboration between teachers and therapists can result in effective early
intervention that prevents students from experiencing more significant issues as they progress in
the educational system (Chiu et al., 2008). “To improve general health and well-being of all
students, occupational therapists must move beyond a direct service model approach and explore
alternate service delivery models” (Ball, 2018, p. 263). Christner (2015) also found that
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professional development was effective in enhancing educators’ awareness of school based
occupational therapy.
Teacher Perspectives on School-Based OT Services
Bolton and Plattner (2019) investigated the perceptions of occupational therapists and
teachers regarding the role of occupational therapy in the school setting. The researchers
surveyed elementary teachers and school-based occupational therapists to gain an understanding
of the perceived value of OT services, the most common reasons for OT referrals, and the
characteristics of OT service delivery in the school setting. The survey results indicated that
while most teachers value OT services in the school setting, not all teachers fully understand the
full spectrum of OT services available. Occupational therapists reported that they frequently
provide services to individual students but rarely provide class wide consultation or
interventions.
Benson et al. (2016) collected data on teacher’s perceptions of the role of occupational
therapists in school through a 31-question survey. Both general and special education teachers
were included in the survey, and respondents were all full-time teachers working in Pennsylvania
public schools. The results of the study identified four main themes representing teacher’s
perceptions. In general, occupational therapists were viewed as being student-focused, offering
valuable support, and being effective team members. Most respondents reported no negative
interactions with school-based occupational therapists and 77% of the respondents identified the
occupational therapist as a valuable member of the school team.
Despite the mostly positive perceptions, teachers did report a lack of collaboration and
communication with occupational therapists as evidenced by a lack of daily support and non-
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attendance at team meetings (Benson et al., 2016). Participants indicated that caseload demands
and itinerant status resulted in the OT not being a fully integrated team member. In addition,
teachers reported a need for therapists to have more direct interaction with teachers to allow
students to succeed in the classroom environment. Overall, teachers stated there was a need for
more participation and involvement from the therapist with additional time allocated for
classroom visits and teacher and student interactions (Benson et al., 2016).
Occupational therapy strategies cannot be successfully implemented in a school setting
without the classroom teacher's support (Benson, 2013). Benson et al. (2016) supported this
finding and the need for ongoing collaboration and communication between teachers and
therapists. If teachers do not fully understand the role of the school-based occupational therapist,
the therapist’s role as an effective member of the educational team can be negatively impacted.
To enhance their role in the school setting, therapists must work to educate teachers regarding
their role, establish effective communication, improve collaboration, contribute as an active
member of educational teams, and ensure adequate time to support the teacher, student and team
(Benson et al., 2016).
School-based occupational therapists will be utilized more effectively if their colleagues
are aware of their entire scope of practice. The roles of occupational therapists working in
a school setting have been developing to meet the students' ever-growing needs. It is
crucial that teachers are aware of these expanded roles, as they cover all areas of the
school environment. (Edick et al., 2022, p. 2)
Edick et al. (2022) conducted a study to explore elementary teacher’s perspectives on
occupational therapists in the school setting. The researchers investigated the perceived value of
collaboration with the occupational therapist as well as gauged how well teachers understood the
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roles of the occupational therapist. The researchers used an anonymous survey to gather
information from k-6 general and special education teachers working in the public school
system. The findings indicated that most teachers believe they understand the role of the
occupational therapist and view therapists as an asset to the educational team. One of the main
needs identified to improve collaboration between therapists and teachers is the need for formal
time to collaborate. To offer preventative consultation to students in the general education
setting, therapists must have adequate time to develop a working relationship with teachers and
the flexibility in scheduling to allow for ongoing consultation and collaboration (Edick et al.,
2022).
Promoting Effective Consultation and Collaboration
While numerous examples of collaboration between teachers and therapists can be found
in the literature, there is a lack of information on the actual strategies that have a positive impact
on this collaboration. Friedman et al. (2022) conducted a quantitative quasi-experimental study
to determine the effectiveness of a training and coaching intervention on improving collaboration
between teachers and therapists. The researchers identified the teacher and therapists’ selfreported ability to communicate, understand each other's roles, and resolve conflicts at the
dependent variables in the study. Following the intervention, both teachers and therapists
reported improvements in their skills across all three areas. The results of the study support the
effectiveness of ongoing training and coaching to assist teachers and therapists in improving their
ability to collaborate in the school setting (Friedman et al., 2022).
The success of a collaborative consultative model of occupational therapy services has
been linked to several key characteristics. First, therapists need adequate time to participate in
the school community and to develop strong relationships with educators and other school staff.
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Secondly, services need to be provided in a consistent and responsive manner. Finally, services
should be delivered in an inclusive manner designed to benefit all students, with therapists and
teachers working alongside each other as equal team members (Campbell et al., 2012). Through
successful collaboration, therapists had the ability to “reach children who were struggling with
motor coordination at an early age and to provide teachers with strategies to help children before
academic or socio-emotional difficulties had developed (Campbell et al., 2012, p. 57). In
addition, therapists participating in this collaborative classroom-based approach reported
improved personal growth and job satisfaction and felt a higher level of inclusion in the school
community (Campbell et al., 2012).
Summary
Traditionally, school-based occupational therapy services have been primarily accessible
for students identified with special needs and eligible for services under IDEA or Section 504 of
the Rehabilitation Act. School-based therapists spend much of their workday conducting
evaluations to determine eligibility or in the provision of direct services for identified students.
While IDEA mandates early intervening services for students in general education, occupational
therapists have had very little participation in regular education initiatives such as RTI or MTSS.
Limited examples in the literature support the inclusion of the occupational therapist in prereferral collaboration in the general education environment. The expansion of this role provides
an opportunity for school-based occupational therapists to expand their role in the school
community, reach at-risk students in a timelier fashion, and better meet the needs of students in
the least restrictive environment.
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CHAPTER III
Methodology
A comprehensive review of the literature provides supporting evidence as to the value of
the inclusion of occupational therapists in pre-referral interventions in the general education
setting. In the school setting, occupational therapy services are primarily available to students
with disabilities who are found eligible when deemed necessary to meet identified goals and
objectives (Cantu, 2003). Despite the traditional model of delivering OT services through 504
plans and IEPs, the literature contains a small but growing basis for the expansion of school
based occupational therapy in regular education initiatives (Reeder et al., 2011).
Purpose
The role of school-based occupational therapy services for students identified with
special needs has been well-established in the literature. The use of re-referral interventions such
as RTI and MTSS to meet the needs of students in the regular education setting are also well
supported as effective research-based interventions. The purpose of the current study is to
determine the potential impact of incorporating the occupational therapist as a pre-referral
regular education resource for teachers and students in the regular education classroom.
Each year, Colonial Intermediate Unit 20 receives a large number of referrals for
occupational therapy evaluations of regular education students, and in particular kindergarten
students. District administrators have expressed concerns regarding the cost of related services
provided by the IU and are looking for ways to decrease costs while still meeting the needs of all
students. Because the IU OT staff only provide services to students identified through IDEA or
Section 504, there is often little collaboration between regular education teachers and IU
therapists regarding students in the general population. This lack of collaboration may result in
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teachers being ill equipped with strategies to address issues prior to moving to an occupational
therapy evaluation.
Through the use of pre-referral consultation services, an occupational therapist could
achieve multiple outcomes. Consultation services can assist teachers in developing skills to
better meet the needs of students with fine motor deficits in the classroom. When teachers are
better equipped to meet the needs of diverse learners, the need for further evaluation and
individualized services may be lessened. In addition, collaboration with occupational therapists
and teachers may impact the teacher’s perspectives regarding the effectiveness of the
Intermediate Unit as a district partner and improve the overall reputation of the IU as a service
provider.
Through the implementation of the proposed action research plan, I hope to achieve
several outcomes. First, by providing more support from occupational therapists in the regular
education setting, I hope to decrease the number of referrals for occupational therapy evaluations
for kindergarten students. The CIU20 occupational therapy department employs 11 full-time
master's level clinicians. Much of their work time is devoted to conducting evaluations. A large
percentage of the evaluations result in referred students not qualifying for occupational therapy
service. By providing professional development and collaboration in regular education, I hope to
better meet the needs of students through the least restrictive methods and enable teachers to
meet the needs of students with minor issues without the need for direct therapy. Finally, my
overall goal is to create more awareness of the Colonial Intermediate Unit’s occupational therapy
department and improve collaboration and communication with the district partners who utilize
our services.
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Fiscal Considerations
Based on the board approved contract rates for the 2022-2023 school year, member
districts pay $136.93 per hour for occupational therapy services. During the 2021-2022 school
year, Colonial Intermediate Unit charged a rate of $132.94 per hour for occupational therapy
services. The average salary of a CIU20 registered occupational therapist is $61,902. The
current project will require an initial visit and five monthly visits to four regular education
classrooms. Each visit will require approximately one hour of therapist's time plus 30 minutes of
travel to and from the location. The estimated total amount of required therapist time for the
duration of the project is 30 hours. The prorated salary for the average OTR is $47.29. The total
budgetary impact based on salary is estimated at $1,419.00.
Over the past four years, the districts’ cost for occupational therapy services has increased
by 54%. This increase is the result of a steady rise in the number of students CIU20 evaluates
and treats on an annual basis. In 2019, an additional occupational therapist was added to the
department to meet the increased demand for evaluations and services. Although this cost is not
directly related to the impact of the current intervention on the CIU20 budget, the long-term goal
of the project is to reduce costs for member districts utilizing the IU for occupational therapy
services. Table 1 provides information on the annual costs of OT services for the Bethlehem
Area School District over the past four school years.
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Table 1
Annual Cost of OT Services in Bethlehem Area School District
Bethlehem Area School District Annual Occupational Therapy Cost
School Year
Total District Cost for OT Services
2018-2019
$495,441.76
2019-2020
$584,811.91
2020-2021
$628,710.40
2021-2022
$767,633.33
The proposed project will entail minimal indirect costs for the district and the
intermediate unit. The consultation visits will not be billed to the district but provided as a
component of the indirect time allocated for the district’s therapist. Full-time employees are
reimbursed for mileage at the IRS rate of $0.585 per mile. The estimated mileage for each trip is
36 miles, with an estimated total cost of $126.36. All training materials will be modified by the
program supervisor based on existing materials that were previously developed as a part of the
program’s professional development time. An additional $100.00 is included in the supply line
of the projected budget. This amount may be used to cover any materials recommended by the
therapist as a result of the consultation process. For example, modified paper and pencils are
frequently recommended as accommodations for students with fine motor needs.
Multi-Tiered System of Support (MTSS) is a comprehensive framework that includes a
continuum of evidence-based supports and services to meet the needs of all students. Over half
of the school districts in Pennsylvania implement an MTSS system as a school improvement
measure. IDEA requires that schools provide students with appropriate instruction in the general
education settings. Currently, the main roles of school based occupational therapists are
conducting evaluations to determine eligibility for special education services and the provision of
direct services to identified students. Traditional MTSS models have not incorporated
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occupational therapists as a pre-referral resource in the provision of regular education
interventions. Increasing OT involvement in the pre-referral intervention process has the
potential to increase teacher competencies, decrease wasted resources on unnecessary
evaluations, and decrease the number of students requiring higher levels of specialized
intervention. The proposed project will evaluate whether the provision of pre-referral
consultation services will impact the number of evaluations requested by regular education
teachers. On a larger scale, this type of consultation model could reduce the overall cost of
CIU20 occupational therapy services for our member districts while empowering district
teachers to meet the needs of diverse learners in the least restrictive environment.
Setting
Colonial Intermediate Unit 20 Occupational Therapy
As the eighth largest IU in Pennsylvania CIU20 provides related services for students in
school districts across Northampton, Monroe and Pike Counties. The related services offered by
the intermediate unit include physical therapy, speech therapy, vision services, audiological
services, orientation and mobility services, and occupational therapy services. The occupational
therapy department is a component of the larger Pupil Personnel Services department. Within the
department there are currently 11 masters level clinicians (Occupational Therapists, Registered)
and over 35 Certified Occupational Therapy Assistants (COTAs). Each of these individuals
maintains licensure with the American Occupational Therapy Association as well as the
Pennsylvania State Board of Occupational Therapy Education and Licensure.
Bethlehem Area School District
Bethlehem Area School District is the sixth largest school district in Pennsylvania. The
district is in Northampton County within the Colonial Intermediate Unit #20 catchment area. The
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district encompasses approximately 42 square miles (about the area of Manhattan) and has an
enrollment of just over 13,000 students. According to the Future Ready PA Index (Pennsylvania
Department of Education, 2023), 54.7% of the student population is Economically
Disadvantaged, 7.3% of students are identified as English Language Learners, and 17.5% of the
student population receives Special Education services. The ratio of male to female students is
52% to 48%. The district is fairly diverse regarding race and ethnicity; Table 2 provides
information on the race and ethnicity of the student body according to current data provided on
the PA Future Ready Index (Pennsylvania Department of Education, 2023):
Table 2
Bethlehem Area School District Percent Enrollment by Race/Ethnicity
Percent Enrollment by Race/Ethnicity
American Indian/Alaskan Native
0.2%
Asian
2.8%
Black
11.1%
Native Hawaiian or other Pacific Islander
0.2%
Hispanic
44.4%
White
39.3%
2 or more races
2.0%
Note. Adapted from the 2023 Future Ready PA Index, by Pennsylvania Department of Education,
2023 (https://www.futurereadypa.org/).
Bethlehem Area School District is comprised of 16 neighborhood elementary schools
which house kindergarten through grade five. The district also includes two middle schools
serving sixth through eighth grade students, and two high schools. The district has offered an
early childhood education program for eligible pre-kindergarten children through PA Pre-K
Counts funding for the past several years. The district’s kindergarten program is a full-day
program offered to all residents who turn five years old by October first of each year. The
district provides laptops for all students to be used during academic programming. All district
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elementary students receive instruction in library, art, music, technology, and physical education
once a week. The district issues report cards based on academic and social performance to
parents four times each academic year. According to the mission statement provided on the
district website, Bethlehem Area School District
in partnership with the home and community, is committed to providing a safe and
supportive environment in which each student will attain the knowledge, skills, and
attitudes necessary to become a productive citizen and life-long learner in our
technologically demanding and culturally diverse society” (Bethlehem Area School
District, 2019, para.1).
The current study was conducted at two elementary schools located within the Bethlehem
Area School District, Asa Packer Elementary School and Governor Wolf Elementary School.
Asa Packer Elementary School
Asa Packer Elementary School is located just off Stoke Park Road in Bethlehem, PA.
The building houses kindergarten through fifth grades, as well as one CIU20 classroom, and has
an enrollment of about 400 students. The school’s website identifies 4 key components that are
responsible for the school’s strong community. These components include parent partnerships,
family events, a focus on technology, and the school’s designation as a Leader in Me building
based on Stephen Covey’s 7 Habits (Covey et al, 2014).
Asa Packer differs slightly from the district overall in regard to race and ethnicity. In
particular, Asa Packer has a smaller percentage of Hispanic students and a larger percentage of
White students. Table 3 provides information on the race and ethnicity of Asa Packer’s student
body according to current data provided on the PA Future Ready Index. As of April, of the 20222023 school year, 51 kindergarten students were enrolled in this elementary school.
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Table 3
Asa Packer Percent Enrollment by Race/Ethnicity
Percent Enrollment by Race/Ethnicity
American Indian/Alaskan Native
0.0%
Asian
2.7%
Black
8.3%
Native Hawaiian or other Pacific Islander
0.0%
Hispanic
21.7%
White
65.5%
2 or more races
1.8%
Note. Adapted from the 2023 Future Ready PA Index, by Pennsylvania Department of Education,
2023 (https://www.futurereadypa.org/).
According to the school’s website, Asa Packer “is a diverse learning community that
fosters student growth and success in a safe and challenging environment. Our goal is to
empower children to become life-long learners and responsible citizens” (Bethlehem Area
School District, 2023, para. 1).
Governor Wolf Elementary School
Governor Wolf Elementary School is located in the northeast section of Bethlehem.
Governor Wolf’s website describes the school as an environment that strives to maintain high
expectations for students in a cooperative climate. The mission of the school is based on
motivating, inspiring, leading, and encouraging all students to support academic and social
growth and development (Bethlehem Area School District, 2023). The school is also designated
as a Leader in Me building based on Stephen Covey’s 7 Habits (Covey et al, 2014).
Governor Wolf also differs slightly from the district overall in regard to race and ethnicity
but shares similar characteristics with Asa Packer. Table 4 provides information on the race and
ethnicity of Governor Wolf’s student body according to current data provided on the PA Future
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Ready Index. As of April, of 2022-2023 school year, 73 kindergarten students were enrolled in
this elementary school.
Table 4
Governor Wolf Percent Enrollment by Race/Ethnicity
Percent Enrollment by Race/Ethnicity
American Indian/Alaskan Native
0.2%
Asian
2.7%
Black
10.3%
Native Hawaiian or other Pacific Islander
0.2%
Hispanic
38%
White
47%
2 or more races
2.0%
Note. Adapted from the 2023 Future Ready PA Index, by Pennsylvania Department of Education,
2023 (https://www.futurereadypa.org/).
Participants
Eight kindergarten teachers will be invited to participate in the study. All teachers will be
sent pre- and post- surveys using Google Forms. Four of the participating classrooms are in Asa
Packer Elementary School, located within the Bethlehem School District. The kindergarten
teachers at Asa Packer will receive the professional development and consultation training
intervention. The remaining four kindergarten classrooms that will be invited to participate in the
study are located within Governor Wolf Elementary School, also located in Bethlehem Area
School District. The Governor Wolf classrooms will serve as a control group for the study and
will not receive the professional development and consultation training intervention.
In addition to the kindergarten teachers, study participants will include the building
principal from the elementary school participating in the intervention. The principals provided
initial consent for the building faculty members’ participation. At the end of the intervention
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phase, the researcher will interview the principal to gain qualitative data on his perspective
regarding the value of the occupational therapy services provided by CIU20.
The key participant in the current study is the master's level Occupational Therapist
responsible for implementing the intervention. The therapist participating in the current study
was chosen for multiple reasons. First, she is the most senior therapist assigned to Bethlehem
School District. She has been employed by the Colonial Intermediate Unit for 10 years as an OT.
Several years ago, this therapist participated in a project to develop professional development for
regular education teachers in the district as a strategy to reduce requests for OT evaluations
across the district. The therapist has a good rapport with district teachers and administrators,
which was a factor that could facilitate the implementation of the intervention.
In addition to the direct participants, the researcher relied on another Occupational
Therapist, Registered who is currently employed by CIU20 as a collaborating consultant. This
OTR provided input into the design of the study. She also helped the researcher understand state
and federal regulations related to the delivery of school-based occupational therapy services.
Intervention/Research Plan
To conduct the proposed action research study, the researcher designed a mixed method
design to gather both quantitative and qualitative data related to my research questions. The
proposed intervention will involve monthly classroom based occupational therapy consultation
visits scheduled during the school day. The therapist will visit each classroom in the intervention
group for a 30-minute monthly consultation for six months. Consultation services may include
observation, discussion with the teacher, recommendations for class wide adaptations, and
modeling of occupational therapy strategies. The consultation visits will not impact instructional
time or interfere with class activities. The therapist will be available for assistance if requested
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by the teacher but will refrain from disrupting the classroom routine to the greatest extent
possible. The visits will be scheduled by the occupational therapist based on the classroom
teacher’s availability. The therapist will email the teachers at least two weeks prior to the
proposed visit to coordinate the date and time of the visit.
Data on teacher perceptions will be collected using pre- and post- survey measures to
determine whether the intervention impacts teacher perceptions regarding the role and efficacy of
OTs in the school setting. Data will be pulled from the IU referrals database to compare the
number of evaluations requested in kindergarten classrooms participating in the intervention to
classrooms not participating in the intervention. Interviews will be conducted with the
participating occupational therapist and the building principal post intervention to gain
information on the perceived effectiveness of the intervention. The post-intervention interviews
with the building principal will be included to gather insight on the building administrator’s
perception of the impact of OT services for classrooms participating in the intervention.
For a period of five months, classroom consultation will be provided on a monthly basis.
Following the intervention, interviews will be conducted with the participating occupational
therapist.
Data collected for the project will be kept confidential. No identifying information will be
collected in the electronic surveys. Participants will be randomly assigned a participant
identification number to compare pre and post results and only be identified by this random
number. Participant names and random number assignments will be kept in a master list stored
separately from the survey data collected. The master list will be destroyed after the data has
been coded. All hard-copy data will be kept in a secure office location at the CIU20 main office
in a locked file. No personally identifying information will be shared with school personnel. All
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electronic data will be stored on a secure server and password protected. Thematic coding will be
used to organize and analyze interview responses from principals and the occupational therapist.
Research Design, Methods & Data Collection
The current study includes an analysis of pre- and post- survey measures to determine
whether the intervention impacted teacher perceptions regarding the role and efficacy of OTs in
the school setting. The quantitative data collected through the pre- and post- surveys will be
reported and visually displayed through graphs and tables to determine if the perceptions of the
teachers who participated in the intervention changed. The post- survey results of the two groups
will be compared through descriptive statistics using an analysis of the means. The researcher
will also analyze data on the number of evaluations requested in kindergarten classrooms which
participate in the intervention and in the control group classrooms. The total number of
evaluations per classroom for each of the participating teachers will be calculated. The mean
number of evaluations for the classroom teachers who participated in the intervention will be
compared to the mean number of evaluations for the non-participating teachers. These means
will be compared to determine if there is a difference between the two groups. Data will be
pulled from the IU referrals database to compare the number of evaluations requested in
kindergarten classrooms participating in the intervention to the number of referrals in classrooms
not participating.
Research Questions
1. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of self-competency related to addressing
occupational therapy concerns in the regular education setting?
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2. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of the value of IU OT services?
3. How does the provision of pre-referral professional development and class wide
consultation impact the number of initial referrals for kindergarten occupational therapy
evaluations?
The first research question will examine whether the provision of professional
development and class wide consultation can impact general education classroom teachers’
perceptions of their own competency when supporting students with occupational therapy needs
in the general education classroom setting. The second question will compare the perceptions of
general education teachers who have participated in pre-referral professional development and
class wide consultation prior to the intervention and at the conclusion of the intervention. In
addition, the researcher will compare the perceptions of the teachers who participated in the
intervention to teachers who did not participate. The third research question will use district
referral data to determine if the provision of the intervention impacts the number of referrals for
students whose teachers participated in the intervention.
Each participating kindergarten teacher completed a pre- and post- survey to collect
quantitative data regarding perspectives regarding the effectiveness of school-based occupational
therapy services. The survey was designed to collect data to assess the teacher's perspectives on
the role and efficacy of OTs in the school setting. Teachers rated each survey item by indicating
their agreement with statements using a five-point Likert scale ranging from Strongly Disagree
to Strongly Agree (Appendix A). The survey required teachers to answer 10 questions to gain
information on their perspectives related to the established research questions. Teachers in the
control and intervention groups completed the surveys during the first and sixth months of the
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study using a Google Form distributed through email. Participants will include their randomly
assigned participant identification number in the survey pre and post results so that the results
from the two surveys can be compared.
Teacher Pre- and Post- Survey Statements
•
As a regular education teacher, I utilize an occupational therapist to support students in
regular education.
•
Prior to referring a student for an occupational therapy evaluation, I attempt strategies to
address fine motor deficits in the classroom.
•
The occupational therapist is a valuable resource to me as a teacher.
•
If I need assistance from an occupational therapist, my assigned building provider is
available and accessible.
•
I understand the role of the school-based occupational therapist at the elementary school
level.
•
I am satisfied with the support I receive from the Intermediate Unit Occupational Therapy
Department.
•
I believe my regular education students can benefit from classroom consultation from an
occupational therapist prior to a referral for evaluation.
•
All students who demonstrate fine motor deficits or sensory concerns should be referred
for an occupational therapy evaluation.
•
I am knowledgeable regarding strategies that can benefit students with fine motor and
sensory concerns.
•
My school district offers professional development opportunities related to occupational
therapy topics.
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At the end of the intervention phase during the sixth month of the implementation
process, the researcher will interview the occupational therapist who participated in the
intervention. The interview will be conducted by the researcher at the Intermediate Unit central
office, and responses will be recorded. The interview is expected to take approximately 15
minutes and is composed of open-ended questions in a semi-structured format that may lead to
additional follow-up questions.
Occupational Therapist Interview Questions
•
What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
•
What impact did the current intervention have on student performance in the regular
education classroom?
•
What impact did the current intervention have on teacher’s perceptions regarding the
value of occupational therapy services in the school environment?
•
What impact did the current intervention have on your relationship with the classroom
teachers?
•
What impact did the current intervention have on your level of participation in the
building as a whole?
Also, at the conclusion of the intervention phase during the sixth month of the
implementation process, the researcher will conduct a brief interview with the building principal
whose kindergarten classrooms participated in the intervention. The interview will be conducted
by the researcher in the school building, and responses will be recorded. The interview is
expected to take approximately 15 minutes and is composed of open-ended questions in a semistructured format that may lead to additional follow-up questions.
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Principal Interview Questions
•
What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
•
What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
•
What impact did the current intervention have on student performance in the regular
education classroom?
•
What impact did the current intervention have on your perceptions regarding the value of
Occupational Therapy services in the school environment?
•
What impact did the current intervention have on the Occupational Therapists’ level of
participation in the building as a whole?
•
What impact did the current intervention have on your impression of the value of IU
related services as a support for your building?
Validity
Mertler (2019) states that it is the responsibility of an action researcher to take
appropriate measures to ensure that the research is sound. For action research to have rigor, it
must be considered in light of its quality, accuracy, credibility, and validity. Data collection and
analysis must be conducted in a manner that ensures unbiased results and objectivity. Several
techniques can be employed to show evidence of rigor and validity. In the current study,
triangulation of data, experience with the process, and prolonged engagement and persistent
observation were employed to support the researcher’s assumption of validity (Mertler, 2019).
To develop the intervention implemented in the current study, it was necessary for the
researcher to have an in-depth knowledge of school based occupational therapy practices. As the
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author was neither an experienced researcher nor a registered occupational therapy, it was
necessary to enlist the aid of a collaborator. The author relied on collaboration with a doctoral
level Occupational Therapist, Registered, currently employed by CIU20, to assist in designing
the intervention, developing survey and interview questions, and analyzing the results of the
study. This collaborator also provided assistance to the researcher in understanding state and
federal regulations related to the delivery of school based occupational therapy services. The
expertise of this collaborator provided a higher level of rigor and credibility due to her
educational background, training, and experience with the action research process. It also helped
to ensure construct validity in that the questions included in the surveys and interviews were
designed to elicit meaningful information on the perspectives of the participants related to the
value of school-based occupational therapy services.
Triangulation of data involves including multiple sources of data within a research study.
Including multiple data sources helps in verifying the accuracy of data and giving credibility to
the study’s findings (Mertler, 2019). The research design includes three sources of data. The first
source will be gathered through the pre- and post- surveys administered to the participating
teachers. The second source of data will be gathered through the interviews conducted with the
building principal and participating occupational therapist. Finally, data on the number of
referrals requested across the control and intervention classrooms will be analyzed to investigate
the impact of the intervention on the number of referrals requested throughout the
implementation phase of the study. The inclusion of these multiple data sources within the study
design will provide further support of the validity of the findings through the established method
of data triangulation.
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A final means of establishing validity will be the use of prolonged engagement. The
classrooms participating in the intervention group will receive classroom consultation for a
period of six months. For participants to understand the outcomes of the project, they need
sufficient time to fully explore the experience (Mertler, 2019). By extending the intervention
over a period of six months, it allows the therapist to develop a rapport with the classroom
teachers, gain a better understanding of the classroom dynamics, and have ample time to observe
students and make recommendations based on ongoing engagement in the regular education
setting.
Summary
The research questions identified for the current action research project were designed to
investigate the impact of school-based pre-referral consultation through specific outcome
measures. The provision of more support from occupational therapists in the regular education
setting may be a method of decreasing the number of referrals for occupational therapy
evaluations for kindergarten students. The intervention was designed to better meet the needs of
students through the least restrictive methods and empower teachers to meet the needs of
students without the need for higher levels of support. Finally, expanding the role of occupational
therapists as classroom collaborators and consultants may positively impact the perceptions of
school personnel on the value of the occupational services provided by the intermediate unit.
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Chapter IV
Data Analysis and Results
The focus of this chapter is an analysis of the data collected over the five-month
implementation phase of the study. The data collected was aligned to the research questions
identified as the focus of this action research project. The first research question “how does the
provision of pre-referral professional development and class wide consultation impact teachers’
perceptions of self-competency related to addressing occupational therapy concerns in the
regular education setting?” was designed to investigate whether the current intervention would
impact the perceptions of regular education kindergarten teachers when compared to teachers not
participating in the intervention. The second research question “how does the provision of prereferral professional development and class wide consultation impact teachers’ perceptions of the
value of IU OT services?” was also designed to investigate whether the current intervention
would impact the perceptions of regular education kindergarten teachers when compared to
teachers not participating in the intervention. The final research question “how does the
provision of pre-referral professional development and class wide consultation impact the
number of initial referrals for kindergarten occupational therapy evaluations?” focused on an
analysis of referral data to further analyze the impact of the intervention.
To conduct the proposed action research study, the researcher implemented a mixed
method designed to gather quantitative and qualitative data. The proposed intervention consisted
of monthly classroom based occupational therapy consultation visits scheduled during the school
day at Asa Packer Elementary School. The visits were conducted by the CIU20 occupational
therapist assigned to the building. Each classroom in the control group at Asa Packer was
provided a 30-minute monthly consultation for a period of five months. Consultation services
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included observation, discussion with the teacher, recommendations for class wide adaptations,
and modeling of occupational therapy strategies. The consultation visit was designed so that it
did not impact instructional time or interfere with class activities. At the request of the teacher,
the therapist provided assistance with student specific concerns. The occupational therapist
scheduled each visit via email based on the classroom teacher’s availability.
To ensure anonymity, survey participants were randomly assigned participant
identification numbers. The numbers were assigned via email by the department secretary and
recorded in a master list and stored separately from the survey data collected. The pre and post
survey results collected via the Google survey were identifiable only by the random numbers.
Following the completion of the intervention phase the master list was destroyed.
At the start of the project, all kindergarten teachers within Asa Packer Elementary School
and Governor Wolf Elementary School were invited to participate. The control and experimental
settings were not randomized but were products of convenience sampling. At Asa Packer, three
of the kindergarten teachers agreed to participate in the project. At Governor Wolf, three teachers
initially agreed to participate. However, one teacher in the building was unable to continue with
the project due to a medical leave.
Survey Data and Analysis
The 10-question survey was given to the regular education kindergarten teachers in both
the intervention and control groups to understand their perceptions related to the research
questions. The post intervention survey results were analyzed to compare that of the control
group and the intervention group. In addition, the pre and post intervention responses in each
group were analyzed to determine whether there was a difference between the pre and post
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survey responses between the two groups. The following tables and graphs provide specific
information and visual representations of the analysis of survey results.
Analysis of Post Intervention Survey Responses
The post intervention survey data is broken down into two tables. Table 5 contains
questions related to the teachers’ perceptions of their own competency to address occupational
therapy concerns in the regular education setting.
Table 5
Post Intervention Survey Responses: Teacher Perceptions of Self-Competency
Control Group
n=2
Strongly Disagree 0
Disagree 1
Undecided 0
Agree 0
Strongly Agree 1
Intervention Group
n=3
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Strongly Disagree 0
Prior to referring a student for an occupational
therapy evaluation, I attempt strategies to address fine Disagree 0
Undecided 0
motor deficits in the classroom.
Agree 1
Strongly Agree 1
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Question
As a regular education teacher, I utilize an
occupational therapist to support students in regular
education.
I am knowledgeable regarding strategies that can
benefit students with fine motor and sensory
concerns.
All students who demonstrate fine motor deficits or
sensory concerns should be referred for an
occupational therapy evaluation.
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 1
Strongly Agree 1
Strongly Disagree 0
Disagree 2
Undecided 0
Agree 0
Strongly Agree 0
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
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My school district offers professional development
opportunities related to occupational therapy topics.
53
Strongly Disagree 2
Disagree 0
Undecided 0
Agree 0
Strongly Agree 0
Strongly Disagree 1
Disagree 1
Undecided 1
Agree 0
Strongly Agree 0
The survey asked each of the regular education teacher participants to indicate whether
they disagreed or agreed with each statement provided on a scale including strongly disagree,
disagree, undecided, agree, and strongly agree. The responses were separated and analyzed for
the control group and the intervention group. The first five questions analyzed were related to
teacher perceptions of self- competency. For the first question, one teacher in the control group
agreed strongly that she utilizes the occupational therapist to support students in regular
education while the second teacher disagreed. For questions two and three, both teachers in the
control group agreed that they attempt strategies to address fine motor deficits prior to referring a
student for an occupational therapy evaluation and that they are knowledgeable regarding
strategies that can benefit students with fine motor and sensory concerns. Both teachers in the
control group also disagreed that all students with fine motor deficits or sensory concerns should
be referred for an occupational therapy evaluation and that their school district offers
professional development opportunities related to occupational therapy topics.
In the intervention group, the responses indicated that one of the teachers typically
responded much differently than the other two. For example, in question one, one of the
respondents strongly disagreed that she utilizes the occupational therapist to support students in
regular education while the second two respondents agreed. The same pattern emerged regarding
attempting strategies prior to referring students for occupational therapy evaluations, knowledge
regarding strategies that can benefit students with fine motor and sensory concerns, and
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regarding whether all students who demonstrate deficits should be referred for an evaluation. For
the question regarding whether their school district offers professional development
opportunities related to occupational therapy topics, the three teachers in the control group varied
in their responses, ranging from strongly disagree to undecided in their responses, although none
of the teachers agreed with this statement.
Table 6 contains questions related to the teachers’ perceptions of the value of the IU
occupational therapy services.
Table 6
Post Intervention Survey Responses: Value of IU OT Services
Question
Control Group
n=2
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 0
Strongly Agree 2
The occupational therapist is a valuable resource to Strongly Disagree 0
Disagree 0
me as a teacher.
Undecided 0
Agree 2
Strongly Agree 0
If I need assistance from an occupational therapist, Strongly Disagree 0
Disagree 1
my assigned building provider is available and
Undecided 0
accessible.
Agree 1
Strongly Agree 0
Strongly Disagree 0
Disagree 0
I understand the role of the school-based
occupational therapist at the elementary school level. Undecided 1
Agree 1
Strongly Agree 0
I believe my regular education students can benefit
from classroom consultation from an occupational
therapist prior to a referral for evaluation.
Intervention Group
n=3
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 2
Strongly Agree 1
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Strongly Disagree 0
Disagree 0
Undecided 2
Agree 1
Strongly Agree 0
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
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Strongly Disagree 0
Disagree 0
Undecided 2
I am satisfied with the support I receive from the
Agree 0
Intermediate Unit Occupational Therapy Department. Strongly Agree 0
55
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 3
Strongly Agree 0
The remaining five survey questions were designed to gain information on the teachers’
perspectives regarding the value of intermediate unit occupational therapy services. The
responses from the participants in the control group were fairly consistent in this area. Both
teachers strongly agreed that regular education students can benefit from classroom consultation
from an occupational therapist prior to referral. They also agreed that the occupational therapist
is a valuable resource to them as teachers. Both teachers were undecided as to whether they were
satisfied with the support they receive from the intermediate unit occupational therapy
department. The two teachers disagreed on whether the assigned building provider is available
and accessible when they need assistance from an occupational therapist. Both teachers were
undecided as to whether they were satisfied with the support they receive from the intermediate
unit occupational therapy department. One teacher agreed that she understood the role of the
school-based occupational therapist at the elementary school level while the second teacher was
undecided.
In the intervention group, all the teachers either agreed or strongly agreed that regular
education students can benefit from classroom consultation prior to a referral for occupational
therapy. Two teachers agreed that the occupational therapist is a valuable resource to them while
the third strongly disagreed. One teacher felt that the occupational therapist is available and
accessible when needed while the remaining two teachers were undecided. Two of the teachers
agreed that they understand the role of the school-based occupational therapist at the elementary
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level while one strongly disagreed. However, all three teachers agreed that they are satisfied with
this report they receive from the intermediate unit occupational therapy department.
In addition to analyzing the post- intervention responses between the control and
intervention groups, responses within each group were analyzed. The control group responses
from the pre-intervention survey compared to those of the post-intervention survey are presented
in Figure 1. Although this group did not participate in the intervention, the survey was delivered
to the control group in the same manner as the intervention group to provide a point of
comparison.
Figure 1
Survey results from the control group were analyzed to determine if there was a
difference between the pre-intervention survey responses and the post intervention survey
responses over the course of the five-month period through a comparison of mean response
scores. The questions included in the survey can be found in Appendix A. In general, the survey
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results for the control group did not vary greatly when comparing the fall responses to the spring
responses. For questions two, three, four, five, six, and seven, the teachers’ responses remain
consistent from the fall to the spring. For question two, there was a slight decrease in the mean
score response. For question eight, there was a slightly larger decrease in the mean score
response, and for question 10, there was a slight decrease in the mean score of the responses.
Survey responses from the intervention group prior to the intervention were also
compared to the group’s responses following the intervention. The intervention group responses
from the pre-intervention survey compared to those of the post-intervention survey are presented
in Figure 2. The purpose of this comparison was to determine if participation in the intervention
would have an impact on teacher perceptions as conveyed through the survey responses.
Figure 2
The survey results from the intervention group were also analyzed to compare the
teachers' responses during the fall administration of the survey when compared to the spring
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administration of the survey using an analysis of the mean response score for each question. In
the intervention group, the scores remained consistent for question four and question seven.
There was a slight decrease in the mean score of responses for question one, question two,
question three, question five, and question eight. The intervention group responses showed an
increase in mean score for question six, question nine, and question 10.
Analysis of Pre and Post Intervention Survey Responses between Groups
To determine if there was a difference in the pre- and post- survey results between the
two groups, the researcher calculated the mean response score for each group and compared the
data. The mean response scores are visually represented in Figure 3.
Figure 3
Analysis of Referral Data
CIU20 receives referrals for occupational therapy evaluations through an electronic
referral system. Member school districts complete the referral form, which is found on the IU
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website, to request services or evaluations from the IU. Once the referral is submitted, it is
processed by department secretaries and routed to the appropriate service providers. A database
of all requested referrals is maintained in Google Sheets. For the current study, this referral data
was used to analyze the number of referrals received from Asa Packer and Governor Wolf
kindergarten teachers during the 2022-2023 school year. All referrals for each building were
pulled from the database. Any students not in kindergarten for the current school year were
removed from the count. In addition, kindergarten students in classes not participating in the
study were also removed from the final count.
For the current study, the researcher compiled referral data from the 2022-2023 school
year from the beginning of the year through May 1, 2023. Asa Packer Elementary School
submitted 17 referrals for occupational therapy evaluations for students in K-5 classroom
programs. Governor Wolf submitted 18 referrals for occupational therapy evaluations for
students in K-5 classroom programs. During the 2021-2022 school year, Asa Packer Elementary
School submitted 23 referrals for occupational therapy evaluations for students in K-5 classroom
programs. Governor Wolf submitted 24 referrals for occupational therapy evaluations for
students in kindergarten through fifth grade classroom programs during the 2021-2022. Overall,
the two buildings had a similar rate for occupational therapy evaluation referrals for the last two
years.
To compare referral rates across the classrooms participating in the control and
intervention group, the researcher removed all students in grades one through five from the
referral data. In addition, referrals from the kindergarten teachers not participating in the project
were excluded. The remaining kindergarten referrals were compared across the Asa Packer
intervention classrooms and the Governor Wolf control group classrooms. Overall, Asa Packer
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had four referrals from the participating classrooms. The Governor Wolf classrooms had only
two referrals from the participating teachers. Despite the intervention, the number of referrals
from the teachers participating in the intervention was lower overall than those of the teachers
assigned to the control group.
The referral rates for the classrooms in the control and intervention groups were also
compared across the 21-22 school year and the 22-23 school year. At Governor Wolf, the
classrooms in the control group submitted a total of two referrals for occupational therapy
evaluations during the 21-22 school year. The same classrooms submitted two referrals for
occupational therapy evaluations during the 22-23 school year. At Asa Packer, the classrooms in
the intervention group submitted a total of seven referrals for occupational therapy evaluations
during the 21-22 school year. The same classrooms submitted four referrals for occupational
therapy evaluations during the 22-23 school year. Overall, the number of referrals in the control
group stayed the same across the two school years, while the number of referrals from the
classroom teachers in the intervention group dropped. Table 7 represents the number of referrals
by building and year for both the control group and the intervention group.
Table 7
Number of Referrals by School Year
_______________________________________________________________________
School
Group
School Year
Number of Referrals
______________________________________________________________________
Governor Wolf
Control
21-22
2
Governor Wolf
Control
22-23
2
Asa Packer
Intervention
21-22
7
Asa Packer
Intervention
22-23
4
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Interview Data
Occupational Therapist Interview
Following the completion of the intervention, the researcher conducted an interview with
the participating occupational therapist. The interview was conducted via zoom due to
construction at the main office. Responses were recorded by the researcher. The interview
consisted of five predetermined questions designed to gather information about the therapist’s
thoughts regarding the effectiveness of the intervention. In addition to these five questions, the
research asked two follow-up questions to gain further insight on the responses provided.
Question 1: What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
Question 1 Response:
For at least some of the teachers who requested items, they found they were helpful
without needing to put in a referral. For example, for sensory items, the students were
able to focus more at their desk without having to get up and move around. We used kick
bands and sensory stickers for some students. The teachers liked the wiggle wobble feet
that they used on the feet on some students’ chairs. One student was struggling with
cutting and I spoke to the teacher about giving her a reminder to keep her thumb up. Once
she was given the reminder the student was able to do this throughout that activity and
generalized this for the rest of the year. The teacher reported this to me. One of the three
teachers was very receptive and always let me know if things worked or not. I tried to go
in and not disrupt the classroom, but this teacher would often stop and talk to me and ask
for suggestions about how to handle different situations.
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Question 2: What impact did the current intervention have on student performance in the regular
education classroom?
Question 2 Response:
The students were able to focus more, especially those who needed sensory and
movement. Many of them were able to stay at their desks longer. Movement around the
classroom decreased. These students were constantly up and around the classroom, which
was a distraction for the teacher and the other students. It was a constant disruption to try
and get them back to their desk area.
Question 3: What impact did the current intervention have on teacher’s perceptions regarding the
value of occupational therapy services in the school environment?
Question 3 Response:
I feel like they liked it. One of them was more receptive and asked a lot of questions. At
the end she asked about seeing me the following month. She liked being able to bounce
ideas off me and get ideas rather than needing to put in a referral for an evaluation to get
input.
Question 4: What impact did the current intervention have on your relationship with the
classroom teachers?
Question 4 Response:
I think it definitely helped. I have been in this school for the last several years. I think it
opened up communication more. Usually, I am just going to the door and pulling a
student out for an evaluation. This allowed me to have more open conversations and the
ability to give them suggestions.
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Question 5: What impact did the current intervention have on your level of participation in the
building as a whole?
Question 5 Response:
It made me be in the building at least once a month. In the past there were times when I
would not have been there if there were no referrals. It definitely increased my presence
by being there for a scheduled visit each month. It was neat to see the kids without
being there for a specific student. I got to see the classroom as a whole and see how one
student with OT concerns can impact the entire class and not just that student.
Follow-up Question 1: If the district added an occupational therapist as a member of their MTSS
team, do you think this would be a valuable addition to the team?
Follow-up Question 1 Response: “Yes, I do. The district does have suggestions based on general
areas of concern. This would allow us to give specific recommendations for specific kids based
on the teacher’s concerns.”
Follow-up Question 2: Do you think providing pre-referral consultation regularly could decrease
referral rates?
Follow-up Question 2 Response:
I am going to say yes and no. I think yes if it is just a simple thing like giving reminders
of using a thumb up for cutting skills. It’s not something that needs to be addressed in a
pull-out session. I feel that most of the teachers do know when there are needs that can’t
be addressed in the classroom and there is a need for a direct pull-out.
Principal Interview
Question 1: What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
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Question 1 Response: “It allowed for more access to sensory related tools for all students in the
classroom environment.”
Question 2: What impact did the current intervention have on student performance in the regular
education classroom?
Question 2 Response: “It helped some students in the short term. Students still had difficulty
focusing, but this allowed for additional strategies to be implemented in the classroom on a
regular basis.”
Question 3: What impact did the current intervention have on your perceptions regarding the
value of Occupational Therapy services in the school environment?
Question 3 Response: “There is a continuing and growing need for support for all students. Some
interventions work immediately and last while other interventions work short term and need to
be varied and/or changed.”
Question 4: What impact did the current intervention have on your impression of the value of IU
related services as a support for your building?
Question 4 Response: “There is a need for more sensory and OT interventions throughout the
building for all students. We are seeing an increase in this, more than we previously have
experienced in our building.”
Question 5: What impact did the current intervention have on the Occupational Therapists’ level
of participation in the building as a whole?
Question 5 Response: “During the project, the OT was in the building on a more regular basis,
not just when conducting evaluations or meeting with the COTA who provides direct service.”
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Follow-up Question 1: Prior to this intervention, did your regular education teachers have access
to the occupational therapists as a resource for supporting students not receiving services through
a 504 plan or IEP?
Follow-up Question 2 Response: “We have utilized them in the past.”
Follow-up Question 2: As the building principal, do you feel the OTs could contribute to your
MTSS process?
Follow-up Question 2 Response: “Yes. Their input would be valuable in making decisions about
students who may benefit from OT Services. We’ve also taken suggestions on possible
interventions when they are part of the team.”
Analysis of Interview Responses
The researcher conducted a thematic analysis of the interviews conducted to analyze the
responses. Both interviews were reviewed to determine if common themes were present when
comparing the principal’s responses to those of the occupational therapist. Based on the analysis,
three main themes emerged from the data.
The first theme consistent across both interviews was the prevalence of sensory issues for
students at the elementary level. The therapist reported that teachers sought suggestions on
providing students alternative ways to meet sensory needs while decreasing movement around
the classroom. The teachers also responded positively to suggestions of OT equipment that
could be utilized independently by students in the regular education environment. The building
principal also reported sensory needs as one of the major concerns related to occupational
therapy within the building. The principal reported the intervention provided teachers with better
ability to provide all students with access to sensory related tools. As the therapist shared,
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students with sensory needs can create a disruption to the classroom environment, distract other
students, and result in lost instructional time due to the need for teacher redirection.
The second theme that emerged in the interviews was the belief that there has been an
increase in occupational therapy needs across the building. According to the building principal,
the school team has seen an increase in students that surpasses what was seen in previous years.
The principal stated that “there is a continuing and growing need for support for all students.” He
noted that some interventions need to be adjusted to continue to be effective and require ongoing
monitoring by the OT to ensure continued effectiveness.
Finally, the third theme identified in the therapist and principal interviews was the
perceived value of the suggestions and recommendations provided to the teachers by the
occupational therapist. The principal noted that as a part of the MTSS team, an occupational
therapist can provide suggestions on possible interventions that could be implemented to support
students in the regular education classroom. He stated that the OT’s input could be useful in
determining whether students are appropriate for direct OT service prior to a referral. The
occupational therapist shared that during the intervention, one of the teachers “would often stop
and talk to me and ask for suggestions about how to handle different situations.” The therapist
also shared that participating in the project allowed her “to have more open conversations and
the ability to give them suggestions.” The theme emerged again when the therapist was asked
whether she believed the addition of an OT to the MTSS team would be of value. She responded
that while the district team has been provided general suggestions related to general areas of
concern, as a member of the MTSS team she could provide specific recommendations for
specific students based on the teacher’s concerns.
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Discussion of the Data Analysis Process
The researcher employed triangulation to verify the accuracy of the data and give
credibility to the findings. Multiple sources of data were collected and analyzed within the
current research study. The research design included the collection of three sources of data. Preand post- surveys administered to the participating teachers provided the first source of data. The
second source of data was gathered through the interviews conducted with the building principal
and participating occupational therapist. The final source of data analyzed was collected from
the IU electronic referral database. This information included the number of referrals requested
from teachers in the control and intervention classrooms across the current school year through
the end of the implementation phase of the study. In addition, referral data from the same
classrooms during the 2021-2022 was collected and analyzed. Through the analysis of data from
multiple sources, the researcher hoped to provide further support of the validity of the findings.
Summary
The purpose of this mixed method research design was to examine the impact of prereferral occupational therapy consultation on teacher perceptions and OT evaluation referral
rates. Teacher surveys were used to collect data on teacher perceptions to determine if the
intervention impacted teacher perceptions related to two of the three research questions. Referral
data was also analyzed to assess whether the intervention had an impact on referral rates when
the intervention group was compared to the control group. Interviews were conducted with the
participating Occupational Therapist and the building principal of the intervention group to gain
further insight into the impact of the intervention. Chapter IV provides a detailed report of the
data analyses, results, and a discussion of the interpretation of results. Chapter V will present
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conclusions developed from the analysis of these results, implications for school administrators,
a discussion of research limitations, and recommendations for future research.
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Chapter V
Conclusions and Recommendations
After analyzing the data collected over the implementation phase of the study, the results
provided mixed support for the effectiveness of the intervention. Data collected from survey
responses, interviews, and OT evaluation referral data were used to generate conclusions and
formulate recommendations. The focus of Chapter V is to present these conclusions and
recommendations based on the analysis of the data collected as it relates to each research
question.
Conclusions
Research Question One
Survey Responses. The survey results from the teachers who participated in the
intervention as well as the control group were analyzed to answer the first research question,
“How does the provision of pre-referral professional development and class wide consultation
impact teachers’ perceptions of self-competency related to addressing occupational therapy
concerns in the regular education setting?” The survey results were compared between the two
groups as well as pre- and post- intervention to evaluate any changes over the course of the
intervention.
Within the control group, the teachers’ post intervention responses related to teacher
perceptions of self-competency were mixed regarding their likelihood to utilize an occupational
therapist to support students in regular education. Both teachers expressed that they do attempt
strategies to address fine motor deficits prior to an OT referral. The control group teachers also
reported they feel knowledgeable about strategies to address fine motor and sensory concerns
despite expressing that their district does not provide professional development opportunities
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related to occupational therapy topics. Both teachers also disagreed that all students with fine
motor deficits or sensory concerns should be referred for an occupational therapy evaluation.
In the intervention group, the post-intervention survey responses differed across the three
teachers on almost every response. Two of the three teachers reported that they attempt
strategies prior to referring students for occupational therapy evaluations, believe they are
knowledgeable regarding strategies to address fine motor and sensory concerns, and feel all
students who demonstrate deficits should be referred for an evaluation. None of the post
intervention responses from the teachers in the control group supported the belief that the school
district offers professional development opportunities related to occupational therapy topics.
A comparison of the pre-and post-survey results within the control group showed the
mean of the survey responses did not vary greatly over the five-month time span in which the
intervention was implemented. As this group did not participate in the intervention, it was
reasonable to predict their responses would not change greatly over the course of the project.
The mean of the teachers’ responses did decrease for question two, question eight, and question
ten; all three of these questions were related to the teachers’ perceptions of their own selfcompetency. For question two, the spring responses showed more agreement with the statement
that the teachers attempt strategies to address fine motor deficits in the classroom prior to a
referral. For question eight, the mean score in fall indicated a higher degree of agreement with
the concept that all students who demonstrate fine motor deficits or sensory concerns should be
referred for an occupational therapy evaluation. For question ten, the mean of the spring response
showed slightly higher agreement with the idea that the school district offers professional
development opportunities related to occupational therapy topics. As these teachers did not
participate in the intervention, it is unclear as to why their responses showed this difference
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across the duration of the study. It is possible that the interactions these teachers had with their
assigned therapist outside of the intervention may have had an impact on their survey responses.
Overall, the results indicate the intervention did have some positive impact on the teachers’
perceptions of self-competency related to addressing occupational therapy concerns in the
regular education setting.
The analysis of results from the intervention group teachers' responses during the fall
administration and the spring administration of the survey revealed some changes in the mean
response scores for each question related to perceptions of self-competency. The mean scores
from the spring administration indicated that the teachers agreed more with the statement that
prior to referring a student for an occupational therapy evaluation, the teacher attempts strategies
to address fine motor deficits in the classroom. The spring results also showed increased
agreement with the teachers’ belief that they utilize an occupational therapist to support students
in regular education.
However, the teachers also showed greater agreement in the spring with the statement
that all students who demonstrate fine motor deficits or sensory concerns should be referred for
an occupational therapy evaluation. The intervention group’s spring responses indicated they felt
less knowledgeable regarding strategies that can benefit students with fine motor and sensory
concerns than prior to the intervention. The teacher’s spring responses also indicated greater
disagreement that the school district offers professional development opportunities related to
occupational therapy topics. The intervention group’s fall and spring survey responses indicated
the teachers maintained the belief that regular education students can benefit from classroom
consultation from an occupational therapist prior to a referral for evaluation. It is hypothesized
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that the intervention may have highlighted to the teachers areas in which they needed assistance
and increased their reliance on the OT as an expert.
Occupational Therapist and Principal Interviews. In addition to the survey responses,
the interview conducted with the participating occupational therapist provided additional insight
into each of the identified research questions. The therapist shared her perceptions of the impact
of the intervention on the teachers' competency related to addressing occupational therapy
concerns in regular education. From the perspective of the OT, the intervention allowed some of
the teachers to better address the sensory needs of students in the classroom. Through
consultation, the therapist was able to identify sensory needs and make recommendations for
simple modifications to assist students with more appropriately meeting those needs. In addition,
the therapist coached a particular teacher on implementing a simple intervention for cutting. The
teacher was able to implement this strategy, and the student corrected their scissor grip and
generalized the skill for the rest of the year.
The principal of Asa Packer Elementary provided additional insight into the impact of the
intervention on the teacher’s ability to address occupational therapy concerns in the regular
education setting. According to the principal, the intervention allowed for more access to sensory
related tools for all students and provided opportunities for strategies to be implemented in the
classroom on a regular basis.
Research Question Two
Survey Responses. The second research question “How does the provision of prereferral professional development and class wide consultation impact teachers’ perceptions of the
value of IU OT services?” was also evaluated through an analysis of the survey data. The
responses collected from the regular education kindergarten teachers who participated in the
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intervention were compared to that of teachers not participating in the intervention to determine
if there were differences between the two groups. In addition, the survey results from the
teachers who participated in the intervention were analyzed to determine if the pre-intervention
responses differed from the post intervention responses.
The post intervention survey questions designed to gain information on the teachers’
perspectives regarding the value of intermediate unit occupational therapy services elicited fairly
consistent responses from both control group participants. The teachers' responses indicate they
believe their students can benefit from OT consultation prior to referral and view the
occupational therapist as a valuable resource. However, the teachers' responses did not indicate
that they are satisfied with the support they receive from the IU OT department and only one
teacher agreed that she understood the role of the school-based occupational therapist at the
elementary school level. Based on these responses, it is evident that the IU services are not
highly valued by all district teachers, and there is a need to improve teachers’ understanding of
the IU’s services and build better relationships between teachers and therapists within the schools
we serve.
The analysis of results from the intervention group teachers' responses during the fall
administration and the spring administration of the survey also revealed some changes in the
mean response scores for each question related to perceptions of satisfaction with IU OT
services. The mean scores from the spring administration indicated that the teachers agreed more
with the statement that they understand the role of the school-based occupational therapist at the
elementary school level. In addition, the spring results also showed increased agreement with
the teachers’ belief that the occupational therapist is a valuable resource. These two changes
support the effectiveness of the intervention on the teachers’ level of satisfaction with the IU OT
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services. The teachers’ responses regarding the belief that regular education students can benefit
from classroom consultation from an occupational therapist prior to a referral for evaluation
stayed the same over the course of the intervention, with all the teachers agreeing to some level.
The teachers’ views regarding the availability of the OT provider also remained the same but
indicated a lower level of agreement. The mean score for the question of whether the teachers are
satisfied with the support they receive from the Intermediate Unit occupational therapy
department indicated slightly less agreement in the spring. However, the teachers still reported
agreement with this statement.
Occupational Therapist and Principal Interviews. The interview with the participating
Occupational Therapist also gave insight into the second research question “How does the
provision of pre-referral professional development and class wide consultation impact teachers’
perceptions of the value of IU OT services?” While the participating teachers varied in their
responsiveness to the intervention, one teacher was reported to have sought out the therapist’s
input on multiple occasions. The therapist reported that in addition to their conversations during
the classroom visit, the teacher would frequently approach her “and ask for suggestions about
how to handle different situations.” The therapist also shared that because the sensory
recommendations allowed students to focus and remain in their seats, the teachers expressed
satisfaction over the reduction in disruptions during instruction. A final piece of evidence
supporting the teacher’s perceptions regarding the value of OT services was the request by one
participant that the therapist continue the visits even after the intervention was over.
During the interview, the OT made the statement “I got to see the classroom as a whole
and see how one student with OT concerns can impact the entire class and not just that student.”
Being present in the classroom had benefits not just for the teachers and students, but for the
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occupational therapist as well. Rather than simply taking students out of the classroom and
conducting testing in isolation, the therapist had the opportunity to regularly observe students in
the natural environment. The visits provided an opportunity to increase communication between
the therapists and teachers. It allowed the therapist to gain a better understanding of the teacher’s
skills and instructional methods as well as the demands of the classroom environment.
During the principal interview, the principal was asked to describe the impact of the
current intervention on his perceptions regarding the value of occupational therapy services in
the building. He shared that students have continuous and growing needs for additional support,
and he sees a need for additional OT interventions throughout the building. To ensure the
success of interventions, there is a need for the OT to provide ongoing support to adjust and vary
interventions and maintain their effectiveness. Overall, the survey data and interviews provided
some support that the provision of pre-referral professional development and class wide
consultation can impact the teachers’ perceptions of the value of IU OT services and improve
their understanding of the role of the school-based occupational therapist.
Research Question Three
Referral Data. The final research question “How does the provision of pre-referral
professional development and class wide consultation impact the number of initial referrals for
kindergarten occupational therapy evaluations?” was evaluated through an analysis of the
number of occupational therapy referrals requested by teachers in the intervention classrooms
compared to those requested by the teachers who did not participate in the intervention in the
current school year. In addition, data from the 2021-2022 school year was compared to data from
the 2022-2023 school year. This data provided additional information on whether the
intervention may have had an impact on the rate of referrals.
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For the current study, the CIU20 occupational therapy referral data was used to analyze
the number of referrals received from Asa Packer and Governor Wolf kindergarten teachers
during the 2022-2023 school year and the prior year. A comparison of the data between the two
groups and across the two school years was used to gather more evidence on the effectiveness of
the intervention on reducing referral rates in the intervention group. Overall, the control group
classrooms had lower rates of referrals than the intervention group teachers. Based on this, the
intervention did not result in a significant difference in the between group data. However, the
number of referrals in the control group stayed the same across the two school years, while the
comparison of referral data across the two school years did provide some evidence of support for
the intervention. When comparing the 21-22 school year to the current year, the number of
referrals from the classroom teachers in the intervention group dropped. The referral rates for
classrooms assigned to the control group stayed the same across the 21-22 and 22-23 school
years. Based on this analysis, the intervention was associated with a decrease in referrals for OT
evaluations for the teachers in the intervention groups when compared to the prior year.
Interview Data. One of the major themes identified in the therapist and principal
interviews was the perceived value of the suggestions and recommendations provided to the
teachers by the occupational therapist. The principal pointed out that as a member of the MTSS
team, an occupational therapist would be able to provide suggestions on how to support students
in the regular education classroom and provide useful input regarding when students should be
referred for evaluation. By providing this input, it is reasonable to predict that certain students
would not be recommended for further evaluation, and referral rates could be impacted.
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During the OT interview, the therapist shared her views on whether pre-referral
consultation regularly could decrease referral rates. The quote below provides evidence of the
therapist’s perspective on this question.
I am going to say yes and no. I think yes if it is just a simple thing like giving reminders
of using a thumb up for cutting skills. It’s not something that needs to be addressed in a
pull-out session. I feel that most of the teachers do know when there are needs that can’t
be addressed in the classroom and there is a need for a direct pull-out.
Application to CIU20
Although the results of the current study were mixed, the teachers, building principal and
occupational therapist reported several positive outcomes as a result of pre-referral occupational
therapy consultation. Overall, the consultation increased the presence of the occupational
therapist in the elementary school setting. The consultation also allowed teachers to gain
assistance from an occupational therapist without initiating a referral for an evaluation. Reducing
referral rates also allows the therapists more time in their schedules to directly impact nonidentified students and support district personnel.
The current intervention was limited to kindergarten teachers in one elementary school in
the Bethlehem Area School District. Bethlehem Area School District contains 16 elementary
schools and a total of 22 kindergarten through twelfth grade buildings. In addition to the
Bethlehem Area School District, CIU20 provides occupational therapy services to 12 other
school districts in Monroe, Pike, and Northampton Counties. Expanding the provision of prereferral occupational therapy services would allow the IU to positively impact thousands of
students across our partner districts.
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CIU20 offers IU20’s training and consulting services through the Training and
Consulting (TaC) department. The TaC team emphasizes the importance of bringing research to
practice and strives to improve classroom instruction across our districts by supporting educators
and helping them to meet the needs of all students.
The mission of TaC is to support Pennsylvania special education regulations and
initiatives by partnering with local education agencies to build their capacity to provide
both quality special education services and preventative interventions and programs that
promote student success. (Colonial Intermediate Unit 20, n.d., para. 1)
According to the CIU20 website, the TaC department’s philosophy promotes the belief
that “every student is capable and teacher growth benefits everyone in the school” (Colonial
Intermediate Unit 20, n.d.). The department promotes student and educator success through the
development of multiple approaches to teaching and learning. Both MTSS and Inclusive
Practices are initiatives currently identified as areas of focus for the TaC department. However,
the TaC department currently does not include an occupational therapist or provide any
assistance to our districts in this area. The current action research project provides an example of
a model by which pre-referral occupational therapy services could be added to the existing
training and consultation services offered by the IU. The participation of school-based
occupational therapists in inclusive settings allows non-identified students to benefit from their
specialized expertise without necessitating more restrictive supports. In addition, the addition of
occupational therapists to MTSS teams would expand the ability of those teams to support
students prior to a referral for special education services.
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Fiscal Implications
Colonial Intermediate Unit 20 billed our member districts a fee of $136.93 per hour for
occupational therapy services during the 2022-2023 school year. Based on recent trends, OT
costs are predicted to continue increasing as the number of evaluations requested by our districts
continues to increase annually. The provision of pre-referral professional development and
consultation allows an occupational therapist to directly support classroom teachers in the regular
education environment. In addition, the OT has access to a larger number of students who may
benefit from individualized recommendations resulting from observation and discussion between
the teachers and therapists. If teachers gain proficiency in meeting the OT needs of their students,
there is a potential of decreasing both requests for OT evaluations and the number of students
qualifying for individualized direct services through a 504 plan or IEP.
From a fiscal perspective, the long-term goal of the current project was to propose a
new service delivery method that could result in reduced costs for member districts utilizing the
IU for occupational therapy services. While there would be new costs associated with the
expansion of occupational therapists in the training and consultation department, a more efficient
and proactive approach may be a more effective alternative to the delivery of individualized
therapy services for some students.
Limitations
The current intervention was limited to kindergarten teachers in one elementary school in
the Bethlehem Area School District. The intervention was delivered over five months. To truly
investigate the impact of OT consultation services on referral rates, it would be beneficial to
deliver the intervention over a longer period. Implementing the consultation intervention over a
full school year would allow more time for collaboration between the teachers and therapist. It
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would allow the therapist to gain a greater understanding of individual student needs and the
dynamics of the classroom environment. Extending the intervention phase would also allow the
therapist more time to evaluate the effectiveness of recommendations and make adjustments as
needed.
In addition to the brief period of the intervention, the number of teachers participating in
the intervention was small. Because of the small group size, it was difficult to determine the
impact of the intervention on the teacher’s perceptions. Including more classroom teachers in the
intervention would increase the reliability and validity of the survey data analysis.
Within the control and experimental groups, data was not collected on the individual
characteristics of the classroom teachers. The survey results analysis revealed differences within
each group that seemed unrelated to the intervention's implementation. It is possible that
individual teacher characteristics, such as number of years' experience or educational background
may have impacted the survey responses and resulted in confounding variables. Collecting
additional data on individual teacher characteristics may have allowed for a better understanding
and analysis of the survey responses.
Recommendations for Future Research
Based on results and conclusions of the current action research study, there are several
areas that could be investigated more fully through future research. Replicating the study over a
longer period would allow for a better comparison of referral data across school calendar years.
The impact of pre-referral consultation and professional development may take a greater period
to affect referral rates.
The current action research project was limited to regular education kindergarten teachers
and classrooms. Another area of future research would be to expand the intervention across all
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grade levels at the elementary school level. Most OT referrals received by the intermediate unit
are for students at the elementary level, and teachers at all grade levels may benefit from access
to occupational therapy consultation in the general education classroom setting.
The first two research questions identified in the current action research project focused
on the impact of pre-referral OT consultation and professional development on the perceptions of
regular education teachers regarding their own self-competency as well as their perceptions
regarding the value of the IU OT services. The third question was designed to investigate the
impact of pre-referral consultation and professional development on OT evaluation referral data.
In addition to these factors, the intervention created a new avenue for the occupational therapist
to support students and teachers in the general education classroom. An additional research
question might explore the impact of this participation on the therapist. How might this new role
impact the job satisfaction of the occupational therapist in the school setting? In the current
climate, when retention of professional educators is a critical concern, finding ways to increase
job satisfaction is an important consideration.
Additionally, the intervention could be explored by investigating the impact on student
performance data. The addition of an occupational therapist to the elementary school MTSS team
would provide an opportunity to explore this further. In the current study, the consultation and
collaboration between the teacher and therapist was limited to the monthly classroom visits.
Adding the therapist as a participant in MTSS team meetings would provide the opportunity to
track the impact of specific recommendations on individual student performance. During the OT
interview, the researcher asked the therapist whether she believed the addition of an OT to the
MTSS team would be of value. The therapist responded that as a member of the MTSS team she
could provide specific recommendations for specific students based on the teacher’s concerns.
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During the principal interview, when asked if he felt the OTs could contribute to the MTSS
process, the principal responded as follows. “Yes. Their input would be valuable in making
decisions about students who may benefit from OT Services. We have also taken suggestions on
possible interventions when they are part of the team.” Providing an opportunity for the OT to
participate as a team member in the MTSS process may also have a positive impact on the
therapist’s presence in the building and the perceived value of OT services provided by the IU.
Summary
The purpose of this mixed method action research project was to evaluate the impact of
pre-referral professional development and class wide consultation on several factors.
Quantitative and qualitative data were analyzed to determine the impact of the intervention on
teacher perceptions regarding their own abilities to address occupational therapy concerns in the
regular education setting. In addition, the data was analyzed to determine whether the
intervention impacted the teachers’ and principal’s perceptions regarding the value of
occupational therapy services in a district elementary school building. Finally, the data was
analyzed to draw conclusions regarding whether pre-referral professional development and class
wide consultation can impact the number of occupational therapy referrals requested by regular
education kindergarten teachers.
Intermediate Units strive to be “entrepreneurial, highly skilled, technology-rich, and agile
providers of cost-effective, instructional, and operational services to school districts.”
(Pennsylvania Association of Intermediate Units, n.d.).
Over the years, intermediate units have responded to a wide array of needs as they
developed in schools and communities throughout the state. Today, intermediate units
continue to fulfill their mission of service by addressing traditional and emerging needs,
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serving as essential links for learning in Pennsylvania, and as a liaison between local
schools and the Pennsylvania Department of Education. (Pennsylvania Association of
Intermediate Units, n.d., para. 2)
To remain vital, Intermediate Units must continuously evolve to meet the changing needs
of the districts, students, and communities we serve. Moving beyond the traditional role of the
school-based occupational therapist is one way in which our organization can create new
opportunities for mutually beneficial relationships with our district partners and expand access to
meaningful supports and services for our students.
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APPENDICES
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Appendix A
Teacher Survey Questions (pre- and post-)
Please respond to the following questions using the rating scale provided:
(1-Strongly Agree, 2-Agree, 3-Undecided, 4-Disagree, 5-Strongly Disagree)
As a regular education teacher, I utilize an occupational therapist to support students in regular
education.
Prior to referring a student for an occupational therapy evaluation, I attempt strategies to address
fine motor deficits in the classroom.
The occupational therapist is a valuable resource to me as a teacher.
If I need assistance from an occupational therapist, my assigned building provider is available
and accessible.
I understand the role of the school-based occupational therapist at the elementary school level.
I am satisfied with the support I receive from the Intermediate Unit Occupational Therapy
Department.
I believe my regular education students can benefit from classroom consultation from an
occupational therapist prior to a referral for evaluation.
All students who demonstrate fine motor deficits or sensory concerns should be referred for an
occupational therapy evaluation.
I am knowledgeable regarding strategies that can benefit students with fine motor and sensory
concerns.
My school district offers professional development opportunities related to occupational therapy
topics.
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Appendix B
Occupational Therapist Interview Questions
What impact did the current intervention have on the teachers’ ability to address Occupational
Therapy concerns in the regular education classroom?
What impact did the current intervention have on student performance in the regular education
classroom?
What impact did the current intervention have on teacher’s perceptions regarding the value of
occupational therapy services in the school environment?
What impact did the current intervention have on your relationship with the classroom teachers?
What impact did the current intervention have on your level of participation in the building as a
whole?
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Appendix C
Principal Interview Questions
What impact did the current intervention have on the teachers’ ability to address Occupational
Therapy concerns in the regular education classroom?
What impact did the current intervention have on student performance in the regular education
classroom?
What impact did the current intervention have on your perceptions regarding the value of
Occupational Therapy services in the school environment?
What impact did the current intervention have on the Occupational Therapists’ level of
participation in the building as a whole?
What impact did the current intervention have on your impression of the value of IU related
services as a support for your building?
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Appendix D
Teacher Consent Letter
Dear Teacher,
As a regular education teacher at the elementary school level, you are being asked to participate
in a research study to evaluate the impact of pre-referral occupational therapy consultation. Your
participation in this study will help the researcher learn more about how consultation in the
regular education setting can impact occupational therapy referral data, improve student
outcomes, and better support teachers in meeting the needs of students with occupational therapy
needs.
What will I be asked to do if I take part in this study?
If you agree to participate in this study, you will be asked to complete two Google Form
electronic survey questionnaires (pre- and post- intervention). Four classrooms will participate in
five monthly classroom consultations with an IU Occupational Therapist scheduled during the
school day based on the teacher’s availability. The therapist will visit each classroom in the
intervention group for a 30-minute monthly consultation for a period of five months.
Consultation services may include observation, discussion with the teacher, recommendations for
class wide adaptations, and modeling of occupational therapy strategies. The consultation visit
will not impact instructional time or interfere with class activities, and there will be no active
presentations provided by the therapist during the class visit. The therapist will be available for
assistance if requested by the teacher but will refrain from disrupting the classroom routine to the
greatest extent possible. The pre- and post-intervention interviews will ask you questions
regarding your perceptions of the IU occupational therapy services.
Where will this study take place?
Both surveys will be provided via an online survey tool (Google Forms) using a secure website.
How long will the study last?
The study is projected to last approximately 5 months and two electronic survey questionnaires
(pre- and post- intervention). Total participation time will vary. The pre- and post-surveys may
take up to 10 minutes each or 20 minutes total to complete.
What happens if I don’t want to participate?
Your participation is voluntary; you can choose whether you want to participate in the study or
not. There will be no penalty if you choose not to participate.
Can I quit the study before it ends?
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Yes, you can withdraw from the study at any point by notifying the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-810-7538. There will be no penalty for withdrawing from the study
nor will you be asked to provide an explanation for your decision.
.
What are the risks?
There are minimal risks to this study. You will not be asked questions of a sensitive nature.
Participants are reminded that they are not required to answer any questions which they choose.
Participants can also stop their participation at any time without question.
How will I benefit from participating?
If you decide to be in this study, you will assist the researcher in better understanding the current
perceptions of district teachers regarding CIU20 occupational therapy services. The intervention
may provide you with tools to help you meet the needs of students with occupational therapy
needs in the classroom and reduce the need to refer students for occupational therapy
evaluations.
Will my responses be kept confidential and private?
Yes, the survey data and interview responses we collect from you will be kept confidential,
which means only the researcher will see or have access to it. Your survey responses will be
anonymous. No names will be reported in the report of the findings. Personal identifiers will not
be used in the analysis of interview results. Data will be stored on a secure server and password
protected. Returning the survey is an indication of consent to use the data.
Who do I contact if I have questions about this study?
If you have questions about this study, please contact the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-819-7538. If you would like to speak with someone other than the
researcher, please contact Dr. Mary Wolf, Assistant Professor at California University of
Pennsylvania, at wolf@calu.edu.
Approved by the California University of Pennsylvania Institutional Review Board. This
approval is effective 10/4/2022 and expires 10/3/2023.
By signing below, you agree to participate in this survey for the purpose of this research study.
___________________
Signature
________________________
Printed Name
________________
Date
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Appendix E
Principal/Occupational Therapist Consent Letter
Dear Principal/Occupational Therapist,
You are being asked to participate in a research study to evaluate the impact of pre-referral
occupational therapy consultation. Your participation in this study will help the researcher learn
more about how consultation in the regular education setting can impact occupational therapy
referrals, improve student outcomes, and better support teachers in meeting the needs of students
with occupational therapy needs.
What will I be asked to do if I take part in this study?
If you agree to participate in this study, you will be asked to participate in one post- intervention
interview following five monthly classroom consultations in 4 regular education classrooms. The
interview will include questions regarding your perceptions of the IU occupational therapy
services and the perceived effectiveness of the consultation.
Where will this study take place?
Interviews will occur in the elementary school conference room.
How long will the study last?
The study is projected to last approximately 5 months and two electronic teacher survey
questionnaires (pre- and post- intervention). Total participation time will vary. The pre- and postsurveys may take up to 10 minutes each or 20 minutes total to complete. The building principal
and occupational therapist will participate in a brief interview at the end of the study. The length
of the interview is anticipated to be 30 minutes or less.
What happens if I do not want to participate?
Your participation is voluntary; you can choose whether you want to participate in the study or
not. There will be no penalty if you choose not to participate.
Can I quit the study before it ends?
Yes, you can withdraw from the study at any point by notifying the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-810-7538. There will be no penalty for withdrawing from the study
nor will you be asked to provide an explanation for your decision.
What are the risks?
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There are minimal risks to this study. You will not be asked questions of a sensitive nature.
However, participants are reminded that they are not required to answer any questions of which
they choose. Participants can also stop their participation at any time without question.
How will I benefit from participating?
If you decide to be in this study, you will assist the researcher in better understanding the current
perceptions of district teachers regarding CIU20 occupational therapy services. The results could
support class wide consultation as a method to reduce referrals for occupational therapy
evaluations.
Will my responses be kept confidential and private?
Yes, the survey data and interview responses we collect from you will be kept confidential,
which means only the researcher will see or have access to it. No names will be reported in the
report of the findings. Data will be stored on a secure server and password protected.
Who do I contact if I have questions about this study?
If you have questions about this study, please contact the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-810-7538. If you would like to speak with someone other than the
researcher, please contact Dr. Mary Wolf, Assistant Professor at California University of
Pennsylvania, at wolf@calu.edu.
Approved by the California University of Pennsylvania Institutional Review Board. This
approval is effective 10/4/22 and expires 10/3/2023.
By signing below, you agree to participate in this survey for the purpose of this research study.
_______________________
Signature
________________________
Printed Name
___________
Date
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Appendix F
Institutional Review Board Approval
Institutional Review Board
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Melissa Sovak, Ph.D.
Dear Jennifer,
Please consider this email as official notification that your proposal titled “Improving Student
Outcomes and Teacher Perceptions through Pre-Referral Occupational Therapy Consultation”
(Proposal #PW22-023) has been approved by the Pennsylvania Western University Institutional
Review Board as submitted.
The effective date of approval is 10/04/2022 and the expiration date is 10/03/2023. These dates
must appear on the consent form.
Please note that Federal Policy requires that you notify the IRB promptly regarding any of the
following:
(1) Any additions or changes in procedures you might wish for your study (additions or changes
must be approved by the IRB before they are implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are necessitated by any events
reported in (2).
(4) To continue your research beyond the approval expiration date of 10/03/2023, you must file
additional information to be considered for continuing review. Please contact
instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Melissa Sovak, PhD.
Chair, Institutional Review Board
Improving Student Outcomes and Teacher Perceptions Through Pre-Referral
Occupational Therapy Consultation
A Doctoral Capstone Project
Submitted to the School of Graduate Studies and Research
Department of Education
In Partial Fulfillment of the
Requirements for the Degree of
Doctor of Education
Jennifer Marie Curtis
Pennsylvania Western University
July 2023
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© Copyright by
Jennifer Marie Curtis
All Rights Reserved
July 2023
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Dedication
To my children, Abigail and Benjamin. Thank you for your love and inspiration. May you follow
your dreams and continue to grow and learn. I am proud of you both.
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Acknowledgment
Thank you to everyone who helped me to complete the Pennsylvania Western Doctor of
Education program. Thank you to my family, Daniel, Abigail, and Ben, for supporting me and
giving me the time to accomplish this goal. Thank you to my parents, Ken and Carol Harryn, for
supporting me throughout my education and encouraging me to pursue my doctorate.
Thank you to Dr. Mary Wolf, Faculty Capstone Committee Advisor, for your guidance
and support. Your suggestions and feedback were instrumental in allowing me to successfully
implement and complete my capstone project.
Thank you, Dr. Frank DeFelice, for serving as my external committee chair. I appreciate
your willingness to support me in this endeavor. I am grateful for your support and for providing
me with the opportunity to conduct this research project at Colonial Intermediate Unit 20.
Thank you to Dr. Jack Silva for allowing me to conduct my intervention within the
Bethlehem Area School District. Thank you to Jonathan Horvath, Principal of Asa Packer
Elementary School for participating and welcoming me into your building. Thank you to all the
teachers who participated in the study.
Thank you to my colleagues at Colonial Intermediate Unit 20 who supported me
throughout this process. Thank you, Allison Hubbs, Rebecca Miller, and Stephen Rupp for your
encouragement and feedback. I owe special thanks to Tiffany Smith for her participation as the
consulting therapist. Tiffany, without your willingness to participate and your ongoing
commitment, I could not have completed this project.
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Table of Contents
Dedication
iv
Acknowledgement
v
List of Tables
x
List of Figures
xi
Abstract
xii
CHAPTER I. Introduction
1
Capstone Focus
1
Background
1
Research Questions
4
Summary
5
CHAPTER II. Review of the Literature
6
IDEA and Related Services
6
Section 504 and School-Based Occupational Therapy
8
ESSA and School-Based Occupational Therapy
8
Occupational Therapy Licensing and Regulations
9
School-Based Occupational Therapy: Roles and Responsibilities
10
Medical Model Versus School-Based Occupational Therapy
13
Occupational Therapy Consultation for Identified Students
14
Handwriting Instruction and School-Based Occupational Therapy
16
IDEA and Early Intervening Services
17
Workload Versus Caseload Models
18
Occupational Therapy Referral Process
18
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Class Wide Interventions
19
Occupational Therapy as a Component of RTI
21
Examples of the Inclusion of OT in the RTI process
21
Therapist Perspectives on School-Based OT Services
25
Professional Development and School-Based OT Services
28
Teacher Perspectives on School-Based OT Services
29
Promoting Effective Consultation and Collaboration
31
Summary
32
CHAPTER III. Methodology
Purpose
Fiscal Considerations
Setting
33
33
35
37
Colonial Intermediate Unit 20 Occupational Therapy
37
Bethlehem Area School District
37
Asa Packer Elementary School
39
Governor Wolf Elementary School
40
Participants
41
Intervention/Research Plan
42
Research Design, Methods & Data Collection
44
Research Questions
44
Teacher Pre- and Post- Survey Statements
46
Occupational Therapist Interview Questions
47
Principal Interview Questions
48
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Validity
48
Summary
49
CHAPTER IV. Data Analysis and Results
51
Survey Data and Analysis
52
Analysis of Post Intervention Survey Responses
53
Analysis of Pre and Post Intervention Survey Responses between Groups
59
Analysis of Referral Data
59
Interview Data
62
Occupational Therapist Interview
62
Principal Interview
64
Analysis of Interview Responses
66
Discussion of the Data Analysis Process
68
Summary
68
CHAPTER V. Conclusion and Recommendations
Conclusion
69
69
Research Question One
69
Survey Responses
69
Occupational Therapist and Principal Interviews
72
Research Question Two
72
Survey Responses
72
Occupational Therapist and Principal Interviews
74
Research Question Three
Referral Data
75
75
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ix
76
Application to CIU20
77
Fiscal Implications
79
Limitations
79
Recommendations for Future Research
80
Summary
82
References
84
APPENDIX A. Teacher Survey Questions (pre- and post-)
93
APPENDIX B. Occupational Therapist Interview Questions
94
APPENDIX C. Principal Interview Questions
95
APPENDIX D. Teacher Consent Letter
96
APPENDIX E. Principal/Occupational Therapist Consent Letter
97
APPENDIX F. IRB Approval
100
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List of Tables
Table 1. Annual Cost of OT Services in Bethlehem Area School District
36
Table 2. Bethlehem Area School District Percent Enrollment by Race/Ethnicity
38
Table 3. Asa Packer Percent Enrollment by Race/Ethnicity
40
Table 4. Governor Wolf Percent Enrollment by Race/Ethnicity
41
Table 5. Post Intervention Survey Responses: Teacher Perceptions of Self-Competency
53
Table 6. Post Intervention Survey Responses: Value of IU OT Services
55
Table 7. Number of Referrals by School Year
61
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List of Figures
Figure 1. Control Group Pre- and Post- Survey Responses
57
Figure 2. Intervention Group Pre- and Post- Survey Responses
58
Figure 3. Control Versus Intervention Group Post- Survey Responses
59
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Abstract
Each year, Colonial Intermediate Unit 20 conducts a large number of at the request of school
districts. The current action research plan investigated the impact of providing professional
development and collaboration from an occupational therapist in the regular education setting.
Regular education teachers in the intervention group received classroom-based occupational
therapy consultation visits over five months. Participants in the intervention group and a control
group completed pre and post surveys to analyze their own perceptions of self-competency
related to addressing occupational therapy concerns in the regular education setting and the
teachers’ perceptions of the value of school-based occupational therapy services. The
occupational therapist and building principal participated in post-intervention interviews to
gather insight on their perceptions regarding the impact of OT services. In addition, referral data
was analyzed to determine whether the provision of pre-referral professional development and
class wide consultation could impact the number of initial referrals for kindergarten occupational
therapy evaluations. Overall, the survey data and interviews provided some support that the
provision of pre-referral professional development and class wide consultation can impact the
teachers’ perceptions of self-competency related to addressing occupational therapy concerns in
the regular education setting and the value of IU OT services. The results also showed that the
intervention was associated with a decrease in referrals for OT evaluations for the teachers in the
intervention groups when compared to the prior year.
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CHAPTER I
Introduction
Capstone Focus
Each year, Colonial Intermediate Unit 20 (CIU20) receives many referrals for
occupational therapy evaluations of regular education students, particularly kindergarten
students. District administrators have expressed concerns regarding the cost of related services
provided by the Intermediate Unit (IU) and are looking for ways to decrease costs while still
meeting the needs of all students. Because the IU Occupational Therapy (OT) staff only provide
services to students identified with a disability, there is often little collaboration between regular
education teachers and IU therapists regarding students in the general population. This lack of
collaboration may result in teachers being ill equipped with strategies to address issues prior to
moving to an occupational therapy evaluation. Increasing occupational therapists' presence and
involvement in pre-referral general education interventions would provide an opportunity to
intervene earlier to meet students' needs. Expanding these efforts could reduce the number of
special education referrals and equip regular education teachers to better address occupational
therapy issues in the regular education setting.
Background
CIU20 covers 1200 square miles in Northampton, Monroe, and Pike Counties. The IU
provides services for 13 school districts, three career centers, four charter schools and 65 nonpublic schools. CIU20 employs more than 1400 employees with annual budgets exceeding $226
million. Overall, the IU impacts over 86,000 public school students, which equals approximately
4.7% of the public-school students in the state. Over 9,000 students are served in IU programs.
CIU20 is the eighth largest IU based on the public-school student population served. As an
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intermediate unit, CIU20 serves a diverse student population with great variability in
demographics and socioeconomic variables across districts and counties.
CIU20’s mission statement is to develop and maintain positive relationships that support
student growth, are responsive to stakeholders’ crucial needs, and demonstrate effective results
through services and programs for students. CIU20’s vision is to be a vibrant, vital, influential,
and innovative child-centered organization serving children, families, and the people who serve
them wherever they might be and whatever they may need.
CIU20 provides some level of occupational therapy services for 13 school districts within
its geographical catchment area. Ten of the districts use the IU for all OT services provided to
students in both district and IU classrooms. Over the past several years, three districts have made
the decision to use outside agencies rather than the IU due to concerns with the cost of services.
During the 2020-2021 school year, the IU occupational therapy department conducted 544
evaluations of students across the kindergarten through twelfth grade continuum. The length of
time to complete an evaluation ranged from one hour to nine hours. The average amount of time
required to conduct an evaluation was 3.23 hours. Overall, 1,759 hours of therapist time were
devoted to the evaluation process for the 2020-2021 school year. During the 2021-2022 school
year, the IU occupational therapy department conducted 706 evaluations of students across the
K-12 continuum. The length of time to complete an evaluation ranged from one hour and ten
minutes to eight hours. The average amount of time required to conduct an evaluation was three
hours. Overall, 2,124 hours of therapist time were devoted to the evaluation process for the 20212022 school year. This time includes report writing, data analysis, and face to face evaluations.
Travel time, scheduling, and follow-up meetings are not included but require extra time from
each therapist.
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Multi-Tiered System of Support (MTSS) is a comprehensive framework that includes a
continuum of evidence-based supports and services to meet the needs of all students. Over half
of the school districts in Pennsylvania implement an MTSS system as a school improvement
measure. IDEA requires that schools provide students with appropriate instruction in the general
education settings. However, as independent service agency staff, Intermediate Unit
representatives are rarely involved in the MTSS process or general education intervention.
Currently, the main roles of school based Occupational Therapists are conducting evaluations to
determine eligibility for special education services and the provision of direct services to
identified students. Traditional MTSS models have not incorporated Occupational Therapists as a
pre-referral resource in providing regular education interventions. Increasing OT involvement in
the pre-referral intervention process has the potential to increase teacher competencies, decrease
wasted resources on unnecessary evaluations, and decrease the number of students requiring
higher levels of specialized intervention.
Research Questions
The following research questions will be explored through the implementation of the
proposed action research project:
1. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of self-competency related to addressing
occupational therapy concerns in the regular education setting?
2. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of the value of IU OT services?
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3. How does the provision of pre-referral professional development and class wide
consultation impact the number of initial referrals for kindergarten occupational therapy
evaluations?
Summary
Through the implementation of the proposed action research plan, the researcher hopes to
achieve several outcomes. First, providing more support from occupational therapists in the
regular education setting can decrease the number of referrals for occupational therapy
evaluations for kindergarten students. By providing professional development and collaboration
in regular education, teams can better meet the needs of students through the least restrictive
methods. Finally, increasing the involvement of IU therapists in pre-referral processes can create
more awareness of the CIU20’s occupational therapy department and improve collaboration and
communication with district partners. A review of the literature provides supporting evidence as
to the value of the involvement of occupational therapists in MTSS and the regular education
environment.
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CHAPTER II
Review of the Literature
Over the past 50 years, the role of the occupational therapist has continued to expand and
evolve in the school setting. Historically, school-based occupational therapy services have been
primarily accessible to students with disabilities. Students who exhibit weaknesses that impact
their ability to access the classroom environment and curriculum are frequently referred for
formal occupational therapy evaluations. Following a formal evaluation, eligible students
typically receive direct occupational therapy services, either individually or in a group, to target
identified areas of need. Based on this service model, a significant percentage of therapist time in
the educational setting is devoted to evaluations and the provision of direct services.
Although more recent legislation has supported the use of early intervening services for
non-identified students, occupational therapists have not had a significant role in these initiatives.
Expanding the role of the occupational therapist through consultation and collaboration with
general educators can provide effective ways to meet the needs of struggling students in the
general education setting.
IDEA and Related Services
The Education for All Handicapped Children Act (Public Law 94-142) was first signed
into effect in 1975 by President Gerald Ford. The act was considered a civil rights landmark and
opened the door for students with disabilities in public school settings. In 1990, the act was
reauthorized and officially renamed the Individuals with Disabilities Education Act, or IDEA.
IDEA mandated the right of students with disabilities to receive a free appropriate public
education (FAPE) in the least restrictive environment (LRE). Individuals who meet criteria under
the identified disability categories, and demonstrate the need for specially designed instruction,
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are eligible to receive special education services and related services. Legally, it is the IEP team's
decision on whether occupational therapy is needed as a component of the program to support
the student in attaining goals and objectives (U.S. Department of Education, 1990). While the
role of the occupational therapist in the school setting varies from state to state, therapists
generally work at the individual, classroom, and school level to address issues that impact a
student’s successful participation in the general education curriculum.
According to IDEA, a student’s IEP must outline the related services and supplementary
aids and services to be provided in order for a student to participate with nondisabled peers (U.S.
Department of Education, 1990). Related services include many services such as transportation
and other supportive services that are necessary to allow a student with a disability to benefit
from special education. These services include speech-language pathology and audiology
services, interpreting services, psychological services, physical therapy, and occupational therapy
(U.S. Department of Education, 1990).
IDEA further defines occupational therapy as the services provided by an occupational
therapist with appropriate credentials, with the goals of:
improving, developing, or restoring functions impaired or lost through illness, injury, or
deprivation; improving ability to perform tasks for independent functioning if functions
are impaired or lost; and preventing, through early intervention, initial or further
impairment or loss of function. (U.S. Department of Education, 1990, p. 10)
Within the school setting, practitioners work with the school team to evaluate a student’s
needs, determine what behaviors are expected within the school environment, and develop
interventions to address deficits. “As children with disabilities moved into public schools,
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occupational therapists were challenged with the task of developing alternatives to the medical
model of practice, a barrier experienced by many OTs today” (Ball, 2018, p. 264).
Section 504 and School-Based Occupational Therapy
In some cases, a student with a disability may not meet eligibility for special education
services under IDEA. Because schools receive federal funds, they must comply with both the
Americans with Disabilities Act (1990) and Section 504 of the Rehabilitation Act of 1973.
Section 504 provides another opportunity for certain students to receive school-based
occupational therapy services in the educational setting. Students with impairments which
severely limit major life activities may also be eligible for school-based occupational therapy.
The purpose of Section 504 is the protection of students with disabilities from discrimination.
Students who do not qualify for special education under IDEA may be eligible for protections
under Section 504. A 504 plan can provide students with reasonable accommodations that allow
them to benefit from and participate in the educational environment (U.S. Department of Labor,
n.d.). For some students, occupational therapy services are provided through a 504 plan. These
services can be provided individually or in a group setting and may include direct service and
consultation.
ESSA and School-Based Occupational Therapy
President Obama signed the Every Student Succeeds Act (ESSA) on December 10, 2015.
This act reauthorized the Elementary and Secondary Education Act (ESEA) and upheld the
nation’s longstanding commitment to equal opportunity for all students. ESSA replaced the
previous version of the law, the No Child Left Behind (NCLB) Act, which was enacted in 2002.
Primary focuses of ESSA were to close the achievement gap for disadvantaged or high-need
students and to increase accountability at the state and local levels.
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The terms "specialized instructional support personnel' and "related services" are defined
in the Every Student Succeeds Act (U.S. Department of Education, 2015). Instructional support
personnel include school counselors, school nurses, psychologists, school psychologists, social
workers, and school social workers; occupational and physical therapists; art, dance/movement,
and music therapists; and, speech language pathologists, and audiologists. ESSA requires that
state and local education agencies engage in meaningful consultation with specialized
instructional support personnel to best meet the needs of students in the educational setting.
Occupational Therapy Licensing and Regulations
The American Occupational Therapy Association (AOTA) is an organization that
represents over 230,000 occupational therapists and students throughout the United States. The
organization is dedicated to occupational therapy advancement with a focus on education and
research. The mission statement of the organization is to “advance occupational therapy practice,
education, and research through standard setting and advocacy on behalf of its members, the
profession, and the public” (American Occupation Therapy Association [AOTA], 2023, para.2).
The ability to practice as an occupational therapy is regulated by state law. All 50 states require
that both occupational therapists and occupational therapy assistants obtain licensure to practice
in both medical and educational settings. In Pennsylvania, the State Board of Occupational
Therapy governs the certification process for individuals seeking to obtain licensure. To be
licensed as a registered occupational therapist in Pennsylvania, an individual must complete a
four-year program in occupational therapy. In addition, all applicants must have successfully
completed a supervised fieldwork experience in an approved educational institute or training
program. Finally, applicants must obtain a passing score on an Occupational Therapist
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Registered (OTR) licensure examination or qualify for a waiver of the licensure examination
administered by the National Board for Certification in Occupational Therapy (NBCOT).
The Pennsylvania Department of State also oversees licensure for Certified Occupational
Therapy Assistants. This certification requires completion of a two-year degree program in
occupational therapy, completion of two months of supervised fieldwork experience, and a
passing score on the Certification Examination for Occupational Therapy Assistant prepared and
administered by the National Board for Certification in Occupational Therapy (NBCOT).
Maintenance of both OTR and Certified Occupational Therapy Assistant (COTA) licensure
requires ongoing professional development and documentation of continuing education credits.
School-Based Occupational Therapy: Roles and Responsibilities
According to the 2019 AOTA Workforce and Salary Survey, 18.8% of occupational
therapists and 15.4% of occupational therapy assistants work with students in school-based
environments in the United States (AOTA, 2020). AOTA developed several documents that
provide an overview of occupational therapy (OT) services in the school setting (AOTA, 2012).
Across all settings, occupational therapists assist individuals in meaningful activities in the
natural environment. Targeted activities may include education, work, play, socialization, and
activities of daily living. In a 2017 brochure developed for school administrators, AOTA further
clarified the continuum of services that occupational therapists can provide under the Individuals
with Disabilities Education Act (IDEA), Every Student Succeeds Act (ESSA), and Section 504
of the Rehabilitation Act of 1973. These activities include individualized special education
services, training for families and school personnel, participation on collaborative teams,
participating in district initiatives, and providing assistance for students who need additional
support in regular education. AOTA provides examples of early intervening services an
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occupational therapist can provide; these measures include periodic screenings, teacher training,
modeling whole classroom interventions, working with small groups, and assisting with team
problem solving.
For students who receive occupational therapy services as a component of an
Individualized Education Plan, services can be delivered directly or through a consultation
model. Hasselbusch and Penman (2008) interviewed teachers and occupational therapists to gain
insight into consultative practices used to support students with autism in regular education
environments. The researchers identified the development of relationships with school staff as a
key factor in the provision of successful consultation services in the school setting. Engagement
with the staff and developing a presence as a part of the school community required sufficient
time and varied across teachers and buildings. In addition, therapists who delivered effective
consultation were characterized by the ability to problem-solve on the spot and demonstrate
flexibility (Hasselbusch & Penman, 2008).
According to the American Occupational Therapy Association, the goal of occupational
therapy is to help an individual to achieve well-being and health, and to allow for participation
and engagement in occupation and life (AOTA, 2010). Although occupational therapy services
differ in certain settings, the evaluation process includes certain fundamental components
regardless of the environment. Through the evaluation process, the therapist determines the need
for service, identifies problems that need to be addressed, develops goals and interventions, and
develops a plan for assessment of progress (AOTA, 2010). Occupational therapy services in
schools can be delivered directly, indirectly, or through a consultation model. Direct service can
be provided in a separate environment or in the classroom but typically disrupts the student’s
participation in classroom activities. Indirect service involves a therapist teaching another adult a
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strategy which can then be implemented with a student. Consultation involves the identification
of strategies that can promote student success in the educational setting and focuses on
environmental changes that support student success (Villeneuve, 2009).
Benson (2013) conducted a study to better understand the views of school-based
therapists regarding conceptual models and current practice trends related to occupational
therapy. The researcher conducted interviews with 16 occupational therapists working in
educational settings with students across the K-12 continuum. Therapists reported working with
students using both pull-out and push-in methods. Pull-out instruction refers to working with
students outside of the classroom either individually or in small groups. Push-in instruction refers
to the provision of therapy within the naturally occurring classroom environment and routine.
“The relationship with the teacher often dictated the type of services. For example, some teachers
expect the child to be removed from the classroom, and others expect the support in the
classroom” (Benson, 2013, p. 169).
Therapists reported that they typically met informally with the teacher at the start of
sessions. Many therapists noted that they preferred push-in services as the best way to address
real-life issues in the natural environment. However, the therapists expressed some frustration
with the push-in model with certain individuals, and noted it was at times seen as a disruption to
the classroom routine. Overall, therapists reported better relationships and interactions with
special education teachers than general educators and expressed that the relationship with the
teacher was a critical factor in the successful implementation of services (Benson, 2013).
I enjoy it when I have a good working relationship with the teacher in the classroom. We
[OT and teacher] are working collaboratively…the teacher sees me as an asset rather than
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a nuisance. I have had teachers treat me both ways, so when something we do makes a
difference and the teacher notices [it’s a good thing]. Special educators are much more
educated in what we do and are much more open to our suggestions. Regular education
teachers have a much harder time. (Benson, 2013, pp. 171-172)
Medical Model Versus School-Based Occupational Therapy
In the school setting, occupational therapy's main goal is to allow a student to participate
in the school environment, including naturally occurring activities and routines. Therapists
consider the expectations across all school environments, including not just the classroom but all
educational settings. Transitioning in the hallways, accessing transportation, participating in
physical education, and eating in the cafeteria are examples of school-based activities that an
occupational therapist can consider when assessing a student’s needs (Cantu, 2003).
Occupational therapy services offered in the school setting differ from those offered
outside of school through a medical model. Private therapists may identify and target skill
deficits that do not impact a student’s ability to participate educationally. Due to these
differences, it is common for parents to question the differences between therapies offered in
outside medical settings. When parents do not understand these differences, it can create conflict
with school administrators regarding eligibility for school based occupational therapy. Unless a
student is found eligible as a child with a disability, he or she may not have access to
occupational therapy services in the school setting. Once a student is deemed eligible,
occupational therapy is only provided if it is determined necessary to meet identified goals and
objectives (Cantu, 2003).
Unlike occupational therapy services delivered through a medical model, school-based
services cannot be delivered in isolation. Best practice requires that school-based services be
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delivered through a collaborative, transdisciplinary approach. This approach necessitates
participation from general and special education teachers along with occupational therapists and
other related services providers such as speech therapists and physical therapists. Collaboration
on assessment, planning, and the implementation of interventions characterizes a truly
transdisciplinary model. A transdisciplinary model of service delivery has been associated with
improved student outcomes, positive teacher perceptions, and increased collaboration with
families (Mu & Royeen, 2004).
“Effective provision of services in schools is highly dependent upon the practitioner’s
ability to both collaborate interprofessionally and understand/plan for the provision of services in
the Least Restrictive Environment, per IDEA” (Friedman et al., 2022, p. 3).
Occupational Therapy Consultation for Identified Students
In the school setting, occupational therapy consultation is regularly provided for students
with special needs as a related service in IEPs or through a 504 plan. Wehrmann et al. (2006)
conducted a 2-year study to investigate the perceived benefit of school-based occupational
therapy for students with identified fine-motor issues. The consultation model of OT service
delivery was introduced in the 1990’s (Dunn, 1990). Since that time, this service delivery model
has grown in prevalence and acceptance. Occupational therapy consultation is typically based on
an identification of a student’s needs as determined through the evaluation process. The goal of
consultation is to educate the teacher and staff on how to best meet a student’s needs through
strategies and resources that can be implemented or accessed in the classroom setting. Through
this collaborative process, a classroom teacher can gain the skills to accommodate the needs of
diverse learners. The frequency of consultation visits is based on the student's needs but often
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occurs weekly or monthly. The results of the study supported OT consultation as a beneficial
intervention for identified students with fine motor difficulties (Wehrmann et al., 2006). This
result is consistent with findings of previous studies supporting occupational therapy
consultation as a preferred method of school-based service delivery (Dunn, 1990).
Villeneuve and Hutchinson (2015) examined the impact of collaboration between
occupational therapists and teachers on the outcomes of students with developmental disabilities.
The authors used two case studies to investigate the workplace practices that support
collaboration across educators and related services providers. The authors found that
collaboration could be facilitated through the focus of educational programming,
communication, and educational leadership. Occupational therapists’ collaboration on the
development of meaningful goals and demonstrations on integrating practices into a student’s
daily routine prepares teachers to effectively implement recommendations. Providing formal
opportunities for teachers and OTs to collaborate interactively is recommended to promote
meaningful multidisciplinary instruction. Leadership and accountability measures were also
identified as critical components necessary to support a collaborative multidisciplinary model.
Villeneuve (2009) synthesized literature on the use of collaborative consultation by
school-based occupational therapists. The review was guided by two main questions; first, how
consultation can contribute to meaningful outcomes for students with disabilities, and second,
what factors can influence the effectiveness of collaboration between therapists and teachers.
The findings of the literature review support two conditions that are essential in effective
collaboration between occupational therapists and teachers. First, all parties must have a clear
understanding of each member’s function. Teachers must clearly understand the roles and
responsibilities of the OT for the consultation process to be effective. In addition, therapists must
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be knowledgeable regarding the curriculum, classroom procedures, and school policies to ensure
the services they provide are educationally relevant.
Second, effective consultation and collaboration is dependent on sufficient time and
opportunities to work together and share information. Program administrators have a
responsibility to provide teachers and therapists with time within the school day to engage in
collaborative consultation to support students with disabilities in an inclusive setting (Villeneuve,
2009).
Handwriting Instruction and School-Based Occupational Therapy
Occupational therapy interventions for students with writing issues typically consist of
activities targeting the development of motor skills. A variety of fine-motor, visual perception,
visual motor, gross motor and postural strategies can be effective in improving handwriting.
Numerous studies have supported the use of occupational therapy to improve the legibility of
handwriting in the educational setting (Case-Smith, 2002; Feder & Majnemer, 2007).
Case-Smith (2002) studied the effectiveness of handwriting interventions delivered by
occupational therapists on the in-hand manipulation, visual-motor, visual-perception, speech, and
legibility of students between the ages of seven and ten. When compared to students who did not
receive direct service from an occupational therapist, the group showed significant improvements
in legibility. While the therapists in the study reported that they frequently collaborated with
teachers, there was no data collected on how the teacher carried over or supported the
interventions in the classroom setting (Case-Smith, 2002).
Taras et al. (2011) studied the effectiveness of a 14-week handwriting program
incorporating occupational therapy strategies on promoting handwriting skills with children in a
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general education kindergarten program. The program targeted hand skills, the awareness and
directionality of letter formation, and visual motor skills. The researchers reported that general
education kindergarten teachers were not implementing structured handwriting programs as class
wide interventions. In addition, teachers frequently referred students for occupational therapy
evaluations without having ever implemented interventions themselves (Taras et al., 2011). The
researchers conducted pre-and post-intervention handwriting assessments on students in 14
kindergarten classrooms. While students in the intervention received handwriting instruction
from occupational therapists, students in the control groups received handwriting intervention
from their general education teachers. The results of the study showed a significant difference in
post-test results between students receiving instruction incorporating occupational therapy
strategies and the control group (Taras et al., 2011). This study supports the use of occupational
therapy strategies in the general education environment and suggests that expanding the role of
the occupational therapist in the general education kindergarten setting can have positive
outcomes for all students while reducing referrals for OT evaluations in later years.
IDEA and Early Intervening Services
IDEA permits local education agencies to use a portion of funds to support the
development and implementation of services “for students in kindergarten through grade 12 who
are not currently identified as needing special education or related services, but who need
additional academic and behavioral support to succeed in a general education environment”
(U.S. Department of Education, 1990, p. 34). The 2016 IDEA regulations established mandatory
requirements for Comprehensive Coordinated Early Intervening Services (CCEIS). One such
requirement is the mandate that funds be used to identify and address issues that contribute to
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significant disproportionality. Early intervening activities should include professional
development, educational and behavioral evaluations, services, and supports.
Workload Versus Caseload Models
Seruya and Garfinkel (2020) analyzed trends in service delivery models related to schoolbased occupational therapy. Traditionally, occupational therapists have used a caseload model to
provide services in the school setting. This model is based solely on the number of students each
therapist treats. Conversely, a workload model considers all activities an individual engages in to
support students, either directly or indirectly. A caseload model, “provides more opportunities for
occupational therapy practitioners to implement occupation-based interventions in natural
environments” including “engagement in programs that promote positive student outcomes in the
larger community” (Seruya & Garfinkel, 2020, p. 76) such as multi-tiered systems of support
(MTSS). The researchers surveyed over 300 school-based occupational therapists and found that
while most students received OT services through an IEP or 504 plan, approximately 38% of
respondents reported participating in their school’s MTSS program.
Occupational Therapy Referral Process
Bolton and Plattner (2019) gathered survey data from teachers and occupational
therapists regarding the most common reasons for occupational therapy evaluation referrals. The
most common reasons for referrals identified were fine motor skills related to classroom
activities, handwriting, and sensory issues. Occupational therapy evaluations typically consist of
observation in the school setting, parent and teacher input and standardized assessment measures.
The Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery et al., 2010) is a
tool frequently used to determine eligibility for school-based occupational therapy services. The
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VMI assesses an individual’s integration of visual and motor skills and can help guide treatment
recommendations to assess areas of weakness. The VMI is a standardized norm-referenced
measure that can be used with individuals of all ages and has been shown to have high person
and content reliability (Pfeiffer et al., 2015).
The administration of the VMI involves the presentation of a developmental sequence of
geometric forms. Individuals are provided with verbal directions to copy each form using pen
and paper. The authors state that the VMI “can be used to identify, through early screening,
children who may need special assistance, to obtain needed services for them, to test the
effectiveness of educational and other interventions, and to advance research” (Beery et al.,
2010). The administration of the 30-item full form can typically be administered in 10 to 15
minutes (Beery et al., 2010).
Based on the results of standardized assessments, observation data, and input from team
members, the Occupational Therapist will make an eligibility determination regarding the need
for school-based services. In the event a student qualifies for service, an IEP or 504 plan will be
developed to incorporate identified goals, recommendations for accommodations and
modifications, and any other appropriate supports identified to assist the student in successfully
participating in the school setting. For students who do not qualify for services, the process may
result in recommendations that can be implemented in the regular education setting without
individualized intervention.
Class Wide Interventions
Research supports the use of class wide interventions to support regular education
students in a variety of ways. The use of class wide interventions has been shown to have a
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positive impact on student teacher interactions and promote learning and engagement (Conroy et
al., 2008).
RTI and other early childhood screening efforts in schools are very often limited to
reading and math assessments, such as assessments of phonemic awareness. Important as
such measures are, they are not sufficient. Schools need to attend to the whole child,
including physical and other factors that affect academics as well as other important
aspects of a child’s life. (Beery et al., 2010, p. 19)
Reeder et al. (2011) developed a case report of an elementary school in Texas that piloted
a Response to Intervention (RTI) program incorporating occupational and physical therapists. As
a component of the RTI process, OT’s conducted screenings, educated and supported teachers,
provided teachers with resources and strategies, and referred students to special education when
appropriate. The OTs reported that support most frequently requested by teachers were strategies
to address sensory regulation, posture, bilateral integration, pre-writing, and writing skills. The
OT’s provided intervention resources and ongoing class wide consultation and collaboration.
The researchers identified sufficient time for collaboration and to build trust as key components
to the success of the occupational therapist’s role in the RTI model. Through participation in the
RTI model, the therapists developed a flowchart to describe participation in each tier of the RTI
process.
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Occupational Therapy as a Component of RTI
School-based occupational therapists are in a unique position to integrate their profession
into all levels of a multi-tiered system of support. The AOTA developed a practice advisory
paper to address the inclusion of occupational therapy in a Response to Intervention Framework
(AOTA, 2012). The paper provides examples of services that may be provided by an
occupational therapist at each tier of the RTI model.one level, therapists can work to educate and
train teachers, conduct screenings, and implement a population-based approach in the general
education setting. A population-based approach involves interventions applied to an entire
classroom rather than with individual students. Examples of this could include professional
development on sensory processing, making recommendations on classroom management, or
assisting teachers to develop routines. At the tier two level, occupational therapists may review
student data to determine the need for more targeted interventions for struggling students.
Examples of tier two interventions may include interventions relating to seating for small groups
of students, targeted handwriting interventions, or recommendations for adapted materials.
Finally, tier three interventions are implemented with less than five percent of students who do
not respond to lower levels of intervention. For these students, therapists may recommend
individualized interventions, more frequent data collection, and consider the possibility of a
referral for formal evaluation (AOTA, 2012).
Examples of the Inclusion of OT in the RTI Process
Shifts in educational policy have led to higher expectations for kindergarten readiness
with increased demands related to fine motor skills and handwriting. To prepare students for
more structured, academic-focused kindergarten classrooms, occupational therapists have used
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collaborative approaches in the preschool setting to promote kindergarten readiness. Martino
and Lape (2020) piloted a six-week program to address fine motor and sensory issues with
students in a general education preschool program. The program was implemented with
typically developing students and included both fine-motor and sensory activities embedded into
the classroom routine. During the intervention, the occupational therapist developed and
implemented center-based activities multiple times per week. The classroom teachers carried
over the activities by implementing the centers on the days the therapists were not in the
classroom. Pre- and post-test measures were administered to determine the effectiveness of the
intervention. The results of the study supported the use of this collaborative integrated approach
to improve fine motor skills and kindergarten readiness for students in regular education
preschool (Martino & Lape, 2020).
Occupational therapists can play a vital role to increase awareness of the feasibility of
integrating occupational therapy services within preschool classrooms, collaborating with
teachers to help children improve fine motor and visual motor skills necessary for
participation in early literacy curricula. (Martino & Lape, 2020, p. 148)
Cahill and Lopez-Reyna (2013) conducted semi-structured interviews with occupational
therapists participating in problem solving teams through a Response to Intervention framework
in Illinois. The results of this study indicated school personnel lacked an understanding of the
scope of school based occupational therapy as well as the ways in which an OT might contribute
to the school team. Therapists reported that they were more frequently asked to informally
observe a student rather than participate in a problem-solving team process. The authors
identified collaborative consultation with active involvement from both the teacher and therapist
as a potentially effective RTI intervention in the school setting. To expand the role of the
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occupational therapist in the RTI model, it may be necessary to educate school teams on the role
of the occupational therapist and the support they can provide. Expanding the role of the
occupational therapist to include pre-referral collaboration and consultation could significantly
impact the performance of general education students (Cahill & Lopez-Reyna, 2013).
Hintz and Fletcher (2022) conducted a qualitative study to gather information on the
experience of teachers who received support from occupational therapists through a MTSS
framework. The researchers used surveys and semi-structured interviews to gain insight into the
experiences of 13 teachers employed in public schools within the United States. The results of
the study indicated teachers had positive experiences when collaborating with OTs through the
MTSS framework. Teachers reported that OTs provided consultation, recommended strategies
and that they felt the collaboration was an “efficient use of their time with effective solutions
which led to student progress” (Hintz & Fletcher, 2022). The study identified the lack of
documentation and the teachers’ lack of understanding regarding the role of the OT in the
schools setting. In addition, the teachers reported that high caseloads were one impediment to
increasing the role of the OT in the MTSS framework (Hintz & Fletcher, 2022).
For elementary students, handwriting is a critical skill that impacts a student's success
across all academic areas. Asher and Estes (2016) explored the implementation of handwriting
interventions through a Response to Intervention (RTI) framework. Asher and Estes (2016)
surveyed kindergarten through sixth grade teachers in a Midwestern school district to gather
information related to handwriting interventions in regular education classrooms. The results of
the survey indicated that teachers rarely sought out RTI supports for students solely due to
handwriting issues. Teachers reported that the occupational therapist was a valued resource in
the school community. The teachers identified the OT’s participation in RTI meetings,
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recommendations for intervention, and direct student service as the most meaningful
contributions. In addition, the teachers reported that there is a greater demand for OT support that
can be met due to the therapists’ availability. However, only 12% of the survey respondents
stated that they utilized occupational therapy support and services to address handwriting
concerns through the RTI process (Asher & Estes, 2016).
Asher and Estes (2016) also reported that while teachers had favorable views of OT
services, they did not always have a clear understanding of the tiers of support an occupational
therapist might provide through the RTI framework. In the general education classroom,
therapists can provide universal interventions to support effective handwriting instruction and
benefit the entire class. At a tier two level, therapists may offer more targeted interventions that
can be implemented and monitored by the regular education staff. Finally, if these efforts fail,
individualized interventions can be provided at the tier three level. Therapists can assist teachers
in better understanding this scope of practice to ensure appropriate interventions are available
across the continuum. Through the use of tier one and tier two interventions, teachers can
decrease the number of inappropriate or unnecessary referrals and help keep OT workloads at a
reasonable level (Asher, 2006). According to Asher and Estes (2016), “related to RTI programs,
therapists should educate school personnel about potential occupational therapy services related
to handwriting instruction, continue to contribute to problem-solving processes, and build their
roles as consultants.”
Ohl et al. (2013) conducted a study to determine the effectiveness of an RTI intervention
to address visual-motor integration and fine motor skills at the tier one level. The intervention
was implemented with over 100 general education kindergarten students across six elementary
schools. The primary research question investigated was whether the occupational therapy based
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RTI initiative would produce significant improvements in the fine motor and visual motor skills
of the participating kindergarten students. The students’ skills were assessed using several
standardized OT assessments prior to the intervention and following the 10-week period.
During the intervention phase, occupational therapists collaborated with the general
education kindergarten teachers to implement a program specifically developed for the study.
The program included direct intervention involving ten 30-minute weekly lessons delivered by
the OT along with the teacher, visual aids such as posters that were made available in the
classroom, skill modeling by both the teacher and therapist, the integration of a fine motor center
into the classroom routine, and ongoing consultation for struggling students (Ohl et al., 2013).
The results of the study indicated that the intervention group showed statistically
significant gains in both fine motor and visual-motor skills. Most of the teachers in the study
reported that they continued to implement components of the intervention following the
completion of the 10-week period. In addition, most teachers also reported they continued to
collaborate with the OT after the intervention was concluded. While the study did not
investigate the impact on occupational therapy referrals in the intervention group, the authors
listed this as a possible area for future exploration. Overall, the study supported the inclusion of
occupational therapy in an RTI framework and provided evidence that short-term, collaborative
class wide intervention can positively impact students’ pre-handwriting skills (Ohl et al., 2013).
Therapist Perspectives on School-Based OT Services
“Although there has been much discussion about the importance of collaboration between
professionals who work in inclusive classrooms, limited research is available on the actual
process of collaboration, particularly from the point of view of occupational therapists” (Bose &
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Hinojosa, 2008, p. 290). Bose and Hinojosa (2008) explored the perceptions of occupational
therapists regarding their interactions with early childhood educators in pre-kindergarten through
second grade classrooms in New York City. The researchers identified four major themes
through the analysis of interviews conducted with occupational therapists. The therapists had a
positive view of collaboration but provided few specific examples of the collaborative process or
resulting outcomes. The therapists identified the major barriers to effective collaboration as the
lack of time available to meet, a lack of support from administrators, and teachers’ receptiveness
to participating in the process.
The therapist’s perceived role in the school setting was another issue identified as a
contributing factor to successful collaboration. Several respondents indicated that teachers
frequently did not attend to their suggestions. In addition, whether the therapist was viewed as a
part of the school staff, or an outsider influenced their abilities to successfully collaborate with
teachers. Finally, the main activities therapists reported engaging in with teachers were not truly
collaborative in nature. Therapists viewed themselves as experts in their field, and this expert
role may have impeded their ability to participate as an equal team member in the collaborative
process with teachers (Bose & Hinojosa, 2008).
Cahill et al. (2014) surveyed 1,000 practitioners by randomly sampling individuals from
an AOTA database of early intervention and school-based therapists. The purpose of the survey
was to gather data on therapists’ involvement in the RTI process and attitudes towards that
involvement. Respondents indicated that over 75% of their school districts participated in an RTI
process. While most participants supported OT participation in the RTI process, they also
indicated the school personnel do not fully understand how OTs can contribute to it. While
practitioners reported participating in RTI across grade levels, most of the participation in RTI
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was reported at the K-3 level. Survey results indicated that participating in problem-solving
teams, coaching, consultation, and individual intervention were the activities therapists reported
to most frequently participate in.
While many therapists are open to participating in an RTI process, there can be
significant barriers impeding their involvement. Cahill et al. (2014) found that most surveyed
therapists identified limited resources, including time, personnel, and finances, as the main
barrier to their participation in RTI. In addition, they reported teachers' lack of understanding
regarding the scope of school-based occupational therapy, and the possible ways a therapist
might participate in class wide initiatives. Therapists also noted that there was often no precedent
within their districts for the participation of the OT in the RTI process.
Campbell et al. (2012) interviewed occupational therapists regarding their
implementation of collaborative classroom-based intervention. In this study, therapists
implemented Partnering for Change (P4C), a service delivery model that focuses on teacher and
therapist collaboration to enhance participation through environmental modifications and
adaptations. During the implementation phase, therapists spent one full day per week in the
school to allow for relationship building opportunities and consistent service delivery.
Within the P4C project, the therapists’ role included helping the teachers to recognize
children with motor difficulties and those at risk; making adaptations to classroom furniture,
work space, tools, and materials; working with the teacher to trial and monitor instructional
strategies; modeling strategies and techniques for a single student, for a group of students, or for
the whole class, sharing information and resources with families; providing brief “lunch-and-
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learn” in-services on topics chosen by teaching staff; liaising with school resource staff; and
acting as a bridge between the education and health care systems (Campbell et al., 2012, p. 53).
Professional Development and School-Based OT Services
Students with fine motor deficits can have trouble with common classroom activities
throughout the school day. “When performing these tasks, these students are often seen as being
sloppy with their work, unable to work independently, or lazy in getting the task completed”
(Chiu et al., 2008, p. 30). If not addressed, fine motor deficits can lead to secondary issues such
as academic problems, low self-esteem, and behavioral issues. Chiu et al. (2008) noted that a
lack of teacher awareness regarding occupational therapy can impede students’ access to
appropriate services. The provision of professional development is one method that can increase
awareness of how occupational therapy can improve student outcomes in educational settings.
General educators who participated in the workshops rated the areas in which they perceived the
most need for growth. Increasing awareness of factors that can lead to effective changes for
students, developing the ability to explain the needs of students with fine motor issues, and
understanding how to collaborate with OTs to promote student growth were the primary areas
identified for growth. The study's results provide evidence that improved awareness of fine
motor issues and occupational therapy can help teachers meet the needs of students in the general
education classroom. Collaboration between teachers and therapists can result in effective early
intervention that prevents students from experiencing more significant issues as they progress in
the educational system (Chiu et al., 2008). “To improve general health and well-being of all
students, occupational therapists must move beyond a direct service model approach and explore
alternate service delivery models” (Ball, 2018, p. 263). Christner (2015) also found that
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professional development was effective in enhancing educators’ awareness of school based
occupational therapy.
Teacher Perspectives on School-Based OT Services
Bolton and Plattner (2019) investigated the perceptions of occupational therapists and
teachers regarding the role of occupational therapy in the school setting. The researchers
surveyed elementary teachers and school-based occupational therapists to gain an understanding
of the perceived value of OT services, the most common reasons for OT referrals, and the
characteristics of OT service delivery in the school setting. The survey results indicated that
while most teachers value OT services in the school setting, not all teachers fully understand the
full spectrum of OT services available. Occupational therapists reported that they frequently
provide services to individual students but rarely provide class wide consultation or
interventions.
Benson et al. (2016) collected data on teacher’s perceptions of the role of occupational
therapists in school through a 31-question survey. Both general and special education teachers
were included in the survey, and respondents were all full-time teachers working in Pennsylvania
public schools. The results of the study identified four main themes representing teacher’s
perceptions. In general, occupational therapists were viewed as being student-focused, offering
valuable support, and being effective team members. Most respondents reported no negative
interactions with school-based occupational therapists and 77% of the respondents identified the
occupational therapist as a valuable member of the school team.
Despite the mostly positive perceptions, teachers did report a lack of collaboration and
communication with occupational therapists as evidenced by a lack of daily support and non-
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attendance at team meetings (Benson et al., 2016). Participants indicated that caseload demands
and itinerant status resulted in the OT not being a fully integrated team member. In addition,
teachers reported a need for therapists to have more direct interaction with teachers to allow
students to succeed in the classroom environment. Overall, teachers stated there was a need for
more participation and involvement from the therapist with additional time allocated for
classroom visits and teacher and student interactions (Benson et al., 2016).
Occupational therapy strategies cannot be successfully implemented in a school setting
without the classroom teacher's support (Benson, 2013). Benson et al. (2016) supported this
finding and the need for ongoing collaboration and communication between teachers and
therapists. If teachers do not fully understand the role of the school-based occupational therapist,
the therapist’s role as an effective member of the educational team can be negatively impacted.
To enhance their role in the school setting, therapists must work to educate teachers regarding
their role, establish effective communication, improve collaboration, contribute as an active
member of educational teams, and ensure adequate time to support the teacher, student and team
(Benson et al., 2016).
School-based occupational therapists will be utilized more effectively if their colleagues
are aware of their entire scope of practice. The roles of occupational therapists working in
a school setting have been developing to meet the students' ever-growing needs. It is
crucial that teachers are aware of these expanded roles, as they cover all areas of the
school environment. (Edick et al., 2022, p. 2)
Edick et al. (2022) conducted a study to explore elementary teacher’s perspectives on
occupational therapists in the school setting. The researchers investigated the perceived value of
collaboration with the occupational therapist as well as gauged how well teachers understood the
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roles of the occupational therapist. The researchers used an anonymous survey to gather
information from k-6 general and special education teachers working in the public school
system. The findings indicated that most teachers believe they understand the role of the
occupational therapist and view therapists as an asset to the educational team. One of the main
needs identified to improve collaboration between therapists and teachers is the need for formal
time to collaborate. To offer preventative consultation to students in the general education
setting, therapists must have adequate time to develop a working relationship with teachers and
the flexibility in scheduling to allow for ongoing consultation and collaboration (Edick et al.,
2022).
Promoting Effective Consultation and Collaboration
While numerous examples of collaboration between teachers and therapists can be found
in the literature, there is a lack of information on the actual strategies that have a positive impact
on this collaboration. Friedman et al. (2022) conducted a quantitative quasi-experimental study
to determine the effectiveness of a training and coaching intervention on improving collaboration
between teachers and therapists. The researchers identified the teacher and therapists’ selfreported ability to communicate, understand each other's roles, and resolve conflicts at the
dependent variables in the study. Following the intervention, both teachers and therapists
reported improvements in their skills across all three areas. The results of the study support the
effectiveness of ongoing training and coaching to assist teachers and therapists in improving their
ability to collaborate in the school setting (Friedman et al., 2022).
The success of a collaborative consultative model of occupational therapy services has
been linked to several key characteristics. First, therapists need adequate time to participate in
the school community and to develop strong relationships with educators and other school staff.
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Secondly, services need to be provided in a consistent and responsive manner. Finally, services
should be delivered in an inclusive manner designed to benefit all students, with therapists and
teachers working alongside each other as equal team members (Campbell et al., 2012). Through
successful collaboration, therapists had the ability to “reach children who were struggling with
motor coordination at an early age and to provide teachers with strategies to help children before
academic or socio-emotional difficulties had developed (Campbell et al., 2012, p. 57). In
addition, therapists participating in this collaborative classroom-based approach reported
improved personal growth and job satisfaction and felt a higher level of inclusion in the school
community (Campbell et al., 2012).
Summary
Traditionally, school-based occupational therapy services have been primarily accessible
for students identified with special needs and eligible for services under IDEA or Section 504 of
the Rehabilitation Act. School-based therapists spend much of their workday conducting
evaluations to determine eligibility or in the provision of direct services for identified students.
While IDEA mandates early intervening services for students in general education, occupational
therapists have had very little participation in regular education initiatives such as RTI or MTSS.
Limited examples in the literature support the inclusion of the occupational therapist in prereferral collaboration in the general education environment. The expansion of this role provides
an opportunity for school-based occupational therapists to expand their role in the school
community, reach at-risk students in a timelier fashion, and better meet the needs of students in
the least restrictive environment.
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CHAPTER III
Methodology
A comprehensive review of the literature provides supporting evidence as to the value of
the inclusion of occupational therapists in pre-referral interventions in the general education
setting. In the school setting, occupational therapy services are primarily available to students
with disabilities who are found eligible when deemed necessary to meet identified goals and
objectives (Cantu, 2003). Despite the traditional model of delivering OT services through 504
plans and IEPs, the literature contains a small but growing basis for the expansion of school
based occupational therapy in regular education initiatives (Reeder et al., 2011).
Purpose
The role of school-based occupational therapy services for students identified with
special needs has been well-established in the literature. The use of re-referral interventions such
as RTI and MTSS to meet the needs of students in the regular education setting are also well
supported as effective research-based interventions. The purpose of the current study is to
determine the potential impact of incorporating the occupational therapist as a pre-referral
regular education resource for teachers and students in the regular education classroom.
Each year, Colonial Intermediate Unit 20 receives a large number of referrals for
occupational therapy evaluations of regular education students, and in particular kindergarten
students. District administrators have expressed concerns regarding the cost of related services
provided by the IU and are looking for ways to decrease costs while still meeting the needs of all
students. Because the IU OT staff only provide services to students identified through IDEA or
Section 504, there is often little collaboration between regular education teachers and IU
therapists regarding students in the general population. This lack of collaboration may result in
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teachers being ill equipped with strategies to address issues prior to moving to an occupational
therapy evaluation.
Through the use of pre-referral consultation services, an occupational therapist could
achieve multiple outcomes. Consultation services can assist teachers in developing skills to
better meet the needs of students with fine motor deficits in the classroom. When teachers are
better equipped to meet the needs of diverse learners, the need for further evaluation and
individualized services may be lessened. In addition, collaboration with occupational therapists
and teachers may impact the teacher’s perspectives regarding the effectiveness of the
Intermediate Unit as a district partner and improve the overall reputation of the IU as a service
provider.
Through the implementation of the proposed action research plan, I hope to achieve
several outcomes. First, by providing more support from occupational therapists in the regular
education setting, I hope to decrease the number of referrals for occupational therapy evaluations
for kindergarten students. The CIU20 occupational therapy department employs 11 full-time
master's level clinicians. Much of their work time is devoted to conducting evaluations. A large
percentage of the evaluations result in referred students not qualifying for occupational therapy
service. By providing professional development and collaboration in regular education, I hope to
better meet the needs of students through the least restrictive methods and enable teachers to
meet the needs of students with minor issues without the need for direct therapy. Finally, my
overall goal is to create more awareness of the Colonial Intermediate Unit’s occupational therapy
department and improve collaboration and communication with the district partners who utilize
our services.
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Fiscal Considerations
Based on the board approved contract rates for the 2022-2023 school year, member
districts pay $136.93 per hour for occupational therapy services. During the 2021-2022 school
year, Colonial Intermediate Unit charged a rate of $132.94 per hour for occupational therapy
services. The average salary of a CIU20 registered occupational therapist is $61,902. The
current project will require an initial visit and five monthly visits to four regular education
classrooms. Each visit will require approximately one hour of therapist's time plus 30 minutes of
travel to and from the location. The estimated total amount of required therapist time for the
duration of the project is 30 hours. The prorated salary for the average OTR is $47.29. The total
budgetary impact based on salary is estimated at $1,419.00.
Over the past four years, the districts’ cost for occupational therapy services has increased
by 54%. This increase is the result of a steady rise in the number of students CIU20 evaluates
and treats on an annual basis. In 2019, an additional occupational therapist was added to the
department to meet the increased demand for evaluations and services. Although this cost is not
directly related to the impact of the current intervention on the CIU20 budget, the long-term goal
of the project is to reduce costs for member districts utilizing the IU for occupational therapy
services. Table 1 provides information on the annual costs of OT services for the Bethlehem
Area School District over the past four school years.
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Table 1
Annual Cost of OT Services in Bethlehem Area School District
Bethlehem Area School District Annual Occupational Therapy Cost
School Year
Total District Cost for OT Services
2018-2019
$495,441.76
2019-2020
$584,811.91
2020-2021
$628,710.40
2021-2022
$767,633.33
The proposed project will entail minimal indirect costs for the district and the
intermediate unit. The consultation visits will not be billed to the district but provided as a
component of the indirect time allocated for the district’s therapist. Full-time employees are
reimbursed for mileage at the IRS rate of $0.585 per mile. The estimated mileage for each trip is
36 miles, with an estimated total cost of $126.36. All training materials will be modified by the
program supervisor based on existing materials that were previously developed as a part of the
program’s professional development time. An additional $100.00 is included in the supply line
of the projected budget. This amount may be used to cover any materials recommended by the
therapist as a result of the consultation process. For example, modified paper and pencils are
frequently recommended as accommodations for students with fine motor needs.
Multi-Tiered System of Support (MTSS) is a comprehensive framework that includes a
continuum of evidence-based supports and services to meet the needs of all students. Over half
of the school districts in Pennsylvania implement an MTSS system as a school improvement
measure. IDEA requires that schools provide students with appropriate instruction in the general
education settings. Currently, the main roles of school based occupational therapists are
conducting evaluations to determine eligibility for special education services and the provision of
direct services to identified students. Traditional MTSS models have not incorporated
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occupational therapists as a pre-referral resource in the provision of regular education
interventions. Increasing OT involvement in the pre-referral intervention process has the
potential to increase teacher competencies, decrease wasted resources on unnecessary
evaluations, and decrease the number of students requiring higher levels of specialized
intervention. The proposed project will evaluate whether the provision of pre-referral
consultation services will impact the number of evaluations requested by regular education
teachers. On a larger scale, this type of consultation model could reduce the overall cost of
CIU20 occupational therapy services for our member districts while empowering district
teachers to meet the needs of diverse learners in the least restrictive environment.
Setting
Colonial Intermediate Unit 20 Occupational Therapy
As the eighth largest IU in Pennsylvania CIU20 provides related services for students in
school districts across Northampton, Monroe and Pike Counties. The related services offered by
the intermediate unit include physical therapy, speech therapy, vision services, audiological
services, orientation and mobility services, and occupational therapy services. The occupational
therapy department is a component of the larger Pupil Personnel Services department. Within the
department there are currently 11 masters level clinicians (Occupational Therapists, Registered)
and over 35 Certified Occupational Therapy Assistants (COTAs). Each of these individuals
maintains licensure with the American Occupational Therapy Association as well as the
Pennsylvania State Board of Occupational Therapy Education and Licensure.
Bethlehem Area School District
Bethlehem Area School District is the sixth largest school district in Pennsylvania. The
district is in Northampton County within the Colonial Intermediate Unit #20 catchment area. The
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district encompasses approximately 42 square miles (about the area of Manhattan) and has an
enrollment of just over 13,000 students. According to the Future Ready PA Index (Pennsylvania
Department of Education, 2023), 54.7% of the student population is Economically
Disadvantaged, 7.3% of students are identified as English Language Learners, and 17.5% of the
student population receives Special Education services. The ratio of male to female students is
52% to 48%. The district is fairly diverse regarding race and ethnicity; Table 2 provides
information on the race and ethnicity of the student body according to current data provided on
the PA Future Ready Index (Pennsylvania Department of Education, 2023):
Table 2
Bethlehem Area School District Percent Enrollment by Race/Ethnicity
Percent Enrollment by Race/Ethnicity
American Indian/Alaskan Native
0.2%
Asian
2.8%
Black
11.1%
Native Hawaiian or other Pacific Islander
0.2%
Hispanic
44.4%
White
39.3%
2 or more races
2.0%
Note. Adapted from the 2023 Future Ready PA Index, by Pennsylvania Department of Education,
2023 (https://www.futurereadypa.org/).
Bethlehem Area School District is comprised of 16 neighborhood elementary schools
which house kindergarten through grade five. The district also includes two middle schools
serving sixth through eighth grade students, and two high schools. The district has offered an
early childhood education program for eligible pre-kindergarten children through PA Pre-K
Counts funding for the past several years. The district’s kindergarten program is a full-day
program offered to all residents who turn five years old by October first of each year. The
district provides laptops for all students to be used during academic programming. All district
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elementary students receive instruction in library, art, music, technology, and physical education
once a week. The district issues report cards based on academic and social performance to
parents four times each academic year. According to the mission statement provided on the
district website, Bethlehem Area School District
in partnership with the home and community, is committed to providing a safe and
supportive environment in which each student will attain the knowledge, skills, and
attitudes necessary to become a productive citizen and life-long learner in our
technologically demanding and culturally diverse society” (Bethlehem Area School
District, 2019, para.1).
The current study was conducted at two elementary schools located within the Bethlehem
Area School District, Asa Packer Elementary School and Governor Wolf Elementary School.
Asa Packer Elementary School
Asa Packer Elementary School is located just off Stoke Park Road in Bethlehem, PA.
The building houses kindergarten through fifth grades, as well as one CIU20 classroom, and has
an enrollment of about 400 students. The school’s website identifies 4 key components that are
responsible for the school’s strong community. These components include parent partnerships,
family events, a focus on technology, and the school’s designation as a Leader in Me building
based on Stephen Covey’s 7 Habits (Covey et al, 2014).
Asa Packer differs slightly from the district overall in regard to race and ethnicity. In
particular, Asa Packer has a smaller percentage of Hispanic students and a larger percentage of
White students. Table 3 provides information on the race and ethnicity of Asa Packer’s student
body according to current data provided on the PA Future Ready Index. As of April, of the 20222023 school year, 51 kindergarten students were enrolled in this elementary school.
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Table 3
Asa Packer Percent Enrollment by Race/Ethnicity
Percent Enrollment by Race/Ethnicity
American Indian/Alaskan Native
0.0%
Asian
2.7%
Black
8.3%
Native Hawaiian or other Pacific Islander
0.0%
Hispanic
21.7%
White
65.5%
2 or more races
1.8%
Note. Adapted from the 2023 Future Ready PA Index, by Pennsylvania Department of Education,
2023 (https://www.futurereadypa.org/).
According to the school’s website, Asa Packer “is a diverse learning community that
fosters student growth and success in a safe and challenging environment. Our goal is to
empower children to become life-long learners and responsible citizens” (Bethlehem Area
School District, 2023, para. 1).
Governor Wolf Elementary School
Governor Wolf Elementary School is located in the northeast section of Bethlehem.
Governor Wolf’s website describes the school as an environment that strives to maintain high
expectations for students in a cooperative climate. The mission of the school is based on
motivating, inspiring, leading, and encouraging all students to support academic and social
growth and development (Bethlehem Area School District, 2023). The school is also designated
as a Leader in Me building based on Stephen Covey’s 7 Habits (Covey et al, 2014).
Governor Wolf also differs slightly from the district overall in regard to race and ethnicity
but shares similar characteristics with Asa Packer. Table 4 provides information on the race and
ethnicity of Governor Wolf’s student body according to current data provided on the PA Future
PRE-REFERRAL OT CONSULTATION
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Ready Index. As of April, of 2022-2023 school year, 73 kindergarten students were enrolled in
this elementary school.
Table 4
Governor Wolf Percent Enrollment by Race/Ethnicity
Percent Enrollment by Race/Ethnicity
American Indian/Alaskan Native
0.2%
Asian
2.7%
Black
10.3%
Native Hawaiian or other Pacific Islander
0.2%
Hispanic
38%
White
47%
2 or more races
2.0%
Note. Adapted from the 2023 Future Ready PA Index, by Pennsylvania Department of Education,
2023 (https://www.futurereadypa.org/).
Participants
Eight kindergarten teachers will be invited to participate in the study. All teachers will be
sent pre- and post- surveys using Google Forms. Four of the participating classrooms are in Asa
Packer Elementary School, located within the Bethlehem School District. The kindergarten
teachers at Asa Packer will receive the professional development and consultation training
intervention. The remaining four kindergarten classrooms that will be invited to participate in the
study are located within Governor Wolf Elementary School, also located in Bethlehem Area
School District. The Governor Wolf classrooms will serve as a control group for the study and
will not receive the professional development and consultation training intervention.
In addition to the kindergarten teachers, study participants will include the building
principal from the elementary school participating in the intervention. The principals provided
initial consent for the building faculty members’ participation. At the end of the intervention
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phase, the researcher will interview the principal to gain qualitative data on his perspective
regarding the value of the occupational therapy services provided by CIU20.
The key participant in the current study is the master's level Occupational Therapist
responsible for implementing the intervention. The therapist participating in the current study
was chosen for multiple reasons. First, she is the most senior therapist assigned to Bethlehem
School District. She has been employed by the Colonial Intermediate Unit for 10 years as an OT.
Several years ago, this therapist participated in a project to develop professional development for
regular education teachers in the district as a strategy to reduce requests for OT evaluations
across the district. The therapist has a good rapport with district teachers and administrators,
which was a factor that could facilitate the implementation of the intervention.
In addition to the direct participants, the researcher relied on another Occupational
Therapist, Registered who is currently employed by CIU20 as a collaborating consultant. This
OTR provided input into the design of the study. She also helped the researcher understand state
and federal regulations related to the delivery of school-based occupational therapy services.
Intervention/Research Plan
To conduct the proposed action research study, the researcher designed a mixed method
design to gather both quantitative and qualitative data related to my research questions. The
proposed intervention will involve monthly classroom based occupational therapy consultation
visits scheduled during the school day. The therapist will visit each classroom in the intervention
group for a 30-minute monthly consultation for six months. Consultation services may include
observation, discussion with the teacher, recommendations for class wide adaptations, and
modeling of occupational therapy strategies. The consultation visits will not impact instructional
time or interfere with class activities. The therapist will be available for assistance if requested
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by the teacher but will refrain from disrupting the classroom routine to the greatest extent
possible. The visits will be scheduled by the occupational therapist based on the classroom
teacher’s availability. The therapist will email the teachers at least two weeks prior to the
proposed visit to coordinate the date and time of the visit.
Data on teacher perceptions will be collected using pre- and post- survey measures to
determine whether the intervention impacts teacher perceptions regarding the role and efficacy of
OTs in the school setting. Data will be pulled from the IU referrals database to compare the
number of evaluations requested in kindergarten classrooms participating in the intervention to
classrooms not participating in the intervention. Interviews will be conducted with the
participating occupational therapist and the building principal post intervention to gain
information on the perceived effectiveness of the intervention. The post-intervention interviews
with the building principal will be included to gather insight on the building administrator’s
perception of the impact of OT services for classrooms participating in the intervention.
For a period of five months, classroom consultation will be provided on a monthly basis.
Following the intervention, interviews will be conducted with the participating occupational
therapist.
Data collected for the project will be kept confidential. No identifying information will be
collected in the electronic surveys. Participants will be randomly assigned a participant
identification number to compare pre and post results and only be identified by this random
number. Participant names and random number assignments will be kept in a master list stored
separately from the survey data collected. The master list will be destroyed after the data has
been coded. All hard-copy data will be kept in a secure office location at the CIU20 main office
in a locked file. No personally identifying information will be shared with school personnel. All
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electronic data will be stored on a secure server and password protected. Thematic coding will be
used to organize and analyze interview responses from principals and the occupational therapist.
Research Design, Methods & Data Collection
The current study includes an analysis of pre- and post- survey measures to determine
whether the intervention impacted teacher perceptions regarding the role and efficacy of OTs in
the school setting. The quantitative data collected through the pre- and post- surveys will be
reported and visually displayed through graphs and tables to determine if the perceptions of the
teachers who participated in the intervention changed. The post- survey results of the two groups
will be compared through descriptive statistics using an analysis of the means. The researcher
will also analyze data on the number of evaluations requested in kindergarten classrooms which
participate in the intervention and in the control group classrooms. The total number of
evaluations per classroom for each of the participating teachers will be calculated. The mean
number of evaluations for the classroom teachers who participated in the intervention will be
compared to the mean number of evaluations for the non-participating teachers. These means
will be compared to determine if there is a difference between the two groups. Data will be
pulled from the IU referrals database to compare the number of evaluations requested in
kindergarten classrooms participating in the intervention to the number of referrals in classrooms
not participating.
Research Questions
1. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of self-competency related to addressing
occupational therapy concerns in the regular education setting?
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2. How does the provision of pre-referral professional development and class wide
consultation impact teachers’ perceptions of the value of IU OT services?
3. How does the provision of pre-referral professional development and class wide
consultation impact the number of initial referrals for kindergarten occupational therapy
evaluations?
The first research question will examine whether the provision of professional
development and class wide consultation can impact general education classroom teachers’
perceptions of their own competency when supporting students with occupational therapy needs
in the general education classroom setting. The second question will compare the perceptions of
general education teachers who have participated in pre-referral professional development and
class wide consultation prior to the intervention and at the conclusion of the intervention. In
addition, the researcher will compare the perceptions of the teachers who participated in the
intervention to teachers who did not participate. The third research question will use district
referral data to determine if the provision of the intervention impacts the number of referrals for
students whose teachers participated in the intervention.
Each participating kindergarten teacher completed a pre- and post- survey to collect
quantitative data regarding perspectives regarding the effectiveness of school-based occupational
therapy services. The survey was designed to collect data to assess the teacher's perspectives on
the role and efficacy of OTs in the school setting. Teachers rated each survey item by indicating
their agreement with statements using a five-point Likert scale ranging from Strongly Disagree
to Strongly Agree (Appendix A). The survey required teachers to answer 10 questions to gain
information on their perspectives related to the established research questions. Teachers in the
control and intervention groups completed the surveys during the first and sixth months of the
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study using a Google Form distributed through email. Participants will include their randomly
assigned participant identification number in the survey pre and post results so that the results
from the two surveys can be compared.
Teacher Pre- and Post- Survey Statements
•
As a regular education teacher, I utilize an occupational therapist to support students in
regular education.
•
Prior to referring a student for an occupational therapy evaluation, I attempt strategies to
address fine motor deficits in the classroom.
•
The occupational therapist is a valuable resource to me as a teacher.
•
If I need assistance from an occupational therapist, my assigned building provider is
available and accessible.
•
I understand the role of the school-based occupational therapist at the elementary school
level.
•
I am satisfied with the support I receive from the Intermediate Unit Occupational Therapy
Department.
•
I believe my regular education students can benefit from classroom consultation from an
occupational therapist prior to a referral for evaluation.
•
All students who demonstrate fine motor deficits or sensory concerns should be referred
for an occupational therapy evaluation.
•
I am knowledgeable regarding strategies that can benefit students with fine motor and
sensory concerns.
•
My school district offers professional development opportunities related to occupational
therapy topics.
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At the end of the intervention phase during the sixth month of the implementation
process, the researcher will interview the occupational therapist who participated in the
intervention. The interview will be conducted by the researcher at the Intermediate Unit central
office, and responses will be recorded. The interview is expected to take approximately 15
minutes and is composed of open-ended questions in a semi-structured format that may lead to
additional follow-up questions.
Occupational Therapist Interview Questions
•
What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
•
What impact did the current intervention have on student performance in the regular
education classroom?
•
What impact did the current intervention have on teacher’s perceptions regarding the
value of occupational therapy services in the school environment?
•
What impact did the current intervention have on your relationship with the classroom
teachers?
•
What impact did the current intervention have on your level of participation in the
building as a whole?
Also, at the conclusion of the intervention phase during the sixth month of the
implementation process, the researcher will conduct a brief interview with the building principal
whose kindergarten classrooms participated in the intervention. The interview will be conducted
by the researcher in the school building, and responses will be recorded. The interview is
expected to take approximately 15 minutes and is composed of open-ended questions in a semistructured format that may lead to additional follow-up questions.
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Principal Interview Questions
•
What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
•
What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
•
What impact did the current intervention have on student performance in the regular
education classroom?
•
What impact did the current intervention have on your perceptions regarding the value of
Occupational Therapy services in the school environment?
•
What impact did the current intervention have on the Occupational Therapists’ level of
participation in the building as a whole?
•
What impact did the current intervention have on your impression of the value of IU
related services as a support for your building?
Validity
Mertler (2019) states that it is the responsibility of an action researcher to take
appropriate measures to ensure that the research is sound. For action research to have rigor, it
must be considered in light of its quality, accuracy, credibility, and validity. Data collection and
analysis must be conducted in a manner that ensures unbiased results and objectivity. Several
techniques can be employed to show evidence of rigor and validity. In the current study,
triangulation of data, experience with the process, and prolonged engagement and persistent
observation were employed to support the researcher’s assumption of validity (Mertler, 2019).
To develop the intervention implemented in the current study, it was necessary for the
researcher to have an in-depth knowledge of school based occupational therapy practices. As the
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author was neither an experienced researcher nor a registered occupational therapy, it was
necessary to enlist the aid of a collaborator. The author relied on collaboration with a doctoral
level Occupational Therapist, Registered, currently employed by CIU20, to assist in designing
the intervention, developing survey and interview questions, and analyzing the results of the
study. This collaborator also provided assistance to the researcher in understanding state and
federal regulations related to the delivery of school based occupational therapy services. The
expertise of this collaborator provided a higher level of rigor and credibility due to her
educational background, training, and experience with the action research process. It also helped
to ensure construct validity in that the questions included in the surveys and interviews were
designed to elicit meaningful information on the perspectives of the participants related to the
value of school-based occupational therapy services.
Triangulation of data involves including multiple sources of data within a research study.
Including multiple data sources helps in verifying the accuracy of data and giving credibility to
the study’s findings (Mertler, 2019). The research design includes three sources of data. The first
source will be gathered through the pre- and post- surveys administered to the participating
teachers. The second source of data will be gathered through the interviews conducted with the
building principal and participating occupational therapist. Finally, data on the number of
referrals requested across the control and intervention classrooms will be analyzed to investigate
the impact of the intervention on the number of referrals requested throughout the
implementation phase of the study. The inclusion of these multiple data sources within the study
design will provide further support of the validity of the findings through the established method
of data triangulation.
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A final means of establishing validity will be the use of prolonged engagement. The
classrooms participating in the intervention group will receive classroom consultation for a
period of six months. For participants to understand the outcomes of the project, they need
sufficient time to fully explore the experience (Mertler, 2019). By extending the intervention
over a period of six months, it allows the therapist to develop a rapport with the classroom
teachers, gain a better understanding of the classroom dynamics, and have ample time to observe
students and make recommendations based on ongoing engagement in the regular education
setting.
Summary
The research questions identified for the current action research project were designed to
investigate the impact of school-based pre-referral consultation through specific outcome
measures. The provision of more support from occupational therapists in the regular education
setting may be a method of decreasing the number of referrals for occupational therapy
evaluations for kindergarten students. The intervention was designed to better meet the needs of
students through the least restrictive methods and empower teachers to meet the needs of
students without the need for higher levels of support. Finally, expanding the role of occupational
therapists as classroom collaborators and consultants may positively impact the perceptions of
school personnel on the value of the occupational services provided by the intermediate unit.
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Chapter IV
Data Analysis and Results
The focus of this chapter is an analysis of the data collected over the five-month
implementation phase of the study. The data collected was aligned to the research questions
identified as the focus of this action research project. The first research question “how does the
provision of pre-referral professional development and class wide consultation impact teachers’
perceptions of self-competency related to addressing occupational therapy concerns in the
regular education setting?” was designed to investigate whether the current intervention would
impact the perceptions of regular education kindergarten teachers when compared to teachers not
participating in the intervention. The second research question “how does the provision of prereferral professional development and class wide consultation impact teachers’ perceptions of the
value of IU OT services?” was also designed to investigate whether the current intervention
would impact the perceptions of regular education kindergarten teachers when compared to
teachers not participating in the intervention. The final research question “how does the
provision of pre-referral professional development and class wide consultation impact the
number of initial referrals for kindergarten occupational therapy evaluations?” focused on an
analysis of referral data to further analyze the impact of the intervention.
To conduct the proposed action research study, the researcher implemented a mixed
method designed to gather quantitative and qualitative data. The proposed intervention consisted
of monthly classroom based occupational therapy consultation visits scheduled during the school
day at Asa Packer Elementary School. The visits were conducted by the CIU20 occupational
therapist assigned to the building. Each classroom in the control group at Asa Packer was
provided a 30-minute monthly consultation for a period of five months. Consultation services
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included observation, discussion with the teacher, recommendations for class wide adaptations,
and modeling of occupational therapy strategies. The consultation visit was designed so that it
did not impact instructional time or interfere with class activities. At the request of the teacher,
the therapist provided assistance with student specific concerns. The occupational therapist
scheduled each visit via email based on the classroom teacher’s availability.
To ensure anonymity, survey participants were randomly assigned participant
identification numbers. The numbers were assigned via email by the department secretary and
recorded in a master list and stored separately from the survey data collected. The pre and post
survey results collected via the Google survey were identifiable only by the random numbers.
Following the completion of the intervention phase the master list was destroyed.
At the start of the project, all kindergarten teachers within Asa Packer Elementary School
and Governor Wolf Elementary School were invited to participate. The control and experimental
settings were not randomized but were products of convenience sampling. At Asa Packer, three
of the kindergarten teachers agreed to participate in the project. At Governor Wolf, three teachers
initially agreed to participate. However, one teacher in the building was unable to continue with
the project due to a medical leave.
Survey Data and Analysis
The 10-question survey was given to the regular education kindergarten teachers in both
the intervention and control groups to understand their perceptions related to the research
questions. The post intervention survey results were analyzed to compare that of the control
group and the intervention group. In addition, the pre and post intervention responses in each
group were analyzed to determine whether there was a difference between the pre and post
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survey responses between the two groups. The following tables and graphs provide specific
information and visual representations of the analysis of survey results.
Analysis of Post Intervention Survey Responses
The post intervention survey data is broken down into two tables. Table 5 contains
questions related to the teachers’ perceptions of their own competency to address occupational
therapy concerns in the regular education setting.
Table 5
Post Intervention Survey Responses: Teacher Perceptions of Self-Competency
Control Group
n=2
Strongly Disagree 0
Disagree 1
Undecided 0
Agree 0
Strongly Agree 1
Intervention Group
n=3
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Strongly Disagree 0
Prior to referring a student for an occupational
therapy evaluation, I attempt strategies to address fine Disagree 0
Undecided 0
motor deficits in the classroom.
Agree 1
Strongly Agree 1
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Question
As a regular education teacher, I utilize an
occupational therapist to support students in regular
education.
I am knowledgeable regarding strategies that can
benefit students with fine motor and sensory
concerns.
All students who demonstrate fine motor deficits or
sensory concerns should be referred for an
occupational therapy evaluation.
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 1
Strongly Agree 1
Strongly Disagree 0
Disagree 2
Undecided 0
Agree 0
Strongly Agree 0
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
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My school district offers professional development
opportunities related to occupational therapy topics.
53
Strongly Disagree 2
Disagree 0
Undecided 0
Agree 0
Strongly Agree 0
Strongly Disagree 1
Disagree 1
Undecided 1
Agree 0
Strongly Agree 0
The survey asked each of the regular education teacher participants to indicate whether
they disagreed or agreed with each statement provided on a scale including strongly disagree,
disagree, undecided, agree, and strongly agree. The responses were separated and analyzed for
the control group and the intervention group. The first five questions analyzed were related to
teacher perceptions of self- competency. For the first question, one teacher in the control group
agreed strongly that she utilizes the occupational therapist to support students in regular
education while the second teacher disagreed. For questions two and three, both teachers in the
control group agreed that they attempt strategies to address fine motor deficits prior to referring a
student for an occupational therapy evaluation and that they are knowledgeable regarding
strategies that can benefit students with fine motor and sensory concerns. Both teachers in the
control group also disagreed that all students with fine motor deficits or sensory concerns should
be referred for an occupational therapy evaluation and that their school district offers
professional development opportunities related to occupational therapy topics.
In the intervention group, the responses indicated that one of the teachers typically
responded much differently than the other two. For example, in question one, one of the
respondents strongly disagreed that she utilizes the occupational therapist to support students in
regular education while the second two respondents agreed. The same pattern emerged regarding
attempting strategies prior to referring students for occupational therapy evaluations, knowledge
regarding strategies that can benefit students with fine motor and sensory concerns, and
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regarding whether all students who demonstrate deficits should be referred for an evaluation. For
the question regarding whether their school district offers professional development
opportunities related to occupational therapy topics, the three teachers in the control group varied
in their responses, ranging from strongly disagree to undecided in their responses, although none
of the teachers agreed with this statement.
Table 6 contains questions related to the teachers’ perceptions of the value of the IU
occupational therapy services.
Table 6
Post Intervention Survey Responses: Value of IU OT Services
Question
Control Group
n=2
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 0
Strongly Agree 2
The occupational therapist is a valuable resource to Strongly Disagree 0
Disagree 0
me as a teacher.
Undecided 0
Agree 2
Strongly Agree 0
If I need assistance from an occupational therapist, Strongly Disagree 0
Disagree 1
my assigned building provider is available and
Undecided 0
accessible.
Agree 1
Strongly Agree 0
Strongly Disagree 0
Disagree 0
I understand the role of the school-based
occupational therapist at the elementary school level. Undecided 1
Agree 1
Strongly Agree 0
I believe my regular education students can benefit
from classroom consultation from an occupational
therapist prior to a referral for evaluation.
Intervention Group
n=3
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 2
Strongly Agree 1
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
Strongly Disagree 0
Disagree 0
Undecided 2
Agree 1
Strongly Agree 0
Strongly Disagree 1
Disagree 0
Undecided 0
Agree 2
Strongly Agree 0
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Strongly Disagree 0
Disagree 0
Undecided 2
I am satisfied with the support I receive from the
Agree 0
Intermediate Unit Occupational Therapy Department. Strongly Agree 0
55
Strongly Disagree 0
Disagree 0
Undecided 0
Agree 3
Strongly Agree 0
The remaining five survey questions were designed to gain information on the teachers’
perspectives regarding the value of intermediate unit occupational therapy services. The
responses from the participants in the control group were fairly consistent in this area. Both
teachers strongly agreed that regular education students can benefit from classroom consultation
from an occupational therapist prior to referral. They also agreed that the occupational therapist
is a valuable resource to them as teachers. Both teachers were undecided as to whether they were
satisfied with the support they receive from the intermediate unit occupational therapy
department. The two teachers disagreed on whether the assigned building provider is available
and accessible when they need assistance from an occupational therapist. Both teachers were
undecided as to whether they were satisfied with the support they receive from the intermediate
unit occupational therapy department. One teacher agreed that she understood the role of the
school-based occupational therapist at the elementary school level while the second teacher was
undecided.
In the intervention group, all the teachers either agreed or strongly agreed that regular
education students can benefit from classroom consultation prior to a referral for occupational
therapy. Two teachers agreed that the occupational therapist is a valuable resource to them while
the third strongly disagreed. One teacher felt that the occupational therapist is available and
accessible when needed while the remaining two teachers were undecided. Two of the teachers
agreed that they understand the role of the school-based occupational therapist at the elementary
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level while one strongly disagreed. However, all three teachers agreed that they are satisfied with
this report they receive from the intermediate unit occupational therapy department.
In addition to analyzing the post- intervention responses between the control and
intervention groups, responses within each group were analyzed. The control group responses
from the pre-intervention survey compared to those of the post-intervention survey are presented
in Figure 1. Although this group did not participate in the intervention, the survey was delivered
to the control group in the same manner as the intervention group to provide a point of
comparison.
Figure 1
Survey results from the control group were analyzed to determine if there was a
difference between the pre-intervention survey responses and the post intervention survey
responses over the course of the five-month period through a comparison of mean response
scores. The questions included in the survey can be found in Appendix A. In general, the survey
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results for the control group did not vary greatly when comparing the fall responses to the spring
responses. For questions two, three, four, five, six, and seven, the teachers’ responses remain
consistent from the fall to the spring. For question two, there was a slight decrease in the mean
score response. For question eight, there was a slightly larger decrease in the mean score
response, and for question 10, there was a slight decrease in the mean score of the responses.
Survey responses from the intervention group prior to the intervention were also
compared to the group’s responses following the intervention. The intervention group responses
from the pre-intervention survey compared to those of the post-intervention survey are presented
in Figure 2. The purpose of this comparison was to determine if participation in the intervention
would have an impact on teacher perceptions as conveyed through the survey responses.
Figure 2
The survey results from the intervention group were also analyzed to compare the
teachers' responses during the fall administration of the survey when compared to the spring
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administration of the survey using an analysis of the mean response score for each question. In
the intervention group, the scores remained consistent for question four and question seven.
There was a slight decrease in the mean score of responses for question one, question two,
question three, question five, and question eight. The intervention group responses showed an
increase in mean score for question six, question nine, and question 10.
Analysis of Pre and Post Intervention Survey Responses between Groups
To determine if there was a difference in the pre- and post- survey results between the
two groups, the researcher calculated the mean response score for each group and compared the
data. The mean response scores are visually represented in Figure 3.
Figure 3
Analysis of Referral Data
CIU20 receives referrals for occupational therapy evaluations through an electronic
referral system. Member school districts complete the referral form, which is found on the IU
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website, to request services or evaluations from the IU. Once the referral is submitted, it is
processed by department secretaries and routed to the appropriate service providers. A database
of all requested referrals is maintained in Google Sheets. For the current study, this referral data
was used to analyze the number of referrals received from Asa Packer and Governor Wolf
kindergarten teachers during the 2022-2023 school year. All referrals for each building were
pulled from the database. Any students not in kindergarten for the current school year were
removed from the count. In addition, kindergarten students in classes not participating in the
study were also removed from the final count.
For the current study, the researcher compiled referral data from the 2022-2023 school
year from the beginning of the year through May 1, 2023. Asa Packer Elementary School
submitted 17 referrals for occupational therapy evaluations for students in K-5 classroom
programs. Governor Wolf submitted 18 referrals for occupational therapy evaluations for
students in K-5 classroom programs. During the 2021-2022 school year, Asa Packer Elementary
School submitted 23 referrals for occupational therapy evaluations for students in K-5 classroom
programs. Governor Wolf submitted 24 referrals for occupational therapy evaluations for
students in kindergarten through fifth grade classroom programs during the 2021-2022. Overall,
the two buildings had a similar rate for occupational therapy evaluation referrals for the last two
years.
To compare referral rates across the classrooms participating in the control and
intervention group, the researcher removed all students in grades one through five from the
referral data. In addition, referrals from the kindergarten teachers not participating in the project
were excluded. The remaining kindergarten referrals were compared across the Asa Packer
intervention classrooms and the Governor Wolf control group classrooms. Overall, Asa Packer
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had four referrals from the participating classrooms. The Governor Wolf classrooms had only
two referrals from the participating teachers. Despite the intervention, the number of referrals
from the teachers participating in the intervention was lower overall than those of the teachers
assigned to the control group.
The referral rates for the classrooms in the control and intervention groups were also
compared across the 21-22 school year and the 22-23 school year. At Governor Wolf, the
classrooms in the control group submitted a total of two referrals for occupational therapy
evaluations during the 21-22 school year. The same classrooms submitted two referrals for
occupational therapy evaluations during the 22-23 school year. At Asa Packer, the classrooms in
the intervention group submitted a total of seven referrals for occupational therapy evaluations
during the 21-22 school year. The same classrooms submitted four referrals for occupational
therapy evaluations during the 22-23 school year. Overall, the number of referrals in the control
group stayed the same across the two school years, while the number of referrals from the
classroom teachers in the intervention group dropped. Table 7 represents the number of referrals
by building and year for both the control group and the intervention group.
Table 7
Number of Referrals by School Year
_______________________________________________________________________
School
Group
School Year
Number of Referrals
______________________________________________________________________
Governor Wolf
Control
21-22
2
Governor Wolf
Control
22-23
2
Asa Packer
Intervention
21-22
7
Asa Packer
Intervention
22-23
4
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Interview Data
Occupational Therapist Interview
Following the completion of the intervention, the researcher conducted an interview with
the participating occupational therapist. The interview was conducted via zoom due to
construction at the main office. Responses were recorded by the researcher. The interview
consisted of five predetermined questions designed to gather information about the therapist’s
thoughts regarding the effectiveness of the intervention. In addition to these five questions, the
research asked two follow-up questions to gain further insight on the responses provided.
Question 1: What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
Question 1 Response:
For at least some of the teachers who requested items, they found they were helpful
without needing to put in a referral. For example, for sensory items, the students were
able to focus more at their desk without having to get up and move around. We used kick
bands and sensory stickers for some students. The teachers liked the wiggle wobble feet
that they used on the feet on some students’ chairs. One student was struggling with
cutting and I spoke to the teacher about giving her a reminder to keep her thumb up. Once
she was given the reminder the student was able to do this throughout that activity and
generalized this for the rest of the year. The teacher reported this to me. One of the three
teachers was very receptive and always let me know if things worked or not. I tried to go
in and not disrupt the classroom, but this teacher would often stop and talk to me and ask
for suggestions about how to handle different situations.
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Question 2: What impact did the current intervention have on student performance in the regular
education classroom?
Question 2 Response:
The students were able to focus more, especially those who needed sensory and
movement. Many of them were able to stay at their desks longer. Movement around the
classroom decreased. These students were constantly up and around the classroom, which
was a distraction for the teacher and the other students. It was a constant disruption to try
and get them back to their desk area.
Question 3: What impact did the current intervention have on teacher’s perceptions regarding the
value of occupational therapy services in the school environment?
Question 3 Response:
I feel like they liked it. One of them was more receptive and asked a lot of questions. At
the end she asked about seeing me the following month. She liked being able to bounce
ideas off me and get ideas rather than needing to put in a referral for an evaluation to get
input.
Question 4: What impact did the current intervention have on your relationship with the
classroom teachers?
Question 4 Response:
I think it definitely helped. I have been in this school for the last several years. I think it
opened up communication more. Usually, I am just going to the door and pulling a
student out for an evaluation. This allowed me to have more open conversations and the
ability to give them suggestions.
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Question 5: What impact did the current intervention have on your level of participation in the
building as a whole?
Question 5 Response:
It made me be in the building at least once a month. In the past there were times when I
would not have been there if there were no referrals. It definitely increased my presence
by being there for a scheduled visit each month. It was neat to see the kids without
being there for a specific student. I got to see the classroom as a whole and see how one
student with OT concerns can impact the entire class and not just that student.
Follow-up Question 1: If the district added an occupational therapist as a member of their MTSS
team, do you think this would be a valuable addition to the team?
Follow-up Question 1 Response: “Yes, I do. The district does have suggestions based on general
areas of concern. This would allow us to give specific recommendations for specific kids based
on the teacher’s concerns.”
Follow-up Question 2: Do you think providing pre-referral consultation regularly could decrease
referral rates?
Follow-up Question 2 Response:
I am going to say yes and no. I think yes if it is just a simple thing like giving reminders
of using a thumb up for cutting skills. It’s not something that needs to be addressed in a
pull-out session. I feel that most of the teachers do know when there are needs that can’t
be addressed in the classroom and there is a need for a direct pull-out.
Principal Interview
Question 1: What impact did the current intervention have on the teachers’ ability to address
Occupational Therapy concerns in the regular education classroom?
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Question 1 Response: “It allowed for more access to sensory related tools for all students in the
classroom environment.”
Question 2: What impact did the current intervention have on student performance in the regular
education classroom?
Question 2 Response: “It helped some students in the short term. Students still had difficulty
focusing, but this allowed for additional strategies to be implemented in the classroom on a
regular basis.”
Question 3: What impact did the current intervention have on your perceptions regarding the
value of Occupational Therapy services in the school environment?
Question 3 Response: “There is a continuing and growing need for support for all students. Some
interventions work immediately and last while other interventions work short term and need to
be varied and/or changed.”
Question 4: What impact did the current intervention have on your impression of the value of IU
related services as a support for your building?
Question 4 Response: “There is a need for more sensory and OT interventions throughout the
building for all students. We are seeing an increase in this, more than we previously have
experienced in our building.”
Question 5: What impact did the current intervention have on the Occupational Therapists’ level
of participation in the building as a whole?
Question 5 Response: “During the project, the OT was in the building on a more regular basis,
not just when conducting evaluations or meeting with the COTA who provides direct service.”
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Follow-up Question 1: Prior to this intervention, did your regular education teachers have access
to the occupational therapists as a resource for supporting students not receiving services through
a 504 plan or IEP?
Follow-up Question 2 Response: “We have utilized them in the past.”
Follow-up Question 2: As the building principal, do you feel the OTs could contribute to your
MTSS process?
Follow-up Question 2 Response: “Yes. Their input would be valuable in making decisions about
students who may benefit from OT Services. We’ve also taken suggestions on possible
interventions when they are part of the team.”
Analysis of Interview Responses
The researcher conducted a thematic analysis of the interviews conducted to analyze the
responses. Both interviews were reviewed to determine if common themes were present when
comparing the principal’s responses to those of the occupational therapist. Based on the analysis,
three main themes emerged from the data.
The first theme consistent across both interviews was the prevalence of sensory issues for
students at the elementary level. The therapist reported that teachers sought suggestions on
providing students alternative ways to meet sensory needs while decreasing movement around
the classroom. The teachers also responded positively to suggestions of OT equipment that
could be utilized independently by students in the regular education environment. The building
principal also reported sensory needs as one of the major concerns related to occupational
therapy within the building. The principal reported the intervention provided teachers with better
ability to provide all students with access to sensory related tools. As the therapist shared,
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students with sensory needs can create a disruption to the classroom environment, distract other
students, and result in lost instructional time due to the need for teacher redirection.
The second theme that emerged in the interviews was the belief that there has been an
increase in occupational therapy needs across the building. According to the building principal,
the school team has seen an increase in students that surpasses what was seen in previous years.
The principal stated that “there is a continuing and growing need for support for all students.” He
noted that some interventions need to be adjusted to continue to be effective and require ongoing
monitoring by the OT to ensure continued effectiveness.
Finally, the third theme identified in the therapist and principal interviews was the
perceived value of the suggestions and recommendations provided to the teachers by the
occupational therapist. The principal noted that as a part of the MTSS team, an occupational
therapist can provide suggestions on possible interventions that could be implemented to support
students in the regular education classroom. He stated that the OT’s input could be useful in
determining whether students are appropriate for direct OT service prior to a referral. The
occupational therapist shared that during the intervention, one of the teachers “would often stop
and talk to me and ask for suggestions about how to handle different situations.” The therapist
also shared that participating in the project allowed her “to have more open conversations and
the ability to give them suggestions.” The theme emerged again when the therapist was asked
whether she believed the addition of an OT to the MTSS team would be of value. She responded
that while the district team has been provided general suggestions related to general areas of
concern, as a member of the MTSS team she could provide specific recommendations for
specific students based on the teacher’s concerns.
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Discussion of the Data Analysis Process
The researcher employed triangulation to verify the accuracy of the data and give
credibility to the findings. Multiple sources of data were collected and analyzed within the
current research study. The research design included the collection of three sources of data. Preand post- surveys administered to the participating teachers provided the first source of data. The
second source of data was gathered through the interviews conducted with the building principal
and participating occupational therapist. The final source of data analyzed was collected from
the IU electronic referral database. This information included the number of referrals requested
from teachers in the control and intervention classrooms across the current school year through
the end of the implementation phase of the study. In addition, referral data from the same
classrooms during the 2021-2022 was collected and analyzed. Through the analysis of data from
multiple sources, the researcher hoped to provide further support of the validity of the findings.
Summary
The purpose of this mixed method research design was to examine the impact of prereferral occupational therapy consultation on teacher perceptions and OT evaluation referral
rates. Teacher surveys were used to collect data on teacher perceptions to determine if the
intervention impacted teacher perceptions related to two of the three research questions. Referral
data was also analyzed to assess whether the intervention had an impact on referral rates when
the intervention group was compared to the control group. Interviews were conducted with the
participating Occupational Therapist and the building principal of the intervention group to gain
further insight into the impact of the intervention. Chapter IV provides a detailed report of the
data analyses, results, and a discussion of the interpretation of results. Chapter V will present
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conclusions developed from the analysis of these results, implications for school administrators,
a discussion of research limitations, and recommendations for future research.
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Chapter V
Conclusions and Recommendations
After analyzing the data collected over the implementation phase of the study, the results
provided mixed support for the effectiveness of the intervention. Data collected from survey
responses, interviews, and OT evaluation referral data were used to generate conclusions and
formulate recommendations. The focus of Chapter V is to present these conclusions and
recommendations based on the analysis of the data collected as it relates to each research
question.
Conclusions
Research Question One
Survey Responses. The survey results from the teachers who participated in the
intervention as well as the control group were analyzed to answer the first research question,
“How does the provision of pre-referral professional development and class wide consultation
impact teachers’ perceptions of self-competency related to addressing occupational therapy
concerns in the regular education setting?” The survey results were compared between the two
groups as well as pre- and post- intervention to evaluate any changes over the course of the
intervention.
Within the control group, the teachers’ post intervention responses related to teacher
perceptions of self-competency were mixed regarding their likelihood to utilize an occupational
therapist to support students in regular education. Both teachers expressed that they do attempt
strategies to address fine motor deficits prior to an OT referral. The control group teachers also
reported they feel knowledgeable about strategies to address fine motor and sensory concerns
despite expressing that their district does not provide professional development opportunities
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related to occupational therapy topics. Both teachers also disagreed that all students with fine
motor deficits or sensory concerns should be referred for an occupational therapy evaluation.
In the intervention group, the post-intervention survey responses differed across the three
teachers on almost every response. Two of the three teachers reported that they attempt
strategies prior to referring students for occupational therapy evaluations, believe they are
knowledgeable regarding strategies to address fine motor and sensory concerns, and feel all
students who demonstrate deficits should be referred for an evaluation. None of the post
intervention responses from the teachers in the control group supported the belief that the school
district offers professional development opportunities related to occupational therapy topics.
A comparison of the pre-and post-survey results within the control group showed the
mean of the survey responses did not vary greatly over the five-month time span in which the
intervention was implemented. As this group did not participate in the intervention, it was
reasonable to predict their responses would not change greatly over the course of the project.
The mean of the teachers’ responses did decrease for question two, question eight, and question
ten; all three of these questions were related to the teachers’ perceptions of their own selfcompetency. For question two, the spring responses showed more agreement with the statement
that the teachers attempt strategies to address fine motor deficits in the classroom prior to a
referral. For question eight, the mean score in fall indicated a higher degree of agreement with
the concept that all students who demonstrate fine motor deficits or sensory concerns should be
referred for an occupational therapy evaluation. For question ten, the mean of the spring response
showed slightly higher agreement with the idea that the school district offers professional
development opportunities related to occupational therapy topics. As these teachers did not
participate in the intervention, it is unclear as to why their responses showed this difference
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across the duration of the study. It is possible that the interactions these teachers had with their
assigned therapist outside of the intervention may have had an impact on their survey responses.
Overall, the results indicate the intervention did have some positive impact on the teachers’
perceptions of self-competency related to addressing occupational therapy concerns in the
regular education setting.
The analysis of results from the intervention group teachers' responses during the fall
administration and the spring administration of the survey revealed some changes in the mean
response scores for each question related to perceptions of self-competency. The mean scores
from the spring administration indicated that the teachers agreed more with the statement that
prior to referring a student for an occupational therapy evaluation, the teacher attempts strategies
to address fine motor deficits in the classroom. The spring results also showed increased
agreement with the teachers’ belief that they utilize an occupational therapist to support students
in regular education.
However, the teachers also showed greater agreement in the spring with the statement
that all students who demonstrate fine motor deficits or sensory concerns should be referred for
an occupational therapy evaluation. The intervention group’s spring responses indicated they felt
less knowledgeable regarding strategies that can benefit students with fine motor and sensory
concerns than prior to the intervention. The teacher’s spring responses also indicated greater
disagreement that the school district offers professional development opportunities related to
occupational therapy topics. The intervention group’s fall and spring survey responses indicated
the teachers maintained the belief that regular education students can benefit from classroom
consultation from an occupational therapist prior to a referral for evaluation. It is hypothesized
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that the intervention may have highlighted to the teachers areas in which they needed assistance
and increased their reliance on the OT as an expert.
Occupational Therapist and Principal Interviews. In addition to the survey responses,
the interview conducted with the participating occupational therapist provided additional insight
into each of the identified research questions. The therapist shared her perceptions of the impact
of the intervention on the teachers' competency related to addressing occupational therapy
concerns in regular education. From the perspective of the OT, the intervention allowed some of
the teachers to better address the sensory needs of students in the classroom. Through
consultation, the therapist was able to identify sensory needs and make recommendations for
simple modifications to assist students with more appropriately meeting those needs. In addition,
the therapist coached a particular teacher on implementing a simple intervention for cutting. The
teacher was able to implement this strategy, and the student corrected their scissor grip and
generalized the skill for the rest of the year.
The principal of Asa Packer Elementary provided additional insight into the impact of the
intervention on the teacher’s ability to address occupational therapy concerns in the regular
education setting. According to the principal, the intervention allowed for more access to sensory
related tools for all students and provided opportunities for strategies to be implemented in the
classroom on a regular basis.
Research Question Two
Survey Responses. The second research question “How does the provision of prereferral professional development and class wide consultation impact teachers’ perceptions of the
value of IU OT services?” was also evaluated through an analysis of the survey data. The
responses collected from the regular education kindergarten teachers who participated in the
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intervention were compared to that of teachers not participating in the intervention to determine
if there were differences between the two groups. In addition, the survey results from the
teachers who participated in the intervention were analyzed to determine if the pre-intervention
responses differed from the post intervention responses.
The post intervention survey questions designed to gain information on the teachers’
perspectives regarding the value of intermediate unit occupational therapy services elicited fairly
consistent responses from both control group participants. The teachers' responses indicate they
believe their students can benefit from OT consultation prior to referral and view the
occupational therapist as a valuable resource. However, the teachers' responses did not indicate
that they are satisfied with the support they receive from the IU OT department and only one
teacher agreed that she understood the role of the school-based occupational therapist at the
elementary school level. Based on these responses, it is evident that the IU services are not
highly valued by all district teachers, and there is a need to improve teachers’ understanding of
the IU’s services and build better relationships between teachers and therapists within the schools
we serve.
The analysis of results from the intervention group teachers' responses during the fall
administration and the spring administration of the survey also revealed some changes in the
mean response scores for each question related to perceptions of satisfaction with IU OT
services. The mean scores from the spring administration indicated that the teachers agreed more
with the statement that they understand the role of the school-based occupational therapist at the
elementary school level. In addition, the spring results also showed increased agreement with
the teachers’ belief that the occupational therapist is a valuable resource. These two changes
support the effectiveness of the intervention on the teachers’ level of satisfaction with the IU OT
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services. The teachers’ responses regarding the belief that regular education students can benefit
from classroom consultation from an occupational therapist prior to a referral for evaluation
stayed the same over the course of the intervention, with all the teachers agreeing to some level.
The teachers’ views regarding the availability of the OT provider also remained the same but
indicated a lower level of agreement. The mean score for the question of whether the teachers are
satisfied with the support they receive from the Intermediate Unit occupational therapy
department indicated slightly less agreement in the spring. However, the teachers still reported
agreement with this statement.
Occupational Therapist and Principal Interviews. The interview with the participating
Occupational Therapist also gave insight into the second research question “How does the
provision of pre-referral professional development and class wide consultation impact teachers’
perceptions of the value of IU OT services?” While the participating teachers varied in their
responsiveness to the intervention, one teacher was reported to have sought out the therapist’s
input on multiple occasions. The therapist reported that in addition to their conversations during
the classroom visit, the teacher would frequently approach her “and ask for suggestions about
how to handle different situations.” The therapist also shared that because the sensory
recommendations allowed students to focus and remain in their seats, the teachers expressed
satisfaction over the reduction in disruptions during instruction. A final piece of evidence
supporting the teacher’s perceptions regarding the value of OT services was the request by one
participant that the therapist continue the visits even after the intervention was over.
During the interview, the OT made the statement “I got to see the classroom as a whole
and see how one student with OT concerns can impact the entire class and not just that student.”
Being present in the classroom had benefits not just for the teachers and students, but for the
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occupational therapist as well. Rather than simply taking students out of the classroom and
conducting testing in isolation, the therapist had the opportunity to regularly observe students in
the natural environment. The visits provided an opportunity to increase communication between
the therapists and teachers. It allowed the therapist to gain a better understanding of the teacher’s
skills and instructional methods as well as the demands of the classroom environment.
During the principal interview, the principal was asked to describe the impact of the
current intervention on his perceptions regarding the value of occupational therapy services in
the building. He shared that students have continuous and growing needs for additional support,
and he sees a need for additional OT interventions throughout the building. To ensure the
success of interventions, there is a need for the OT to provide ongoing support to adjust and vary
interventions and maintain their effectiveness. Overall, the survey data and interviews provided
some support that the provision of pre-referral professional development and class wide
consultation can impact the teachers’ perceptions of the value of IU OT services and improve
their understanding of the role of the school-based occupational therapist.
Research Question Three
Referral Data. The final research question “How does the provision of pre-referral
professional development and class wide consultation impact the number of initial referrals for
kindergarten occupational therapy evaluations?” was evaluated through an analysis of the
number of occupational therapy referrals requested by teachers in the intervention classrooms
compared to those requested by the teachers who did not participate in the intervention in the
current school year. In addition, data from the 2021-2022 school year was compared to data from
the 2022-2023 school year. This data provided additional information on whether the
intervention may have had an impact on the rate of referrals.
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For the current study, the CIU20 occupational therapy referral data was used to analyze
the number of referrals received from Asa Packer and Governor Wolf kindergarten teachers
during the 2022-2023 school year and the prior year. A comparison of the data between the two
groups and across the two school years was used to gather more evidence on the effectiveness of
the intervention on reducing referral rates in the intervention group. Overall, the control group
classrooms had lower rates of referrals than the intervention group teachers. Based on this, the
intervention did not result in a significant difference in the between group data. However, the
number of referrals in the control group stayed the same across the two school years, while the
comparison of referral data across the two school years did provide some evidence of support for
the intervention. When comparing the 21-22 school year to the current year, the number of
referrals from the classroom teachers in the intervention group dropped. The referral rates for
classrooms assigned to the control group stayed the same across the 21-22 and 22-23 school
years. Based on this analysis, the intervention was associated with a decrease in referrals for OT
evaluations for the teachers in the intervention groups when compared to the prior year.
Interview Data. One of the major themes identified in the therapist and principal
interviews was the perceived value of the suggestions and recommendations provided to the
teachers by the occupational therapist. The principal pointed out that as a member of the MTSS
team, an occupational therapist would be able to provide suggestions on how to support students
in the regular education classroom and provide useful input regarding when students should be
referred for evaluation. By providing this input, it is reasonable to predict that certain students
would not be recommended for further evaluation, and referral rates could be impacted.
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During the OT interview, the therapist shared her views on whether pre-referral
consultation regularly could decrease referral rates. The quote below provides evidence of the
therapist’s perspective on this question.
I am going to say yes and no. I think yes if it is just a simple thing like giving reminders
of using a thumb up for cutting skills. It’s not something that needs to be addressed in a
pull-out session. I feel that most of the teachers do know when there are needs that can’t
be addressed in the classroom and there is a need for a direct pull-out.
Application to CIU20
Although the results of the current study were mixed, the teachers, building principal and
occupational therapist reported several positive outcomes as a result of pre-referral occupational
therapy consultation. Overall, the consultation increased the presence of the occupational
therapist in the elementary school setting. The consultation also allowed teachers to gain
assistance from an occupational therapist without initiating a referral for an evaluation. Reducing
referral rates also allows the therapists more time in their schedules to directly impact nonidentified students and support district personnel.
The current intervention was limited to kindergarten teachers in one elementary school in
the Bethlehem Area School District. Bethlehem Area School District contains 16 elementary
schools and a total of 22 kindergarten through twelfth grade buildings. In addition to the
Bethlehem Area School District, CIU20 provides occupational therapy services to 12 other
school districts in Monroe, Pike, and Northampton Counties. Expanding the provision of prereferral occupational therapy services would allow the IU to positively impact thousands of
students across our partner districts.
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CIU20 offers IU20’s training and consulting services through the Training and
Consulting (TaC) department. The TaC team emphasizes the importance of bringing research to
practice and strives to improve classroom instruction across our districts by supporting educators
and helping them to meet the needs of all students.
The mission of TaC is to support Pennsylvania special education regulations and
initiatives by partnering with local education agencies to build their capacity to provide
both quality special education services and preventative interventions and programs that
promote student success. (Colonial Intermediate Unit 20, n.d., para. 1)
According to the CIU20 website, the TaC department’s philosophy promotes the belief
that “every student is capable and teacher growth benefits everyone in the school” (Colonial
Intermediate Unit 20, n.d.). The department promotes student and educator success through the
development of multiple approaches to teaching and learning. Both MTSS and Inclusive
Practices are initiatives currently identified as areas of focus for the TaC department. However,
the TaC department currently does not include an occupational therapist or provide any
assistance to our districts in this area. The current action research project provides an example of
a model by which pre-referral occupational therapy services could be added to the existing
training and consultation services offered by the IU. The participation of school-based
occupational therapists in inclusive settings allows non-identified students to benefit from their
specialized expertise without necessitating more restrictive supports. In addition, the addition of
occupational therapists to MTSS teams would expand the ability of those teams to support
students prior to a referral for special education services.
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Fiscal Implications
Colonial Intermediate Unit 20 billed our member districts a fee of $136.93 per hour for
occupational therapy services during the 2022-2023 school year. Based on recent trends, OT
costs are predicted to continue increasing as the number of evaluations requested by our districts
continues to increase annually. The provision of pre-referral professional development and
consultation allows an occupational therapist to directly support classroom teachers in the regular
education environment. In addition, the OT has access to a larger number of students who may
benefit from individualized recommendations resulting from observation and discussion between
the teachers and therapists. If teachers gain proficiency in meeting the OT needs of their students,
there is a potential of decreasing both requests for OT evaluations and the number of students
qualifying for individualized direct services through a 504 plan or IEP.
From a fiscal perspective, the long-term goal of the current project was to propose a
new service delivery method that could result in reduced costs for member districts utilizing the
IU for occupational therapy services. While there would be new costs associated with the
expansion of occupational therapists in the training and consultation department, a more efficient
and proactive approach may be a more effective alternative to the delivery of individualized
therapy services for some students.
Limitations
The current intervention was limited to kindergarten teachers in one elementary school in
the Bethlehem Area School District. The intervention was delivered over five months. To truly
investigate the impact of OT consultation services on referral rates, it would be beneficial to
deliver the intervention over a longer period. Implementing the consultation intervention over a
full school year would allow more time for collaboration between the teachers and therapist. It
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would allow the therapist to gain a greater understanding of individual student needs and the
dynamics of the classroom environment. Extending the intervention phase would also allow the
therapist more time to evaluate the effectiveness of recommendations and make adjustments as
needed.
In addition to the brief period of the intervention, the number of teachers participating in
the intervention was small. Because of the small group size, it was difficult to determine the
impact of the intervention on the teacher’s perceptions. Including more classroom teachers in the
intervention would increase the reliability and validity of the survey data analysis.
Within the control and experimental groups, data was not collected on the individual
characteristics of the classroom teachers. The survey results analysis revealed differences within
each group that seemed unrelated to the intervention's implementation. It is possible that
individual teacher characteristics, such as number of years' experience or educational background
may have impacted the survey responses and resulted in confounding variables. Collecting
additional data on individual teacher characteristics may have allowed for a better understanding
and analysis of the survey responses.
Recommendations for Future Research
Based on results and conclusions of the current action research study, there are several
areas that could be investigated more fully through future research. Replicating the study over a
longer period would allow for a better comparison of referral data across school calendar years.
The impact of pre-referral consultation and professional development may take a greater period
to affect referral rates.
The current action research project was limited to regular education kindergarten teachers
and classrooms. Another area of future research would be to expand the intervention across all
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grade levels at the elementary school level. Most OT referrals received by the intermediate unit
are for students at the elementary level, and teachers at all grade levels may benefit from access
to occupational therapy consultation in the general education classroom setting.
The first two research questions identified in the current action research project focused
on the impact of pre-referral OT consultation and professional development on the perceptions of
regular education teachers regarding their own self-competency as well as their perceptions
regarding the value of the IU OT services. The third question was designed to investigate the
impact of pre-referral consultation and professional development on OT evaluation referral data.
In addition to these factors, the intervention created a new avenue for the occupational therapist
to support students and teachers in the general education classroom. An additional research
question might explore the impact of this participation on the therapist. How might this new role
impact the job satisfaction of the occupational therapist in the school setting? In the current
climate, when retention of professional educators is a critical concern, finding ways to increase
job satisfaction is an important consideration.
Additionally, the intervention could be explored by investigating the impact on student
performance data. The addition of an occupational therapist to the elementary school MTSS team
would provide an opportunity to explore this further. In the current study, the consultation and
collaboration between the teacher and therapist was limited to the monthly classroom visits.
Adding the therapist as a participant in MTSS team meetings would provide the opportunity to
track the impact of specific recommendations on individual student performance. During the OT
interview, the researcher asked the therapist whether she believed the addition of an OT to the
MTSS team would be of value. The therapist responded that as a member of the MTSS team she
could provide specific recommendations for specific students based on the teacher’s concerns.
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During the principal interview, when asked if he felt the OTs could contribute to the MTSS
process, the principal responded as follows. “Yes. Their input would be valuable in making
decisions about students who may benefit from OT Services. We have also taken suggestions on
possible interventions when they are part of the team.” Providing an opportunity for the OT to
participate as a team member in the MTSS process may also have a positive impact on the
therapist’s presence in the building and the perceived value of OT services provided by the IU.
Summary
The purpose of this mixed method action research project was to evaluate the impact of
pre-referral professional development and class wide consultation on several factors.
Quantitative and qualitative data were analyzed to determine the impact of the intervention on
teacher perceptions regarding their own abilities to address occupational therapy concerns in the
regular education setting. In addition, the data was analyzed to determine whether the
intervention impacted the teachers’ and principal’s perceptions regarding the value of
occupational therapy services in a district elementary school building. Finally, the data was
analyzed to draw conclusions regarding whether pre-referral professional development and class
wide consultation can impact the number of occupational therapy referrals requested by regular
education kindergarten teachers.
Intermediate Units strive to be “entrepreneurial, highly skilled, technology-rich, and agile
providers of cost-effective, instructional, and operational services to school districts.”
(Pennsylvania Association of Intermediate Units, n.d.).
Over the years, intermediate units have responded to a wide array of needs as they
developed in schools and communities throughout the state. Today, intermediate units
continue to fulfill their mission of service by addressing traditional and emerging needs,
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serving as essential links for learning in Pennsylvania, and as a liaison between local
schools and the Pennsylvania Department of Education. (Pennsylvania Association of
Intermediate Units, n.d., para. 2)
To remain vital, Intermediate Units must continuously evolve to meet the changing needs
of the districts, students, and communities we serve. Moving beyond the traditional role of the
school-based occupational therapist is one way in which our organization can create new
opportunities for mutually beneficial relationships with our district partners and expand access to
meaningful supports and services for our students.
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APPENDICES
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Appendix A
Teacher Survey Questions (pre- and post-)
Please respond to the following questions using the rating scale provided:
(1-Strongly Agree, 2-Agree, 3-Undecided, 4-Disagree, 5-Strongly Disagree)
As a regular education teacher, I utilize an occupational therapist to support students in regular
education.
Prior to referring a student for an occupational therapy evaluation, I attempt strategies to address
fine motor deficits in the classroom.
The occupational therapist is a valuable resource to me as a teacher.
If I need assistance from an occupational therapist, my assigned building provider is available
and accessible.
I understand the role of the school-based occupational therapist at the elementary school level.
I am satisfied with the support I receive from the Intermediate Unit Occupational Therapy
Department.
I believe my regular education students can benefit from classroom consultation from an
occupational therapist prior to a referral for evaluation.
All students who demonstrate fine motor deficits or sensory concerns should be referred for an
occupational therapy evaluation.
I am knowledgeable regarding strategies that can benefit students with fine motor and sensory
concerns.
My school district offers professional development opportunities related to occupational therapy
topics.
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Appendix B
Occupational Therapist Interview Questions
What impact did the current intervention have on the teachers’ ability to address Occupational
Therapy concerns in the regular education classroom?
What impact did the current intervention have on student performance in the regular education
classroom?
What impact did the current intervention have on teacher’s perceptions regarding the value of
occupational therapy services in the school environment?
What impact did the current intervention have on your relationship with the classroom teachers?
What impact did the current intervention have on your level of participation in the building as a
whole?
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Appendix C
Principal Interview Questions
What impact did the current intervention have on the teachers’ ability to address Occupational
Therapy concerns in the regular education classroom?
What impact did the current intervention have on student performance in the regular education
classroom?
What impact did the current intervention have on your perceptions regarding the value of
Occupational Therapy services in the school environment?
What impact did the current intervention have on the Occupational Therapists’ level of
participation in the building as a whole?
What impact did the current intervention have on your impression of the value of IU related
services as a support for your building?
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Appendix D
Teacher Consent Letter
Dear Teacher,
As a regular education teacher at the elementary school level, you are being asked to participate
in a research study to evaluate the impact of pre-referral occupational therapy consultation. Your
participation in this study will help the researcher learn more about how consultation in the
regular education setting can impact occupational therapy referral data, improve student
outcomes, and better support teachers in meeting the needs of students with occupational therapy
needs.
What will I be asked to do if I take part in this study?
If you agree to participate in this study, you will be asked to complete two Google Form
electronic survey questionnaires (pre- and post- intervention). Four classrooms will participate in
five monthly classroom consultations with an IU Occupational Therapist scheduled during the
school day based on the teacher’s availability. The therapist will visit each classroom in the
intervention group for a 30-minute monthly consultation for a period of five months.
Consultation services may include observation, discussion with the teacher, recommendations for
class wide adaptations, and modeling of occupational therapy strategies. The consultation visit
will not impact instructional time or interfere with class activities, and there will be no active
presentations provided by the therapist during the class visit. The therapist will be available for
assistance if requested by the teacher but will refrain from disrupting the classroom routine to the
greatest extent possible. The pre- and post-intervention interviews will ask you questions
regarding your perceptions of the IU occupational therapy services.
Where will this study take place?
Both surveys will be provided via an online survey tool (Google Forms) using a secure website.
How long will the study last?
The study is projected to last approximately 5 months and two electronic survey questionnaires
(pre- and post- intervention). Total participation time will vary. The pre- and post-surveys may
take up to 10 minutes each or 20 minutes total to complete.
What happens if I don’t want to participate?
Your participation is voluntary; you can choose whether you want to participate in the study or
not. There will be no penalty if you choose not to participate.
Can I quit the study before it ends?
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Yes, you can withdraw from the study at any point by notifying the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-810-7538. There will be no penalty for withdrawing from the study
nor will you be asked to provide an explanation for your decision.
.
What are the risks?
There are minimal risks to this study. You will not be asked questions of a sensitive nature.
Participants are reminded that they are not required to answer any questions which they choose.
Participants can also stop their participation at any time without question.
How will I benefit from participating?
If you decide to be in this study, you will assist the researcher in better understanding the current
perceptions of district teachers regarding CIU20 occupational therapy services. The intervention
may provide you with tools to help you meet the needs of students with occupational therapy
needs in the classroom and reduce the need to refer students for occupational therapy
evaluations.
Will my responses be kept confidential and private?
Yes, the survey data and interview responses we collect from you will be kept confidential,
which means only the researcher will see or have access to it. Your survey responses will be
anonymous. No names will be reported in the report of the findings. Personal identifiers will not
be used in the analysis of interview results. Data will be stored on a secure server and password
protected. Returning the survey is an indication of consent to use the data.
Who do I contact if I have questions about this study?
If you have questions about this study, please contact the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-819-7538. If you would like to speak with someone other than the
researcher, please contact Dr. Mary Wolf, Assistant Professor at California University of
Pennsylvania, at wolf@calu.edu.
Approved by the California University of Pennsylvania Institutional Review Board. This
approval is effective 10/4/2022 and expires 10/3/2023.
By signing below, you agree to participate in this survey for the purpose of this research study.
___________________
Signature
________________________
Printed Name
________________
Date
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Appendix E
Principal/Occupational Therapist Consent Letter
Dear Principal/Occupational Therapist,
You are being asked to participate in a research study to evaluate the impact of pre-referral
occupational therapy consultation. Your participation in this study will help the researcher learn
more about how consultation in the regular education setting can impact occupational therapy
referrals, improve student outcomes, and better support teachers in meeting the needs of students
with occupational therapy needs.
What will I be asked to do if I take part in this study?
If you agree to participate in this study, you will be asked to participate in one post- intervention
interview following five monthly classroom consultations in 4 regular education classrooms. The
interview will include questions regarding your perceptions of the IU occupational therapy
services and the perceived effectiveness of the consultation.
Where will this study take place?
Interviews will occur in the elementary school conference room.
How long will the study last?
The study is projected to last approximately 5 months and two electronic teacher survey
questionnaires (pre- and post- intervention). Total participation time will vary. The pre- and postsurveys may take up to 10 minutes each or 20 minutes total to complete. The building principal
and occupational therapist will participate in a brief interview at the end of the study. The length
of the interview is anticipated to be 30 minutes or less.
What happens if I do not want to participate?
Your participation is voluntary; you can choose whether you want to participate in the study or
not. There will be no penalty if you choose not to participate.
Can I quit the study before it ends?
Yes, you can withdraw from the study at any point by notifying the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-810-7538. There will be no penalty for withdrawing from the study
nor will you be asked to provide an explanation for your decision.
What are the risks?
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There are minimal risks to this study. You will not be asked questions of a sensitive nature.
However, participants are reminded that they are not required to answer any questions of which
they choose. Participants can also stop their participation at any time without question.
How will I benefit from participating?
If you decide to be in this study, you will assist the researcher in better understanding the current
perceptions of district teachers regarding CIU20 occupational therapy services. The results could
support class wide consultation as a method to reduce referrals for occupational therapy
evaluations.
Will my responses be kept confidential and private?
Yes, the survey data and interview responses we collect from you will be kept confidential,
which means only the researcher will see or have access to it. No names will be reported in the
report of the findings. Data will be stored on a secure server and password protected.
Who do I contact if I have questions about this study?
If you have questions about this study, please contact the researcher, Jennifer Curtis, at
cur9592@calu.edu or at 610-810-7538. If you would like to speak with someone other than the
researcher, please contact Dr. Mary Wolf, Assistant Professor at California University of
Pennsylvania, at wolf@calu.edu.
Approved by the California University of Pennsylvania Institutional Review Board. This
approval is effective 10/4/22 and expires 10/3/2023.
By signing below, you agree to participate in this survey for the purpose of this research study.
_______________________
Signature
________________________
Printed Name
___________
Date
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Appendix F
Institutional Review Board Approval
Institutional Review Board
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Melissa Sovak, Ph.D.
Dear Jennifer,
Please consider this email as official notification that your proposal titled “Improving Student
Outcomes and Teacher Perceptions through Pre-Referral Occupational Therapy Consultation”
(Proposal #PW22-023) has been approved by the Pennsylvania Western University Institutional
Review Board as submitted.
The effective date of approval is 10/04/2022 and the expiration date is 10/03/2023. These dates
must appear on the consent form.
Please note that Federal Policy requires that you notify the IRB promptly regarding any of the
following:
(1) Any additions or changes in procedures you might wish for your study (additions or changes
must be approved by the IRB before they are implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are necessitated by any events
reported in (2).
(4) To continue your research beyond the approval expiration date of 10/03/2023, you must file
additional information to be considered for continuing review. Please contact
instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Melissa Sovak, PhD.
Chair, Institutional Review Board