National Survey of Occupational Therapy Practitioners’ Involvement in Response to Intervention

Review of the Literature

Few studies have described how occupational therapy practitioners work with educators to support general education students in RtI models, and none have described practitioners’ perspectives on working in such initiatives. In addition to directives from the American Occupational Therapy Association (AOTA; 2007) that outline the functions practitioners may engage in while working in an RtI model, several articles have provided recommendations for practitioners at each tier (e.g., Cahill, 2007; Cahill et al., 2008; Chandler, 2010). These articles suggest that although occupational therapy practitioners can work effectively with team members at different tiers, more research is needed to understand the range of activities in which they may participate and whether team members value their participation.

A search of the literature revealed only two studies that examined specific interventions that occupational therapy practitioners developed and implemented in RtI (Clark et al., 2008; Reeder et al., 2011). Clark et al. (2008) described a case in which an occupational therapist worked with a teacher to identify a first-grade student who was at risk for handwriting difficulties and to develop Tier 2 interventions to support the student. Although the traditional implementation of RtI models involves universal screenings given systematically throughout the school year to identify students at risk for learning difficulties, the student described by Clark et al. (2008) was identified not through universal screening but when her teacher presented her case to the school’s teacher assistance team (TAT). (TATs were a precursor to RtI implementation teams, and many TATs have evolved to implement RtI; VanDerHeyden & Burns, 2011.)

Once the student was identified as having needs, Clark et al. (2008) used the Iowa Writing Assessment and Norms (Clark, 2005) to compare the student’s performance on handwriting tasks with that of her peers and administered the Print Tool (Olsen & Knapton, 2006), a functional assessment of handwriting that also provides corresponding intervention activities based on a student’s areas of need. On the basis of the information from these tools, the occupational therapist, the student’s teacher, the student’s mother, and the school’s support teacher developed a plan for remediation. In addition, this team established target handwriting outcomes for the student based on the Print Tool (e.g., the student will correctly space words 90% of the time during the next Print Tool administration).

The support teacher worked with the student in a small group and followed recommendations from the occupational therapist. The support teacher collected progress monitoring data every 2 wk for the handwriting outcomes developed by the team. After 8 wk of intervention, the TAT determined that the student exceeded the established outcomes and no longer needed Tier 2 interventions related to handwriting.

Reeder et al. (2011) published a case study in which occupational therapists and physical therapists participated in the implementation of a four-tiered RtI model in a school district in Texas. The therapists volunteered to assist with screening 60 prekindergarten students using FirstSTEp (Miller, 1993), a screening tool used to evaluate preschoolers for developmental delays, at one of the schools included in the study. In addition to participating in the screenings, the therapists provided recommendations to educational teams and regularly attended problem solving support team (PSST) meetings at both schools.

One outcome of the therapists’ participation was the development of a flowchart that outlined how and when they participated in RtI. For example, at Tier 1, the PSST identified students with sensory or motor concerns. At Tier 2, the therapists made recommendations that the teacher and other classroom staff implemented. At Tier 3, the therapists observed a student with the parent’s consent and made specific recommendations based on the findings from the observation. The PSST added a fourth tier to the standard RtI model to determine whether this student needed to be referred for an initial evaluation for special education, including related services such as occupational therapy.

In addition to the flowchart, other outcomes involved the teachers’ understanding of the role of occupational therapy. As a result of participating on the PSST, general education teachers requested technical assistance with fine motor skills and handwriting and support for students who were “in constant motion” (Reeder et al., 2011, p. 51). Twenty-one students received occupational therapy–related RtI services during the course of the study; 8 received Tier 3 supports, and 13 received Tier 1 and 2 supports. The specific outcomes for the students receiving occupational therapy–related RtI services were not reported. It was noted, however, that 8 students had needs related to handwriting, 6 had needs related to fine motor skill development, and 6 had needs related to focus or sensory processing. The results suggest that including occupational therapy practitioners early in the problem-solving process increased their ability to collaborate with other educational team members and identify children at risk of needing their services.

None of the current literature focuses on the overall level of occupational therapy practitioners’ involvement in RtI and their attitudes toward being involved in such initiatives. We searched the literature to better understand the perspectives of practitioners related to working in RtI initiatives and did not find any studies.

Purpose

Previous research related to occupational therapy practitioners’ involvement in RtI has described case applications of the RtI framework to a specific district or specific interventions. AOTA implemented a practice advisory regarding the involvement of practitioners in RtI (cf. Bazyk et al., 2012), and educational agencies are adopting RtI models. Each state, however, determines how RtI will be implemented, and each school district exercises local control. Given the varied implementation of RtI, an examination of the RtI activities in which practitioners are involved and their attitudes regarding involvement in such initiatives is critical.

Our purpose in this study was to describe how occupational therapy practitioners across the United States are involved in RtI and their attitudes toward being involved in such initiatives. Specifically, we describe four areas: current involvement of occupational therapy practitioners in RtI, beliefs of practitioners in relation to their participation, perceived barriers to practitioners’ involvement, and factors perceived as facilitating practitioners’ involvement in RtI.

Method

Results

Discussion

Participants reported that the inclusion of occupational therapy practitioners in RtI initiatives was beneficial and that educators and administrators wanted them to be involved in providing RtI services. However, more than half of the participants indicated that school personnel typically did not understand the full scope of occupational therapy practice and that this lack of understanding limited the extent to which occupational therapy practitioners participated in such initiatives. These findings are consistent with previous research suggesting that teachers are unaware of the range of services that school-based occupational therapy practitioners can provide (Casillas, 2010a, 2010b). Although it was beyond the scope of this study, an examination of the association between level of education personnel knowledge about occupational therapy and established guidelines for occupational therapy participation in RtI would be beneficial.

Federal legislation permits local education agencies to use up to 15% of their federal dollars to provide early intervention services, like those associated with RtI, to students who are at risk for failure, with an emphasis on students in kindergarten through Grade 3 (U.S. Department of Education, Office of Special Education and Rehabilitative Sciences, 2007). Not surprisingly, therefore, respondents identified kindergarten through Grade 3 as the grades in which occupational therapy practitioners most often contributed to RtI in their schools and districts. We were, however, somewhat surprised to see that >40% of the participants also provided RtI services to children in Grades 4–8. This finding was surprising given the emphasis in the federal legislation on providing services to children in kindergarten and early elementary school. Moreover, the majority of the participants (n = 183) indicated that they provided educational services to students in the context of RtI.

Lack of resources was the most frequently cited limiting factor to involvement in RtI. Support for moving from a caseload to a workload model was also seen as a need. Additional time and personnel paired with a workload model may provide practitioners with the flexibility in their workday they need to provide services to students with individualized education plans and those who do not receive special education services. Finally, the majority of the participants indicated that school or district guidelines that describe the expectations of practitioners in terms of their involvement in RtI would be helpful.

Limitations and Future Research

This study has several potential biases based on the nature of the sample. First, because the sample was limited to AOTA members of the EISSIS, it may not be representative of all school-based practitioners in the United States. Second, although this study had a fairly high response rate, the respondents may have had a uniquely elevated interest in the topic. Third, although the survey instrument was developed after an extensive review of the literature, no formal validation process was completed. Finally, the nature of the closed-ended questions may have limited the scope of participants’ responses.

More research is needed to evaluate the grades to which occupational therapy practitioners most commonly provide RtI services and the academic areas in which practitioners tend to focus their efforts. Research focused on understanding the types of student concerns that practitioners address will assist in the development of intervention strategies and the provision of technical assistance to teachers. Research is also needed to determine the efficacy of occupational therapy interventions that are already being used in RtI. Such research has the potential to establish a precedent for occupational therapy practitioners as service providers to students in general education. Establishing such a precedent may encourage educators to invite occupational therapy practitioners to participate more frequently on problem-solving teams and within the context of RtI. Finally, more research is needed to determine the efficacy of workload models in terms of student outcome measures. Such research would provide insights into the capacity and training practitioners need to juggle the multiple responsibilities associated with providing services in both special and general education.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice: