Navigating the Barriers – How to Provide Contextually Based “Push In” OT for Students with ADHD

How to Provide Integrated OT Services

Contextually based, push in, integrated, in class support, embedded, inclusionary…. Whatever you call it, the best practice for a school-based occupational therapist is to provide services in the student’s natural environment at the point of performance.  Yet so many of us are still pulling out to build skills. Why? 

Many school-based therapists report 

  • It’s familiar and expected, my district doesn’t do “push in”.
  • I cant find appropriate scheduled times.  
  • The teachers want me to take the student out.
  • The kids expect me to take them out.
  • The social aspect, privacy, will I embarrass my student?
  • I accepted and owned my fine motor specialist role in elementary school. 
  • Change is uncomfortable. It is difficult to get teacher “buy in”.

For me, it is the way it was done when I first started over 20 years ago. 

When I was in school , the practice I learned was based on the “ medical model”.  I learned about performance components and activity analysis and studied the Uniform Terminology III, 1994 edition (UTIII). But in 2002, AOTA shifted to the Occupational Therapy Practice Framework: Domain and Process (OTPF) because Uniform Terminology did not fully elaborate on the core of our profession, OCCUPATION. Our practice is currently guided by the Fourth Edition of the OTPF. 

The Pull Out Model for Students with ADHD is not effective.

Using, the “pull out model” , us “UTIII” trained OTs would do an activity analysis of the occupation the child was having trouble with, break it down into performance components, and then evaluate and remediate those skills hoping to generalize them back into the natural context, therefore, improving classroom performance. 

We might find some weakness in motor skills, or visual attention, some sensory-motor or sensory processing problems, and then try to bottom-up treat those to age-appropriate levels.  The child would improve in our therapy room, little rock star, but it did not always transfer or generalize to classroom performance. Teacher collaboration consisted of a  2-minute hallway consult while walking backward to get to the next student. 

Using this model we keep going, week after week, pulling them out of the general ed classroom, building skills, accessing, and guess what?  Every year the demands back there in the classroom grow at the same rate as the progress you’re making skill building, 2 x a week for 30 minutes in a vacuum. 

The child is receiving OT for … ever?  Writing this out I can understand why the “medical model” is not effective for ADHD, or any student for that matter. The medical model is effective for restoring functions to clients whose natural environmental context and the demands within that context do not change as dramatically as advancing through school grades.  

How Exactly to Provide Contextually Based OT Services

How to provide OT services in the natural classroom environment is a hot topic right now. Rightfully so. Transforming a mostly pull-out practice in the school setting takes considerable time and logistics. 

Best practice for school based OT is to provide strength-based client-centered therapy in the clients’ natural context.  This is news to most administrators and teachers.  And for those of us “UTIII” OT’s, there is a learning curve and some real barriers to navigate.

Navigating Barrier #1: Scheduling 

The Mount Everest of barriers.  I stood in MANY a “push in” watching a teacher read a story to her class for 30 minutes and walked out feeling like an ineffective observer at best. That was in no way a skilled intervention or a good use of this child’s therapy time. Due to the scheduling demands of the “5 million kids” on my caseload, I couldn’t go another time and that was the time that teacher had story time due to her own schedule demands of the 30 kids in her classroom. So, back out this child went. 

  • Scheduling integrated services is common practice with integrated special education or ELL services. Communicate with admin and the people who build these schedules so they know you also need to be integrated. 
  • Let them know that you will need x amount of time in the classroom during whatever subject(s) aligns with the students support needs. Do this as soon as it gets put onto an IEP. (spring the year before). 
  • If you are stretched thin across buildings, let them know your limited time windows. 
  • Teachers have routine times when OT will not only fit right into the classroom culture but will be truly a huge set of helping hands.
  • Email the special education director, and teacher and describe what it is you need to support the student doing and ask for a time that will be helpful to the teacher. 
  • Think outside “academic time”: Specials, art, music, PE, computer class, recess, and lunch may also be the most effective time to support the performance of your students.

Navigating Barrier # 2 Service Model/ Flexibility

Flexibility is key. Make sure your intervention recommendations on IEPs and 504s reflect this flexibility and the need for OT support to school personnel. Check into your state guidelines.

When I look at my caseload for this upcoming year,  I have so many different models depending on the student’s needs, teachers’ needs, and grade levels. 

  • 2nd-Grade ADHD with written expression difficulties: 2 x a week / 30 minutes small group, classroom, with once monthly consultation with the teacher for 30 minutes. 
  • K Student Autism/ADHD:  2 x a week individual, various locations and 1 x week group , classroom, and 1 x week team meeting 30 minutes. 
  • 4th-grade student with ADHD/Dyslexia: 1 x week classroom and 10x a year support to the teacher so I can frontload the support because, by June, we are usually coasting along. 
  • Keep in mind, IEPs and 504 can be amended (without a meeting) when you change services to a less restrictive environment.
  • Less pull-out time is less TORC which is best for the student and district

Navigating Barrier # 3: Teacher Collaboration

You know that feeling you get when “house guests”company”is coming, having to clean up and be on your best self behavior.  Well, you are company in the classroom (at first). Behave like it. 💕

  • Therapists want to build teacher collaboration, trust, and relationships.  They do not need any more work, they are as stretched as thin as you are. We are there to support that teacher in helping that student access their education.  When we reframe “consult” into collaboration it makes a world of difference. 
  • Therapists are not the expert in that classroom.  We are in the teacher’s house and we follow the teacher’s rules. We want to build collaborative relationships and the expert model will undo collaboration instantly. ASK do not instruct.
  • Pre-email and ask the teacher what the preferred method of communication is. Text, email, note, phone call…
  • Let the teacher know exactly what your purpose is in the classroom and ask them where they need support immediately.  Start there. 
  • Use performance-based goal attainment scales to measure the progress of your skilled intervention, so teachers can easily see the benefit of accommodations or strategies. 
  • Therapists need to know the lesson plan without creating more work for teachers.  Lesson plans are usually handed to someone the week prior. Ask to be included so you can be prepared to differentiate on the fly. Post-COVID most of it is not extra work to add you to a google classroom or email. 
  • Therapists can plan a monthly meeting with just the teacher to collaborate, review progress, and problem solve.
  • Do not give teachers long lists of accommodations and strategies. Be selective and specific to the student. 
  • Share information about ADHD and executive functions but keep it to a one-page and specifically relevant to your student.

Navigating Barrier # 4: The “Other” Students 

You are there to support a student inside a group of 15-25 plus.  You do not want that student to feel stressed or embarrassed by your presence.

  • Depending on the student and the needs of the class, be mindful of where you sit, stand, and what you do that may single out your student.
  • Circulate. Give others attention, and assistance, equally at first. You are supporting that student in the natural context.  The context includes the other students and their attitudes and beliefs about your student. Building relationships with them all is supporting your student. 
  • Bring more than one of everything!! If your student needs a slant board or “move and sit cushion” bring two. Ask for volunteers and pick your client and another (clear it with the teacher and you’ll know who else would benefit). This makes your student feel like the chosen one rather than feeling “othered” by equipment.
  • Young kids love novelty and if they don’t need it after the novelty wears off, you’ll find it on the window sill next week. I have given the entire class fidgets ( ie. kneadable erasers) and only the children who needed them kept using them.
  • Sharpened pencils and erasers, give them out like confetti. No one can write with a dull pencil. 
  • Co-teach whole group or mini-group lessons. The teacher will let you know who else may benefit to be paired with your student.

Navigating Barrier #5: Educate Everyone about your Full Scope 

“What is occupational therapy” is historically a hard question to answer because it looks so vastly different depending on the setting. Principals, administrators, parents, teachers, and school psychologists all have their own operative definition of what school-based OT’s do. And it is most likely not anywhere near your full scope. They do not know that you are not a handwriting/ sensory teacher.

However,  special education advocates, lawyers, and impartial hearing judges clearly understand best practices and know the full scope of school-based occupational therapy. An impartial hearing is not the place you want your full scope described to your district. 

School-based therapists need an “elevator pitch” that makes sense for your school-based practice.  What is yours? Write it out, put it in the comments below.

Email or give out educational brochure on what school based OT’s do, drop in the faculty room or by the mailboxes. I linked one from AOTA below.

Point of Performance is Best

An OT has the responsibility to follow AOTA’s Practice Framework and provide client-centered, and occupation-focused occupational therapy (AOTA, 2020). 

When school-based occupational therapy practitioners provide intervention that occurs in natural environments, they are supporting LRE mandates (IDEA, 2004). Best practices for a school-based OT must also align with educational best practices that include providing strength-based services in the least restrictive environment, across settings, and by collaborating with the student/teacher (Florek Clark & Chandler, 2014). 

AOTA’s Practice Framework directs an OT to utilize the knowledge and evidence in their practice area,  (AOTA, 2020). Evidence indicates that the most effective intervention for ADHD is a collaborative, client-centered, top down intervention within their natural context. 

Transforming a mostly pull-out practice in the school setting is not easy, it takes time and logistics that may seem out of your control. Some teachers are more receptive than others. Providing contextually based occupational therapy services is worth it with the time, effort and initial challanges , especially for students with ADHD! 

Click on any of the Free Resources to Download

Occupational Therapy Practice Framework: Domain and Process—Fourth Edition OTPF4.

AOTA What if the role of a School-Based OT Handout

Read the Evidence Base / References

Uniform Terminology for Occupational Therapy — Third Edition. Am J Occup Ther November/December 1994, Vol. 48(11), 1047–1054. doi: https://doi.org/10.5014/ajot.48.11.1047. 

Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. Am J Occup Ther August 2020, Vol. 74(Supplement_2), 7412410010p1–7412410010p87. doi: https://doi.org/10.5014/ajot.2020.74S200. 

Lenin C. Grajo, Catherine Candler, Amanda Sarafian; Interventions Within the Scope of Occupational Therapy to Improve Children’s Academic Participation: A Systematic Review. Am J Occup Ther March/April 2020, Vol. 74(2), 7402180030p1–7402180030p32. doi: https://doi.org/10.5014/ajot.2020.039016

Susan M. Cahill, Stephanie Beisbier; Occupational Therapy Practice Guidelines for Children and Youth Ages 5–21 Years. Am J Occup Ther July/August 2020, Vol. 74(4), 7404397010p1–7404397010p48. doi: https://doi.org/10.5014/ajot.2020.744001

Guidelines for Occupational Therapy Services in Early Intervention and Schools. Am J Occup Ther November/December 2017, Vol. 71(Supplement_2), 7112410010p1–7112410010p10. doi: https://doi.org/10.5014/ajot.2017.716S01

Heather Watt; Push In or Pull Out? Factors Influencing Occupational Therapy Practitioners’ Use of Service Delivery Models in School Systems in Two Western States. Am J Occup TherNovember 2018, Vol. 72(4_Supplement_1), 7211510188p1. doi: https://doi.org/10.5014/ajot.2018.72S1-PO5015

Mu, K., & Royeen, C. (2004b). Interprofessional vs. interdisciplinary services in school-based occupational therapy practice. Occupational Therapy International, 11, 244-247. https://doi.org/10.1002/oti.214

Guidelines for Occupational Therapy Services in Early Intervention and Schools 

Edited by Gloria Frolek Clark, PhD, OTR/L, BCP, SCSS, FAOTA; Joyce E. Rioux, EdD, OTR/L, SCSS; and Barbara E. Chandler, PhD, OTR/L, FAOTA Best Practices for Occupational Therapy in Schools, 2nd Edition,  978-1-56900-411-1, 582 pages, 2019 Ebook ISBN: 978-1-56900-591-0 https://library.aota.org/Best-Practices-OT-Schools-2e/

Lori Flynn
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