Evidence Connection articles provide case examples of how practice decisions may be informed by findings of systematic reviews sponsored by the American Occupational Therapy Association Evidence-Based Practice Project. This Evidence Connection article is the second article in a two-part series. The first article described a case report of occupational therapy provided to a child with a diagnosis of autism spectrum disorder and challenges in sensory integration in a clinic setting (Parham et al., 2019). This article describes the same child’s occupational therapy service delivery by the occupational therapist working in the school setting.
Alejandro is a 6.5-yr-old boy who attends first grade and lives with both parents and a typically developing older sister. His prenatal and birth history was unremarkable. Developmental milestones were met until age 18 mo, when his parents began to notice unusual behavior, including limited eye contact, failure to respond to his name, and repetitive movements. He received a diagnosis of autism spectrum disorder (ASD) at the age of 2 yr, 4 mo, and was found eligible for home-based early intervention services.
When Alejandro was age 35 mo, the early intervention team recommended that he transition to an early childhood special education preschool. Alejandro’s parents declined this option and chose instead to enroll him at age 3.5 yr in the preschool that his sister had attended. Within 6 mo, he was expelled because of disruptive behaviors. At age 4 yr, Alejandro was placed in a home day care setting with one other child. Struggles with social interactions and behavior challenges with daily routines continued in this setting, but the home day care provider was able to calm him most days.
At age 5 yr, Alejandro was enrolled in kindergarten at his neighborhood public elementary school. Alejandro succeeded academically, but difficulties with peer interactions and compliance with classroom routines continued. In first grade, his challenges with self-regulation of behavior, social engagement with peers, and difficulty following classroom routines increased, particularly when he was required to remain seated for desk work. His teacher made several attempts to assist Alejandro by changing his placement in the classroom, providing frequent verbal cues, and encouraging friendship with another peer, but change was minimal. The teacher contacted Alejandro’s parents and suggested scheduling a meeting to discuss how best to support Alejandro.
Multitiered Systems of Support Teaming for Alejandro
The school’s problem-solving team, including an occupational therapist, scheduled a meeting with Alejandro’s parents and his teacher. The teacher reviewed her concerns and described the strategies she had tried in the classroom to assist Alejandro. The parents shared his past day care challenges and their current concerns in the home, namely Alejandro’s refusing to eat a variety of foods, running away or having a tantrum when he became upset, and refusing to work on coloring or writing activities. The team requested that the school occupational therapist, Malcolm, provide assistance to the general education teacher to identify appropriate targeted interventions for Alejandro. Malcolm began by analyzing Alejandro’s performance and participation during his typical school routine. Results are shown in Table 1.
Malcolm reviewed the results of his analysis with Alejandro’s teacher. The teacher suggested trying various sensory techniques she had heard were helpful in supporting attention and self-regulation, such as having Alejandro sit on a ball chair or special seat cushion, brushing his arms and legs, having him wear a weighted vest, and setting up a swing for him to use to support attention and self-regulation. Malcolm was familiar with the systematic review articles published in the American Journal of Occupational Therapy on effectiveness of interventions for children with sensory integration and processing challenges (Bodison & Parham, 2018; Miller-Kuhaneck & Watling; Pfeiffer et al., 2018; Schaaf et al., 2018) and of interventions for children with ASD (Miller Kuhaneck et al., 2015; Tanner et al., 2015; Watling & Hauer, 2015; Weaver, 2015), and he responded to the teacher’s suggestions by sharing this evidence. He explained that insufficient evidence had been found for the use of ball chairs, seat cushions, brushing, weighted vests, and swinging when used as stand-alone sensory interventions or when used in the classroom (Bodison & Parham, 2018; Pfeiffer et al., 2018; Watling & Hauer, 2015). He then shared that evidence supported the use of in-classroom yoga to support students’ self-regulatory behavior and the use of Social Stories to increase desired behaviors (Pfeiffer et al., 2018). Both yoga and Social Stories could be added to Alejandro’s school day to improve his participation across all school environments and support completing assigned work, remaining in the cafeteria for the entire lunch period, and developing safe playground skills.
The teacher had personal experience with yoga and felt comfortable with this option. She expressed interest in being trained in how to use yoga on a daily basis with her entire class so Alejandro would not need to be removed from the classroom to receive this intervention. Malcolm agreed to provide this training. He also developed two Social Stories for the teacher to use in supporting Alejandro’s lunchroom behaviors and playground safety. To monitor Alejandro’s responses to these interventions, Malcolm and the teacher decided to gather data at three baseline points for each targeted skill. The teacher initiated the interventions, and Malcolm returned every 2 wk to review the data with the teacher and discuss any needed changes to the intervention.
During the next team meeting, the teacher presented Alejandro’s performance data. His lunchroom and social behaviors were demonstrating positive changes at a slow rate, but no change was noted in playground safety. Malcolm reported that he had noted concerns in fine motor skills, handwriting, and limited food choices while analyzing Alejandro’s performance. The team concluded that the amount of resources and degree of need were greater than the general education teacher could manage and that a full evaluation was warranted. The parents provided written consent for the evaluation to determine Alejandro’s eligibility for special education and related services.
At the end of the meeting, Alejandro’s parents reported that they had chosen to initiate clinic-based occupational therapy services for Alejandro (see Parham et al., 2019, for a description of these services) in addition to the school-based treatment that Malcolm would provide. They provided written authorization for communication between the clinic-based occupational therapist, Adri, and school personnel regarding Alejandro’s performance in each setting, as well as any additional information that might be relevant to provision of occupational therapy for Alejandro.
Occupational Therapy Evaluation
Malcolm participated on the educational team by conducting a full and individual initial occupational therapy evaluation to determine Alejandro’s eligibility for special education and related services.
Malcolm planned to use multiple methods to gather information about Alejandro’s desired school-related occupations and activities as well as their contexts, limitations, and needed supports to guide team members’ data collection, discussion, and decision making (Frolek Clark, 2016). Conversations in the ongoing team meetings provided data for the occupational profile (American Occupational Therapy Association [AOTA], 2017). Individual teacher and parent interviews added information to facilitate understanding of Alejandro’s daily routines and interests, teacher and parent responses to Alejandro’s challenging behaviors, and the desired outcomes for occupational therapy. Alejandro’s parents stated that he likes computers, music, and television and plays simple games with his sister for short periods of time. He routinely screams and cries for 5–15 min if his parents try to engage him in adult-directed activity or homework. Parents can calm him with hugs and redirection to a preferred activity (playing with his computer, watching cartoons, or swinging outside on a swing). The parents stated that Alejandro eats three foods—cereal, crackers, and pizza—but often gags at the smell of nonpreferred foods. He runs into the street without checking for traffic and leaps off playground equipment without regard for safety; thus, the parents seldom take him into the community. Parents stated feeling that other children avoid Alejandro because he hugs them tightly or enters their personal space without realizing that the other children are uncomfortable. He has no difficulty with sleeping and participates in some chores around the house with repeated requests and some assistance.
His teacher stated that Alejandro is a strong student academically but does not sit to complete written work or fine motor activities. Alejandro frequently tears papers and needs reminders to put papers into and take them out of his backpack. He is independent in self-care except for tying his shoes in a timely manner. Social and play interactions with peers are limited. Social interactions with adults are better but not always appropriate. For example, Alejandro may approach the teacher to talk about dinosaurs during a reading group with other students.
Analysis of Occupational Performance
Malcolm used formal observation, peer comparison during the daily routine, and record review to gather information about Alejandro’s school performance. He also used the Sensory Processing Measure (SPM), Main Classroom Form (Miller Kuhaneck et al., 2007), a standardized measurement of sensory processing, to examine whether sensory challenges might be affecting Alejandro’s performance.
Formal Observations With Quantitative Data Collected.
During three separate observations, Malcolm collected data on the ability of Alejandro and three peers to sit during schoolwork. In comparison with his peers, Alejandro was found to have a significant discrepancy in ability to sit for schoolwork even after 1 mo of intervention from the classroom teacher.
Malcolm reviewed school health records and educational records with no significant findings. Malcolm also consulted the evaluation report the school had received from Adri to learn about the evaluation results she obtained for Alejandro. This report documented that on the SPM Home Form (Parham & Ecker, 2007), Alejandro demonstrated strengths in visual and auditory processing at home but great difficulties in all other sensory systems, including hyporeactivity to tactile sensations, hyperreactivity to smell and taste, and decreased vestibular and proprioceptive processing. Results from the Sensory Integration and Praxis Tests (Ayres, 1989) indicated that Alejandro had strengths in visual perception and visual construction but demonstrated needs in balance, bilateral coordination, tactile perception, vestibular and proprioceptive processing, visual–motor skills, and motor planning to imitate novel body positions and movement sequences. Scores on the Bruininks–Oseretsky Test of Motor Proficiency (2nd ed.; Bruininks & Bruininks, 2005) indicated that Alejandro’s overall motor proficiency was well below average, especially bilateral coordination, motor planning, postural control, fine motor control, and balance.
Malcolm requested that Alejandro’s teacher complete the SPM Main Classroom form (Miller Kuhaneck et al., 2007) to obtain information on Alejandro’s sensory–motor functioning and participation at school, which could be compared with his functioning at home. SPM Main Classroom scores indicated a clear strength in visual processing but difficulties in all other sensory domains. These scores also showed that Alejandro’s most severely compromised functions were social participation and praxis. Malcolm confirmed that Alejandro’s parents had provided written authorization to share information with the clinic-based occupational therapist, then he contacted Adri to discuss the SPM Main Classroom scores. After comparing the Total Sensory Systems scores between home and school and calculating the Environment Difference score, Malcolm and Adri found that sensory-related concerns reported by the parents and the teacher did not differ meaningfully. Item analysis of ratings on the Main Classroom form indicated that Alejandro demonstrated hyporeactivity to tactile sensations (which may contribute to safety concerns on the playground, incoordination, and social difficulties), hyperreactivity to smell and taste (which may contribute to limited food acceptance), and poor vestibular and proprioceptive processing (which likely contribute to difficulties with sustained sitting, incoordination, and safety concerns).
Synthesis of Assessment Findings
Findings from the record review (including clinic-based occupational therapy report, parent and teacher interviews, data collected during formal observations of Alejandro’s school routine, and assessment of sensory–motor functioning) were synthesized to identify Alejandro’s strengths and needs. The collective set of assessment data indicated that Alejandro’s occupational performance in school is affected by difficulty in processing and integrating sensory information, limitations in fine and gross motor skill development and motor planning, and challenges in self-regulation and social participation. Malcolm referred again to the AOTA systematic reviews and practice guidelines on interventions for children with sensory integration and processing challenges and for children with ASD (Tomchek & Koenig, 2016; Watling et al., 2018) to develop evidence-informed recommendations. He synthesized his findings to describe the hypothesized impact of Alejandro’s sensory–motor strengths and challenges on his function and participation at school and home. He shared the following information with the team to help guide decision making for Alejandro’s overall educational program:
Alejandro struggles to complete handwriting and other tabletop activities at school because he has challenges using pencils, materials, and other tools. His fine motor control and dexterity are poor, and he has decreased awareness from the receptors in his joints and muscles (proprioceptive awareness) and touch (tactile hyporeactivity). Evaluation also indicates that he has difficulty with planning and carrying out movements (praxis) and using both sides of his body (bilateral motor coordination).
Alejandro often runs away from his seat during tabletop learning activities. He may be running away because of his challenges with postural control, which make it difficult for him to maintain a stable sitting position and sustain engagement, or it may be an attempt to escape from fine motor activities, which are difficult for him.
It is difficult for Alejandro to participate appropriately and safely in gross motor activities in the gym and on the playground. This may be related to his challenges in balance, bilateral coordination, and motor planning as well as poor body awareness related to difficulties processing input from various sensory systems (vestibular, proprioceptive, and tactile).
Alejandro has difficulty with self-regulation, leading to disruptive behaviors in the classroom and lunchroom. His challenges in self-regulation may be related to his problems with processing sensory information (hyperreactivity to some types of sensation and hyporeactivity to other types of sensation), which make it difficult for him to match the intensity of his responses to situational demands.
The educational team determined that Alejandro was eligible for special education and related services. The team identified the following strengths and needs for Alejandro:
Strengths: academic skills, visual skills, enjoyment of computer games and music; responds well to redirection using a highly favored object (e.g., computer, games)
Needs: increased ability to complete fine motor work, to self-regulate when encountering challenging tasks or nonpreferred stimuli such as foods, and to play safely on the playground; improvement in social skills to make friends in the classroom and on the playground; expansion of options for healthy foods; and decrease in inappropriate behaviors in the lunchroom.
The team used these needs to develop individualized education program (IEP) goals for Alejandro. Specialized instruction to address all of these areas would be provided by the resource room teacher. Occupational therapy services using an integrative model of services that included skill development for Alejandro as well as collaborative consultation with his teacher were added to Alejandro’s IEP so that the occupational therapist could work on Alejandro’s goals together with the teachers.
School-Based Occupational Therapy Intervention Plan
After the IEP meeting, Malcolm proceeded with developing his intervention plan for Alejandro. The clinic-based intervention plan implemented by Adri (see Parham et al., 2019) emphasized Ayres Sensory Integration® intervention with a focus on improving the sensory–motor challenges affecting Alejandro’s occupational participation across home, school, and community contexts. Malcolm designed the school-based intervention plan using evidence-based strategies to support Alejandro’s occupational participation in the classroom, lunchroom, and playground by enhancing his sensory–motor functioning, fine and gross motor abilities, self-regulation skills, and social participation. Table 2 summarizes Malcolm’s intervention planning.
Occupational Therapy Intervention Implementation and Outcomes
Alejandro received occupational therapy services in school focused on enhancing his ability to engage and participate in the educational program. For 3 mo, Malcolm provided occupational therapy sessions in the classroom for approximately 20 min twice each week. He alternated the timing of his sessions to allow him to work with Alejandro during whole classroom fine motor activities, journal writing, or focused handwriting instruction.
In addition, Malcolm provided a 15-min small-group intervention focused on facilitating social interaction with two teacher-recommended peers on the playground once per week. He incorporated an individualized Social Story that described appropriate behaviors Alejandro should use in this context. Malcolm included the classroom paraprofessional in the social interaction group to provide training. After 6 wk, the paraprofessional assumed leadership of the group, and Malcolm provided consultation as needed.
Throughout the intervention processes, Adri and Malcolm communicated regularly and collaborated to optimize Alejandro’s participation at home, in school, and in the community. Malcolm also communicated with the teachers and Alejandro’s parents throughout the school year. Every quarter, the school submitted a progress report on Alejandro’s IEP goals.
Alejandro’s progress on his goals was shared during the annual review of his IEP. Data from the 2 most recent months indicated that Alejandro’s self-regulation had improved, allowing him to remain seated for tabletop activities for up to 15 min with only one verbal cue required. He spontaneously verbalized frustration with schoolwork or discomfort resulting from odors in the room 90% of the time, an improvement from previous behavior of verbalizing only with prompting, and he was able remain in the cafeteria with his peers for the full duration of the lunch period 80% of the time. His fine motor skills and writing improved, and he was now able to consistently write his name and complete worksheets without tearing the paper. The teacher noted that Alejandro was proud to have his work posted in the hallway. On the playground, Alejandro played with peers on swings and monkey bars and in running games. He had not jumped off high equipment for the past 2 mo. Initiating peer interactions sometimes required a verbal cue, but he responded appropriately to play bids made by peers and participated more consistently in the classroom, playground, and lunchroom.
Occupational therapy services in the school using an evidence-based approach were provided to enhance Alejandro’s performance and participation in the school routine. Working collaboratively with educators and other members of the team, Malcolm demonstrated the distinct value of occupational therapy for students in general education and special education. Alejandro made progress in or met all of his goals. His teachers and family benefited from learning new strategies to implement on a daily basis to enhance Alejandro’s performance to meet these goals.
This case demonstrates the use of evidence-based strategies in school-based occupational therapy for a student with ASD and sensory processing difficulties whose occupational therapy evaluation identified specific challenges in the school routine that affected his occupational performance and participation. This case emphasizes the need to implement the following evidence-based evaluation and intervention procedures:
Conduct a comprehensive evaluation that includes screening of all areas of occupation, record review, interviews, observations during natural routines, and assessment tool use (when applicable).
Use evaluation findings to hypothesize why participation challenges occur.
Work with the team to identify the student’s needs and create collaborative student IEP goals to address these needs (not therapy-specific goals).
Provide occupational therapy services that reflect the distinct value of occupational therapy in school settings.
Gather frequent quantitative data to determine the effectiveness of the intervention.
The authors acknowledge Deborah Lieberman and Elizabeth Hunter for their valuable guidance and suggestions.