Clinical Reasoning
Process for Service
Provision in the
Public School
Laura Hall, Wendy Robertson,
Mary Ann Turner
Key Words: decision making. delivery of
health care. pediatrics
This paper outlines the clinical reasoning process llsed
to gUide decisions on the prouision 0/ occupational
therapy services in tbe Wake County Public School S)'Stem in North Carolina. The process is based on CI theoretical Ji'CIInework deriuedfrorn occupationaltherapl'
theory and public /clUJ. Henefits 0/ using the cliniect/
reasoning process include (aj increclsed consistenc)' 0/
decision making among therapists; (b) increased appropriateness a/decisions regarding whether CI student needs educationally based occupC1tionctl therapy
seruices. whcli t)lpe 0/ occupational therap)' seruice
would meet the student's need. and hOle ojien this
seruice should he prolJided; and (i..) imprQl!ed ahi/it}'
of themjJists to articulate to all those inuoll'ed with a
student the reasoning behind decisiolls to prouide
educationall)' based occupationaltheraj)l' seruices
The schematic diagrams that depict this process proulde a usej~t/tool for therapists with {'mied n'ork e.\'periences entering school-hased prClctice.
T
he practice of occupat.ional therapy in the public
school setting presents a number of unique challenges, including the establishment of a standard
to determine which students need services and which
type of service is most appropriate. Although the American Occupational Therapy A'isociation (AOTA) provides
guidelines for service decisions based on an interpretation of the Education for All Handicapped Children Act of
1975 (Public Law 94-142), therapists must "rely on their
own understanding of these written interpretations and
on their professiunal judgement to determine whether a
student needs occupational therapy" (Carr, 1989, p. 503)
P,miculJr statcs can Jlso expand the services mandated
hy the Fednallaw CalT (1989) pl'csenteci critel'ia used in
Louisiana to give therJpists "standards by which to make
cleal--cut dccisions" (p. ':;06) Although Carr (1989) reported numerous benefits from using the Louisiana criteCla, other therapists claimed that the uiteria c1hcriminated against students with severe disabilities (Giangreco,
1990: Rainforth, 1990: Spencer. 1990). In our experience,
therapists in puhlic school svstems still clisagree OIl how
to make decisions 3hoUl service provision.
In struggling to develop justifiable, objective, and
ethic31 cligihilitycriteria. occupational therapists in North
Carolina's Wake Count)' Public School System (WCPSS)
reali7ed that thev had to focus on clelrl\' articulating the
clinical reasoning process used to make decisions JbOUI
service provision. The purpose of articulating this process was to make the most clppropriare decision about
~ervice provision for a particular stuclent regardless of the
pressures of practical considerations such as staff availabilit\· and district resources. Before an)' reasonable eligibility critet'ia call be dfectivelv developed, the clinical
reasoning process emploved to make decisions must be
examined, articulated. and agreecl on. Decisions about
occupational thera!'w treatment and service provision are
the outcome of the clinical l'easoning process (Roger's,
'1983).
Laura lIall. orRL i~ a Staff Occupational Theral)ist, Wake
County Public Schoul System. 3600 Wake forest Road. Raleigh. North Carolina 27611
Wendy Robertson, \IS. CHIZL. is a Staff Occupational Therapist.
Wake Count\, Public School S\'stem. Raleigh. North Carolina.
lvlan' Ann 'l'urner-. \IS om I.. is a Staff Occupational Therapist.
Wake (oum\' Public School Svsrel1l. Raleigh. NOrth Carolina
lbis arlicle li'as {/ccepledlol' pilblicarion .\-far 1. 19')2.
Since 1986. AOTA ane! the American Occupational
Ther:qw Foundation (AOTF) have funded research to
studv clinical reasoning in occupational therapy (Gillette
& Mattinglv, 19B7). This [-esearch, known as the Clinical
Reasoning Stud\', was initiated to examine the reasons
behind occupational therapv clinical decisions ane! thus
to facilitate training of occupational therapy stuclents in
clinical l-easoning. An initial impetus fm this ongoing research was the fealization th::H fieldwork clinician.'; teach
mme bl' action ane! frequently have difficulty articulating
the reasoning behind these actions (Saltz, 1991). Rogers
and MasagJtanr (1982) reached the same conclusion
about the 10 therapist.'; in their descriptive swcJv of the
clinical reasoning process in occupational therapy As
Rogers (1983) pointed out, clinical judgments 01- decisicJIls are not made on the basis of one Of two test scores
or an isolatee! observation. but are determined through
the complex pnxess of clinical reasoning.
The American Iountal o/Occupatiol1at Therapl'
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927
Clinical Reasoning
The clinical reasoning process is the problem-solving
strategy used under cOIlllitions of uncertaintv. The uncer-
taint)' can ari.)e from an iII-defIned problem thal requires
more information than is available at the outset to reach a
solution. The nature ofthe problem changes over time as
information defined b)! the practitioner's underlying philosophy and frame of reference is gathered. Rogers
(1982) perceived functional independence, which is
achieved through an interaction of personal and environmental factors, lU he the philosophy that drives occupational therapy practice.
For occupational therapists in the schools, an illdefined problem often faced is poor handwriting. To clarify the problem and to determine an intervention strategv, the therapist must investigate the student's skills and
environmental expectations and the interaction between
these variables. The investigation or information collection process is structured and organized by multiple hypotheses beginning with broad, nonspecific hypotheses
that arc refined, supported, or not supported as information is gathered (Barrows & Fe]tovich, 1987). Barrows
and Feltovich (1987) stated that "reasoning guided by
multiple hypotheses is the appropriate and effective way
to approach the resolution of poorly understood situations that require resolution" (1'. 90). Some hypotheses
related to poor handwriting are as follows: (a) student has
inadequate visual-motor skills to meet classroom expectations, (b) environmental expectations are not appropriate for this slLldent's developmental level, or (c) poor
handwriting is due to poor tactile and kinesthetic processing. Through the clinical reasoning process, therapists construct a picture of the student within the educational environment that decreases enough of the
uncertainty surrounding the problem to enable them to
formulate "prudent decisions" (Rogers, 1983, p. 614).
Methods to enhance the efficacy of the clinical reasoning process have been offered in the literature (Barrows & Feltovich, 1987; Mattingly & Gillette, 1991; Rogers, 1983; Rogers & Masagatani, 1982). One of thesc
methods is a fixed or routinized approach to data collection to prevent a premature end to information gathering. The medical review of systems used by physicians is
an example of a routinized approach (Barrows & Fe]wvich, 1987). The use of the Occupational Therapy Uniform Evaluation Checklist as recommended by Rogers
(1983) and the Uniform Terminology Grid presented by
Dunn and McGourty (1989) are examples specific to occupational therapy. Another strategy is to continually reassess all information collected in light of each additional
piece of information so that data are not forced to fit a
preset idea. Pelland's (1987) Conceptual Model of Treatment Planning reflected this need for continual adjustment. A third strategy suggested in the literature is the
use of peer and professiona! consultation (Rogers, 1983).
928
Bv sharing int()rmation and diciting possihlc competing
hvpotheses, therapists can formulate a clearer and more
complete picture of the problem. Mattingly and Gillette
(199]) reponed that the therapists involved in the clinical
reasoning study found group viewing sessions that generated various interpretations of the same information
beneficiallO prohlem solving. These three methods were
advocated to ensure that the outcome of the reasoning
process, a clinical judgmenl, would be the most appropriate decision for the specific problem addressed.
Although the results of the clinical reasoning process
(a particular treatment recommendation) are not generalizable, the process itself can be generalized and taught.
At Wake CoulllY Public School System, through open discussion of each occupational therapist's clinical reasoning, the therapists developed a schematic guide to provide structure for the clinical reasoning process used to
make treatment and service determinations within the
educational environment.
Frame of Reference
The nature and scope of questions posed during the data
collection phase of the clinical reasoning process are
defined hy the underlying philosophy and frames of reference. The philosophy driving the clinical reasoning
proce::,s presented is reflected in the Umform Terminologl'Ior Occupational Therapy-Second bdition (AOTA,
] 989b). Occupational therapy practice is defined in terms
of occupational performance areas and occupational performance components. Occupational performance areas
were activities of dailv living, work activities, and play and
leisure activities. Performance components are those
abilities required for occupational performance and include sensorimotor, cognitive, and psychosocial and psychological componcnts (AOTA, 1989b). Frames of reference consistent with the philosophy supporting the
clinical reasoning gUide include the occupational behavior model (Reilly, 19(9) and the Model of Human Occupation (Kielhofner & Burke, 19(0). The occupational behavior model descrihcs children as "individuals who occupy
particular life roles in their families, school and communities" (Takara, 1980, p. 11). Occupational therapy clients in
the school s)!stem are therefore not observed solely in
terms of their disability, but as persons who arc experiencing difficulty with their life roles, primarily with the
student role. This view involves the total child as he or she
funCtions within the context of the school environment.
The view that students cannot be observed in isolation
from their school environment comes from the Model of
Human Occupation, in which human beings arc open
svstems that interact with their environments (Kielhofner
& Burke, 1980) Occupational therapy in the public
school works to cstahlish or reestablish an occupational
role for identified students within the school environ-
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ment that includes work, play, self-care, and the underlying performance components.
Several assumptions underlie the clinical reasoning
process used by occupational therapists in the Wake
County Public School System. One of those assumptions
is that occupational therapy services proVided in the
school environment differ from occupational therapy services provided in a clinical or medical setting. The medical
model identifies dysfunction or disease and develops
strategies to increase function or decrease dysfunction
(Stephens, 1989). The underlying cause of the dysfunction is the focus of treatment (Ottenbacher, 1982). The
educational model begins with a nondysfunctional person who is expected to gain skills and knowledge (Stephens, 1989). The cause of dysfunction is not of direct
concern to educatOrs (Ottenbacher, 1982). School-based
occupational therapists are concerned with dysfunction
and disease only in the context of their effect on the
student's capacity to meet educational goals.
Another assumption is that occupational therapy (.Iiffers philosophically from special education. Occupational
therapy uses a developmental approach targeting sensorimotor developmel1l "within the context of the overall
maturation of the central nervous system" (Royeen &
Marsh, 1988, p. 714). Education tends to be more oriented toward skiJJs acquisition with the emphasis on content, not on the underlying causes and processes. Occupational therapists working within the school system
"must be able to explain how the occupational therapy
services they recommend for a parricular child are consistent with the intent of EHA" (Coutinho & Hunter, 1988,
p. 711). Using an aniculated clinical reasoning process,
these therapists should be able to explain that educationally related occupational therapy services are nor clinical
services placed in a school building. It would then be
clearer thac "a student may need occupational therapy in
the clinical setting (medical model), but would not be
eligible for services in the educational .setting'· (Stephens,
1989, p. 597) if the dysfunction does nO[ directly affect
educational progress.
The mandates of Public Law 94-142 fmm anorher set
of assumptions that guides this clinical reasoning process. Those mandates state that
the terl11 "rcl:m:d services" l11ean~ 1r<IIlSporration :lnd such devcloJlrnelllal. corn.:'ui\'e. and other supporrivc .sc,-,'in" as 'liT ITlIuired LO assist :l child to bl"neflt from speClal educliion. :1I1d
includes
occupmional tlle":1p' (Reg. 300. U. p. I OlS\). The
definiTion of "special educaTion" is <J panicularil' in11)(ln:IJ1L one
unde,- Lhese regulations,
a child is not handiGlpped unle.S' he
or ~he needs ~pecial education. Therefore. if a child (1oes noL need
~[)ecial educall<.>n. there can be no "rel~Led selyin:s.·' :md Lhe child
(heeause nUl "handicapperi") h not cO"LTed under the ,-\0 (C<.>mment 1 f<.>llu,\'ing Keg. 300 14, I' 102;~4)
Public Law 94-142 has been amended and retitled Individuals With Di~al>ililies Education Acr (Public Law
101-476). All students are eligible for occupational therapy as a related service if they are identifkd as being in
need of special education This identification as needing
special education does not mean rhar the studenr needs
occupational therapy to function independently in the
educational environment. Occupational therapy as a related service is proVided only in cases when the student is
not able to benefit from special education already provided for his or her specific educational disability. Occupational therapy as a related service "includes (1) Improving, developing or restoring funcrions impaired or lost
through illness, injury, or deprivarion; (2) Improving ability to perform tasks for independenr functioning when
funcrions are impaired or lost; and (3) Prevenring
through early intervention initial or further impairment of
loss of function" (Gilfoyle & Farace, 1981, p. 811).
Public Law 94-142 describes educational environmcnrs as existing on a continuum from leas/ restrictive
(i.e., regular education classroom with consultative serVices) to most restrictive (i.e., residential placement) and
mandates that students be served in the least restrictive
environment. Occupational therapy services must be provided in a manner consistent wirh this mandate. Using
three types of service (direct, monitoring, and consultation) and adjusting the frequency of service allows occupational therapy services to be provided along a continuum to best meet the studenr's educational needs
The need to define educationally relevanr occupational therapy services and methods of proViding these
services is critical to the practice of school-based occupational rherapy In this paper we present nor eligibilitv
criteria but the reasoning process behind these service
provision decisions. The term elz;r;,ibilitl' itself is misleading because, as explained above, any student identified as
a special education student is eligible for occupational
therapy as a related service. The issues are whether a
studenr needs occuparional rherapy to function effectively in the school environment and what type of service best
meets that student's needs. The phrase /vpe oj," as opposed to level 0/ service shifts the focus away from an
implied differenrial value placed on direct, monitoring,
and consultation services.
A Schematic Guide for the Clinical Reasoning
Process
Determina/ion of the Need/or Service
According to Mattingly (1991), clinical reasoning in occupational therapy results in acrion. "It involves deliberation
about what an appropriate action is in this particular case,
with this particular patient. at this particular time" (Mattinglv, 1991, p. 981). Determining a particular student's
need for occupational therapy service is a complex, nonlinear process in which many factors are considered. Rogers and Holm (1991) stated thar "diagnosric reasoning is
the component of clinical reasoning that results in the
occupational therapv diagnosis" (p. 10'53). Through this
Tbe American Journa/ of Occupaliona/ Therapy
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929
reasoning the problem is defined, an explanation of the
problem is proVided, and signs and symptoms indicativ~
of the problem are outlined.
Stage 1. Referral The initial contact or referral may
be initiated by par~nrs or school personnel as per state
guidelines. A5 mandated by Public Law 94-142, a child
must be identified as having a disability requiring special
education to be eligible for special programs and thereby
to receive occupational therapy as a related service.
Should the child not be identified as a special education
student, the ref~rral process ends with possibJe programmatic consultation or referral for private occupational therapy evaluation and services (see figure 1)
Programmatic consultation, also referred to as colleague consultation, "addresses the needs of other professionals in the educational environment"
(AOTA,1989a, p. 20) to increase the skills and knowledge
of other professionals. 1f the student is in the process of
being identified or is already identified as a special programs student, the referral continues to the next stage.
Stage 2. Screening. Screening is an informal assessment of a student's functioning based on observation,
Stage 1: REFERRAL
t-ecord review, and teacher and parent interviews. As defined bv AOTA, this is a Type 11 screening (AOTA, 1989a).
At this stage, three questions of equal importance are
posed (see Figure 2) The first question is whether the
referring problem seems to affect school performance.
The teacher may be asked to fill out a functional performance questionnaire that was developed by occupational
therapists in the Wake County Public School System to
assess the student's performance in the classroom in
areas related to occupational therapy practice. This allows for a systematic review of students' performance as
preViously discussed to enhance the efficacy of the clinical reasoning process.
The second question is whether the referring problem seems to be within the area of occupational therapy
practice. Occupational therapists in the Wake County
Public School System address visual motor, fine motor,
gross motor, sensory processing, sensory perception,
and neuromuscular components of the performance
areas of school and work, play and leisure, and daily living
skills as appropriate for that student'S functioning within
the school environment. Usually the referring problem is
affecting school performance; however, a child may be
experiencing a clinical problem but be able to function in
the classroom For examrle, a child with cerebral palsy
may benefit from clinical intervention to enhance the
GO TO STAGE 3
YES
Need mOf9
information before
a
decision can be
Go to Stage 2
recei"ed.
~~
- Possible program
consult
Possible referral for
private OT
evaluation/services.
<>o
-
YES
-."..
Key:
L7
l'
I'
NO
. Possible 'tfemLI to
private OT or
.","he'
= Input
disclpUne.
- One time consult
Key:
• Write screening
o
summary.
= Questions/Decisions
Stage 2: SCREENING
~
<>
o
Outcome
Information
gllt'oer1~
"''''<os
~
.. Leads to OccupatlOnaJ
Therapy StlIVK:6s
= Does not lead to Occupational Therapy services
930
.. PrOCeM of
• Does rIOt lead to OT
= Leads to Occupational Therapy services
Figure 1. First stage of the determination of the need for
occupational therapy. Note. OT = occupational therapy.
• OUtoome
Figure 2. Second stage of the determination of the need
= occupational
therapy.
for occupational therapy. Note. OT
Octoher
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quality of his or her movement but may be functioning
effectively in the school environment.
The third question addresses the issue' of developmental problems. A problem is considered developmental if the student's assessed abilities in the three rerformance areas are commensurate with the student's
cognitive functioning and the stuclent is following a typical and predictable developmental sequence of skill acquisition. This situation allows for the continuation of the
information collection and referral process for the student with multiple disabilities who may exhibit fine motor
skills commensurate with mental ability, but whose skill
acyuisition cannot follow a typical developmental sequence. For example, a student with cerebral palsy who is
functioning in the profound range of mental retardation
in cognitive, language, and fine motor areas may continue
to benefit from occupational therapy intervention to develop fine motor or oral motor skills needed to meet the
demands of the educational curriculum. If the information gathered in the screening stage is considered adequate to answer all three questions, then a decision can
be made to end the referral rrocess or to continue to
Stage 3, full evaluation. If more information is needed to
answer any of the questions, Stage 3 is necessarv.
S/age 3: Evalua/ion. Evaluation continues the rrocess of collecting information with a varietv of testing
tools, including criteria-referenced nonslandarc!ized and
slandardized tests, clinical observations of n<.:'uromllscular and sensory functioning based on Ayres's (1976) clinical observations, and observations offunetional skills (see
Figure 3).
Stage 4 Outcome The outcome is a judgment
reached through the synthesis of all the information collected during the first three stages. The presence or absence of a discrepancy between tesled skills and cognitive
ability and the presence or absence of clinical issues determine whether the referring problem falls within the
scope of occupational therapy practice. In a medical set-
ting, the diagnosis is used as a prognosticator for current
and future functioning, In an educational setting, IQ or
mental age as determined by psychological testing is used
to predict a student's potential for academic and vocational success and his or her rate of learning. To attempt
to habilitate a child's fine motor or Visual-perceptual skills
beyond his or her ability to comprehend and conceptualize mav be nonproductive and misleading because success in higher academic and skilled tasks depends heavily
on cognitive skills such as symbolic reasoning, discrimination, analysis, memory, and the ability to make references
(see Figure 4).
In the Wake County Public School System, the therapists have decided to use a psychometric approach in
determining significant deviation. A significant discrepancv is thought to exist when a student scores lower than
one standard deviation below his or her measured IQ or
more than 12 months below his or her mental age on
standardized testing tools measuring gross motor, fine
motor, visual perception, perceptual motor, anc! sensory
integrative functioning. A need for occupational therapy
is determined when any area of occupational pel-formance is significantly discrepant from a student's IQ and
thereb\' prevents the student from accessing his or her
Stage 4: OUTCOME
·Studenl needs OT
lotunC1lon
ettoetl'vely
within !he school
IlnviranrT'll!lnt
·Wri18l1vaJuatlon.
·Develop IEP wM
learn.
NO
Perlorm complete evaluation:
-Testing tools
- Clinical observations
of neuromJseular and
sensory functioning
• Observation 01
funct10nal skills.
Go to Stage 4
•
o.
Key:
&!MiIErm
Key:
-No discrepancy and
no clinical issues
present, problem
o
.
~
• leads 10 Occupational Therapy
Process of Information gathering
services
not
within area
of OT practice.
-Write evaluation.
-Possi~e referral to
another discipline.
J:lm!n!~
• Possible one time
consultation
• Possible reterral for
private OT or to
another disapline.
Write home program
Write evaluation.
OuestlonslOecislol'\$
o .
Ov1come
~
• Leads 10 Ocwpalional
Therapy services
• Does not load \0
Occupational Therapy
services
Stage 3: EVALUATION
Figure 3. Third stage of the determination of the need for
occupational therapy.
Figure 4. Fourth stage of the determination of the need for
occupational therapy. Note. OT = occupational therapy;
IEP = individualized education program.
Tbe American '/oumal or Occupational Tbemp\'
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931
education. The presence of clinical issues is determined
by a cluster of behaviors or soft signs of neurological
dysfunction, not by a single or isolated observation. For
example, a child with Down synclrome who shows global
of service to meet the student's needs must be chosen
(see Figure 5), A<; advocated by AOTA (1989a), the occupational therapy department of the Wake County Public
School System is committed to offering a multiservice
delays in all area~ tested
approach
and has skills commensurate
with cognitive functioning may be unable to meet the fine
motor demands of the classroom because his or her muscle tone is severely hypotonic, which interferes with the
ability to develop fine motor skills in a normal and
predictable sequence. This child would benefit from occupational therapy service to address the underlying neuromuscular dysfunction that is affecting classroom performance and contributing to abnormal developmental
patterns. If no discrepancy exists and there are no clinical
issues, the problem is not considered to be within the
scope of occupational therapy practice and the student
would not require occupational therapy as a related service. If there is a discrepancy or clinical issues and if the
problems identified are affecting school performance, the
student needs occupational therapy as a related service.
Determination of Type
0/ Service
Once it has been determined that the student needs occupational therapy to function in the classroom, the type
to occupational therapy service provision, including direct service, monitoring, and consultation. Direct service uses therapeutic techniques to remediate
problems identified through the evaluation process and
is carried out at least once weekly by an occupational
therapist or certified occupational therapy assistant
(AOTA, 1989a)./Vlonitoring involves "teaching and direct
supervision of other professionals or paraprofessionals
who are involved with the implementation of intervention procedures" (AOTA, 1989a, p. 19), whereby the occupational therapist sets up the program but someone
else carries it out. Case consultation is used "to develop
the most effective educational environment for children
with special needs" (AOTA, 1989a, p. 20). Research on the
efficacy of different service types is very limited. When
Dunn (1990) compared consultation and direct service in
a pilot study, her results indicated that consultation services were as effective as direct services in meeting the
student'S educational goals when the same amount of
time was srent in consultation as in direct treatment.
If the individualized education program (IEP) goals
Student needs
OT to lunctlon In
NO
school
DIRECT
erwtronment
NO
YES
-
MONITORING
YES
Key:
L7
<>
o
CONSULTATION
-1'llU!
- QuestiorlSltledsions
- Outcome
Review
evaluation.
NoOT
needed at
this time.
Figure 5. Determination of type of occupational therapy seNice needed. Note. OT
ualized education program.
932
occupational therapy; IEP
individ-
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require use of purposeful activities and other therapeutic
techniques and there is no one else who can carry out the
program safely, direct service is indicated. If purposeful
activities and other therapeutic techniques are not reqUired to meet the IEP goals, but the student needs skills
training (i.e., a specific handwriting program) that is not
pan of the classroom's regular curriculum and someone
other than the occupational therapist is available to safely
and consistently carry out the skills training program,
then monitoring is indicated. If no one is available to
safely and consistently carry out the program, then direct
service is again the most appropriate. If the IEP goals
require skills training that is part of the curriculum but
some adaptations are needed, then case consultation
would be prOVided. Additionally, jf compensation strategies, changes in environmental expectations, or adaptive
equipment is the only intervention required to meet the
IEP goals, then case consultation would be indicated. Although the primary factor in determining service type is
the treatment strategy employed, there is alwavs an ebb
and flow between service types with continual review of
progress toward meeting the student's IEP goals. This
allows for flexibility in adjusting service type as the Student improves or as more intensive intel-vention is needed. The ultimate goal is for the student to gain functional
independence and graduate from occupational therapy
sel-vices.
Determination ojIrequencv of Service
The questions used to determine frequencv for each service type arc presented in Figures 6-8. As with type of
service. research on the efficacv of frequency of sel-vice is
limited. Jenkins et a!. (1982) compared two levels of frequency of direct sel-vice: once a week versus more than
once a week. Results showed a significant difference in
outcomes onJy \vhen the two experimental groups \Vere
comp,H"ed with the control group, which received no direct service. No significant difference was found between
the two experimental groups; therefore, thc results of
this study indicate thar the only important factor was
whcther the child received direct services, not the frequency of the service.
Determination of the frequency of clil"ect service depends partially on the number ofIEP goal areas addressed
by the occupational therapist (see Figure 6). A large number of goal areas may requin,: more frequent or longer
sessions. Traditionally, dil"eet treatment is provided within 30-min sessions. If a child has difficultv making the
transition to direct occupational therapy service, a longer
treatment session may be more advantageous than an
increase in the frequency of sessions. Alternatively, a Student may not be abJe to tolerate longer treatment sessicms because of attention deficits and therefore would
need two shorter sessions. If the number of IEP goals
requires at least one 30-min session, but an increase in
Once weekly for
45-60 minutes,
plus
classroom
consultation
Twice
weekly
plus
dassroom
consultalion
Re-evaluate
service type
determination
Once weekly
plus classroom
consullatlon
Key:
LJ-Inp..,tt
<>D
•
OUtlsl~ns..·
CeCil
S
-Q<J\corne
Figure 6. Determination of frequency of direct services.
Note. OT = occupational therapy, IEP = individualized
education program.
frequency of services to twice weekly will expedite progress toward meeting those goals, then two weekly sessions would be indicated. For example, a student may be
in an emotional crisis because he or she cannot keep up
with the written demands of the classroom. so the occupational therapist may see the student twice weekly [0
provide more intensive intervention toward developing a
functional means of written communication. Another example would be a child who is on the verge of developing
a critical skill and requires a little extra push for the
emerging skill to hecome functional.
Determination of the frequency of monitoring service depends on the student'S expected rate of progress
in meeting the IEP goals (see Figure 7). Expected rate of
progress is related [0 the difficulty of the skill being taught
and the child's ability and motivation to acqUire the skill.
These elements detcrmine how much and how often the
occupational therapist needs to reevaluate the program.
Determination of the frequency of consultation service depends on the particular environmental (human
and nonhuman) adaptations needed to meet the IEP
goals, the education staffs skill in implementing these
adaptations, and the student's ahility to use these modifications to be functionallv independent (see Figure 8).
Adaptations to the human environment may include altering the education staffs expcctations of the student or
The American journal o/Occupalional TherCl!Jl'
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933
Monitoring
services
provided one
time
weekly plus
consultation.
YES
Monitoring
services
provided two
times
monthly plus
consultallon.
YES
Monitoring
services
provided one
time
monthly plus
consultation.
YES
Key:
Re-evaluate
service type
determination
L7-l
nr.vt
o
o
-OUestlofl$l'
DecIsions
• Outcome
what occu pational therapy can realistically elo for children
in the educational setting (Royeen & Marsh, 1988). The
use of specific uiteria, such as the 12-month discrepancy
between mental age and skills tested by occupational
therapists, mav not be a sensitive enough guideline for
preschoolers, hut the clinical reasoning process used for
service determination will be the same for preschool and
sehoul-age children. The questions will always return to
the child's ability to function in the educational
environment.
Many practical factors can influence a therapist's decision uf whether to place a student on the caseload.
However, allOWing services to be determined by staffing,
schedules, and space can lead to provision of tOken services, long waiting lists, angry parents, and dissatisfied
administrators (King, 1988). Parents who have had to
cope with the stress of having a child with special needs
and who have had to fight for services may push for more
services than neede(l, because they believe that more
services will mean greater progress toward a nondysfunctional child (Huebner, 1990). Dunn (191313) pointed out
that "the intent of Public Law 94-142 is that the type and
amount of service provision may not be determined by
parental wishes ur district resource limitations such as
space 01" jJ<.:I·sonnel shortages, but by the student'S needs"
(p. 718).
Figure 7. Determination of frequency of monitoring services. Note. OT = occupational therapy.
working with the education staff on developing and implementing strategies to allow the student to be functionally independent. Adaptations to the nonhuman environment may include providing adaptive equipment
including typewriters, laptop computers, and feeding
equipment; recommending the use of study carrels,
breaks in schedule, or a specific type of paper or writing
instrument; or adapting the format of tests and work
sheets.
Discussion and Implications
The decision-making process presented reflects an initial
attempt by the occupational therapists of the Wake County Public School System to look at how they think about
service provision decisions. The process is nor a criterion
of eligibility for service determination, but an attempt to
develop a consistent and justifiable approach to making
decisions regarding occupational therapy service provision. A...", public funding becomes less available, occupational therapists are being further pressed to define and
justify occupational therapy services. With the expansion
of services to the 3- to 5-year-old population mandated in
the Education of the Handicapped Act Amendments of
1986 (Public Law 99-457), occupational therapists must
present a clear picture to administrators and parents as to
934
Consultation
services
provided
at least two
times
monthly.
YES
Consultation
services
provided
one time
monthly.
YES
~
NO
Consultatio,'l
services
provided
quarterly.
YES
~
NO
Re-evaluate
service type
determination
Key:
LJ
<>
-Input
= QueshonsIDoc>sions
D .
Outcome
Figure 8. Determination of frequency of case consultation
services. Note. OT = occupational therapy.
Octoher 1992. Volume 46. Number 10
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Following an articulated clinical reasoning process
will increase consistency in decision making among staff
and occurational therapy: Making [he relationship work.
Ameriwn journal of Occupational Therapy, 42, 706-712.
plain these decisions to parents, teachers, area thera-
Dunn. W. (1988). Models of occupational therapy service
provision in the school system. American journal of Occupational Therapv. 42, 718-723
Dunn. W' (1990). A comparison of service provision models in school based occurational therapy services: A pilOt study.
pists, and outside agencies. Another reason to develop a
Occupational Therapy journal of Research, 10, 300-320
therapists and among a particular therapist's cases.
Reaching occupational therapy service decisions through
a clinical reasoning process enables the therapist to ex-
clearly articulated clinical reasoning process related to
school-based services is its value as a training tool for
newly graduated therapists and for those entering schoolbased practice from other practice areas.
The assumptions underlying this clinical reasoning
process need further research to determine efficacy and
validity. Some assumptions that need further testing include the following: (a) Does the use of an articulated
clinical reasoning process increase consistency of decision making among staff;> (b) Is use of discrerancy criteria
a valid measure for determining the need for occupational therapy services? (c) Is the multiservice provision approach a valid means of providing occupational therapy
service in the public schools?
The use of an articulated clinical reasoning process
enables occupational therapists working in public
schools to define their role as providers of a related
service separate from other disciplines. Implementing
this process ensures the development of educationaJIy
relevant, not clinically based, occupational therapy
goals on the IEP. As teachers, parents, and administrators are better able to see a direct link between occupational therapy services and educational progress, the
value of all types (direct, monitoring, and consultation)
of occupational therapy service provision in the school
system will increase. .£
Acknowledgments
This paper was made possible through the collaborative effolls
of the occupational therapists of the Wake Count~f Public School
System; the guidance and SUPPOll of Ai Li Lee, .\1'> OTRL. Ruth
Humphry, PhD. OTRIL, and Jane Rourk, OTR/L. FAOT" , and the suppon of Juanita Van Liere.
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Occupational TlJerapr 34. 11-12
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Hygiene Specialries
874
J. A. Pres ron
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Consultam Dietitians in Health Care Facilities ..... 949
Pyramid Rehabilirarion .
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Saunders Group
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Depanmem of Veterans Affairs
870
Shadyside Hospital
957
Educational Opponunities
953
Smith & Nephew Rolyan
866
Columbus McKinnon Corporation
936
Cover 2
Page
875
O<:loher t992, Volume '16. Numher to
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