Episode 108: Frameworks used in School-based Occupational Therapy
- Jayson Davies
- Aug 28, 2022
- 46 min read
Updated: Nov 9, 2024
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Welcome to the show notes for Episode 108 of the OT Schoolhouse Podcast.
Have you ever thought about the shifts that have happened throughout the history of Occupational Therapy in the schools? Occupational therapy has been a part of the school systems since the ‘70s when legislation was enacted at the national level.
In this episode of the OT Schoolhouse Podcast, we will discuss several shifts in this field within the past 40 years.
Our guest today is Julie Bissell, one of the occupational therapists who jumped into the schools early on to address the educational model in schools. Julie discusses transitioning from a medical model to an educational model and shares how we can facilitate participation and help the children perform in the least restrictive environment.
We will also discuss an article she co-wrote titled Frameworks, Models and Trends in School-Based. This publication discusses a few frameworks within occupational therapy and relates them specifically to school-based practices in individual states and the United States. Also, stay tuned as she enlightens us about an Israeli handwriting assessment and how she assisted in translating this fun card game into English.
Tune in to learn the following objectives:
Learners will identify how the World Health Organization model helps to look at a human and their participation regardless of disability
Learners will identify what the Pedi-Cat assessment addresses
Learners will identify what the educational framework for child success includes and how it relates to the school curriculum.
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Guest Bio
Julie Bissell, OTD, OTR/L, ATP, FAOTA
Julie Bissell has over 30 years of experience as a School-based OT. She received her Master’s and Doctorate in Occupational Therapy from the University of Southern California and had the opportunity to learn from Dr. Jean Ayres. Before her work in schools, she worked with California Children's Services. She is also certified in (RESNA) Assistive Technology and Sensory Integration.
Resources
Episode Transcript
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Amazing Narrator
Hello and welcome to the OT school house podcast, your source for school based occupational therapy tips, interviews and professional development. Now to get the conversation started, here is your host, Jayson Davies class is officially in session.
Jayson Davies
What is happening school based occupational therapy practitioners. Hope you are having a great day as we wrap up August. If you're listening to this on the day that it comes out, but no matter when you're listening to this, I hope it's a great day, whether you're starting off the day finishing up the day, I just hope it has has been a good one for you. Today on the podcast, we are talking about frameworks used within school based occupational therapy. And we're actually going to do a little bit of a history dive. We're going to talk about school based ot over the past. Well, about 40 years, if you can, believe it or not, occupational therapy really got into the school systems back in the 70s. 1976 is actually when some legislation was enacted at the national level. So in this episode of the podcast, we will be discussing the several shifts within the past 40 years or so, and our guest today to help us do that is one of the occupational therapists who jumped into the schools early on to address the educational needs of students. Dr Julie Bissell has been kind of an unofficial mentor to me, whether or not she knows it, but she has been someone who I have been able to go to when I have questions about school based occupational therapy, and she's also someone who has been very heavily involved in some of the legislation and the activism, I guess you could call it here in Southern California and California as a whole, for school based occupational therapy. So today we are going to talk about her history as she moved into the schools away from a medical model, and she's going to talk with us about how we can facilitate participation and help the children perform in the least restrictive environment. We're also going to be discussing an article that she co wrote titled frameworks, models and trends in school based occupational therapy. This is actually an article that we looked at several, I don't know, maybe about 30 or 40 episodes ago, so I'm excited to get her take on it. This publication discusses a few frameworks within occupational therapy and relates them specifically to school based practices in individual States and the United States. Also stay tuned as we kind of wrap things up, because she's going to enlighten us about an Israeli handwriting assessment and how she assisted in translating this fun card game into English. If you want to check out all the links we have links over at ot schoolhouse.com/episode, 108 also on the show notes, you can learn how you can earn professional development for listening to this episode and then taking a quiz afterwards, just like we did in episode 107 so because this is a professional development podcast episode, we do have some learning objectives for today, and so let me read those for you really quickly. Today. We hope that you will be able to identify how the World Health Organization model helps to look at a human and their participation regardless of disability. You're also going to learn what the PD cat assessment addresses, and you're also going to identify what the educational framework for child success includes and how it relates to school curriculum. So help me please give a warm welcome to Dr Julie BISSELL. I'm excited to have her on I'm excited for you to hear this conversation that we have. It's a fun one. It's an insightful one, and it is just a blessing to be able to hear her experiences as she goes through her career, as she went through her career. You'll hear me say congratulations, because she actually is retiring right now. So congrats again to you, Julie, for retiring. And yeah for everyone listening, enjoy the rest of the episode. Hello Julie. Welcome to the OT school house podcast. Thank you so much for being here today. How are you?
Julie Bissell
I'm well, thank you, and thank you for all that you do for school based practice. I love your resources, your podcast. It's always so much fun to tune in and see what you're up to.
Jayson Davies
Yeah, you know it's, it's amazing. You know what this started out is just trying to bring together school based OTs who don't always have other school based OTs to come to. You know, oftentimes we'll work in a district, and there might only be one or two OTs in the entire district, and so it's hard to talk about ideas and whatnot. So I'm so happy that the that the OT school house podcast has given OTs that ability to, you know, talk to someone, basically. So I appreciate, appreciate the thankfulness. So, yeah, you know, let's dive into it. You know, we're here to talk about an article that you and Dr Sharon Cermak worked on together. It's titled frameworks, models and trends in school based occupational therapy in the United States. But before we do. That I would love to hear a little bit about yourself as an occupational therapist. I know you just retired, congratulations, but I would love to hear about your career a little bit.
Julie Bissell
Okay, well, I started over 30 years ago in school based practice. I was working originally with children with orthopedic candy caps through California Children's Services, and then I became one of the first occupational therapists in schools to really address the educational model and look at ot needs as it relates to a child's education. And this is when school based practice was just getting started, and I was working with children, both in consultation model as well as working with their teachers, trying to bring those modifications and accommodations to help a child succeed in their classroom. And this was before we had any school based clinics, but as we got to know the needs of the children, the teachers and administrators were asking us to really set up therapy rooms in order to deliver therapy for children in the school setting. So way back in the day, we had therapy gyms. They were classrooms set up as ot PT therapy room. So we had a model of practice that ranged from working in the classrooms with teachers to working individually with children in the school setting, in an OT PT room. So that was the beginning of my practice. And then.
Jayson Davies
Yeah, I mean, obviously you've been doing this for a long time, and when you talk about that, what you just talked about, you said, you know, we went into the classroom, but we also had the OT, you know, room or the clinic style that we might have sometimes. And when you say that, I still feel that that is somewhat accurate to today. You know, sometimes we push into the classroom. Other times we do more of that pull out model. Some of us have a clinic like room, others of us pull out to the lunch table. You know, we don't always have that private space, potentially, but it actually, in that sense, it sounds similar, but I know things have changed dramatically over the last, you know, 30 years. I mean, idea was really only put in place in 1976 and it really didn't grab hold until, you know, about the 80s, and that's only 40 years ago. And so OTs haven't been in the field that long. So what shifts have you seen? You know, from when you started to now, when you're retiring. Do you think there's been a big shift, or has it remained similar?
Julie Bissell
I think there's been a big shift, and I think the shift has been for the better, for better and for worse in some in some respects. So back in the day, we were delivering therapy services based on our expertise and our in our knowledge, and we're writing goals and objectives and doing assessments with probably half the evidence that goes into the work in the clinical reasoning today. So a lot of our goals were, I would say, you know, 2030, years ago, not as measurable and and there was not as much accountability for our services. Even though we were delivering top quality services and seeing remarkable outcomes, we didn't have to have all the evidence that we do today that that really backs up what we're doing, why and and show me the data kind of thing. So yeah, there was a period of time in my career where some of the fun came out of occupational therapy, where we were going from a model, where we were all about working with the children and finding the best activities that would really support them in their education and and they were having a great time, and we were spending so much time in play. And then it got to the point where there were an increased number of referrals, a decreased number of staff to cover it, and an increased demand for accountability. And then, along with that, when idea came around in I think, 2004 2005 the parents a kind of a litigation shopping list of things that could be going wrong in special ed and and show me the data, show me the proof. And so we went from a feeling of really helping children and having a good time doing it to more worried about, Do I have enough data and trying to be more formal and accountable, I guess in our communication, which I think is a good thing. I think it was good for practice that it moved in that direction. So and I see now that we have more of a balance. OTs of play and accountability. So I think, I think it ended up at this point in a good way.
Jayson Davies
Yeah, you know, that's a great way to look at it. You know, you're in Southern California with me, and so you have seen the complete increase of advocates, lawyers, and even just informed parents that, like you said, you know, accountability. They want to hold us accountable to make sure that we are providing the services that we're supposed to be providing. And as much as that can be frustrating at times when we're in an IEP, I also appreciate their accountability, because they're not just holding us accountability as practitioners. They're holding the entire school district accountable, which, when you look at it from a bigger picture, if they're complaining to the district about ot services, what are they really saying? I think they're telling the district, hey, you need more OTs because your ot doesn't have the time to give my child the services that they need. And so I kind of look at it that way. You know, maybe it's a positive that these parents are reaching out to the district saying, hey, my ot has missed eight sessions this year with my student because that's then telling the district, maybe you need to look at things a little differently. So, yeah, I completely agree with that. You mentioned working at CCS originally. And for anyone who doesn't know that's the California Children's Services here in California, and then you moved over to the schools. Is that right? Yes, real briefly, can you just talk about how that transition was for moving from CCS, which is more of that, you know, medical, clinical model, into the schools. I know you did this early on, and you're really in the forefront of moving to the schools. But what was it like moving from that CCS realm into the educational realm, where you were having to focus on education, because that's where you were.
Julie Bissell
Well, I think, yeah, the transition was interesting, because in the medical model, which was, which was CCS, you look at a child's range of motion, their strength, their stability and mobility and activities of daily living, you know, such as, you know, dressing, feeding and just Independence at Home and and then, of course, California Children's Services in The schools, you you looked at some of those factors as it related to their positioning and orthopedic needs in in the classroom. But then when I transitioned into the educational model, it was so much fun, because the focus switched from just looking at, you know, making it through the day with with your activities of daily living, to really looking in an expanded way into play and participation and and what's it like for a child to actually begin and complete an assignment and to be successful on the playground and and it just opened up a whole world of play, which I really enjoyed and loved about my job.
Jayson Davies
Absolutely, absolutely. That's what we all get into, into ot for really, you know, it's the the service part, the actual therapy. I don't think any of us really get into ot to do the evaluations and to go to the IEPs. You know, we like that hands on approach working with a student, whether it's in the classroom or in the clinic, that actual therapy side of things. So definitely.
Julie Bissell
And then one more thing that helped in that transition is that I worked in undergrad, well, I guess it was graduate school with Dr Jean Ayres in her clinic, and was really interested in the outcomes that I was seeing with the sensory integration frame of reference. And then it was really nice to be able to apply that to a school setting, because I could see that some of the children were not participating in their everyday occupations at school, you know, doing their handwriting or paying attention to the teacher, largely due to some of these underlying factors. And then to be able to address that in a playful way was, I think, a fun transition and a nice addition to the educational system.
Jayson Davies
Yeah, yeah. I, as you know, I'm SIP trained as well, although, unfortunately, I didn't get to work with Dr Ayers. That would have been amazing, obviously. But, yeah, you know, having that si knowledge, I like to tell school based occupational therapy practitioners that even if you don't necessarily have a clinic to work in with SI, I do believe that it's important to have training in SI to understand just where that model comes from, the theory behind it, to understand the brain development and how sensory helps the brain to develop, I think that's so important, even if you don't have a an SI clinic at your school, to potentially do Si, true, Si, you know every day. I think that theory is just so important to still have.
Julie Bissell
And just to really be able to address those participation outcomes in school, because the education. Educational model is all about helping a child participate in the least restrictive environment. And if you can take a child aside and help them pull it all together and then go to the least restricted environment and perform and have that confidence that they they know what to do and how to do it, it's it's so rewarding, and it's good to be able to offer that to children. So that was an interesting part of my transition.
Jayson Davies
Awesome, awesome. Thank you. All right, so I want to dive into this article. I mentioned it earlier. It is the name of the article, frameworks, models and trends and school based occupational therapy in the United States. But as we dive into this first How did this article even come to be? I know it was published in the what was it? The Israeli Journal of Occupational Therapy, which isn't an art, isn't a journal that we, you know, always go to. So how did this article even come to be?
Julie Bissell
That's so random, isn't it? Right? Of occupational therapy. Well, Dr Cermak and I were working at the University of Southern California and and we were involved in a research project that had to do with a child's self assessment of handwriting. And this was a tool that had already been developed in Hebrew by Debbie Griever and Serena Goldstein, and they were involved with the Israeli Journal of Occupational Therapy. So as we were finishing up this research project, they asked if we would write an article on frameworks, models and trends in school based practice in United States. So they chose the topic and asked us to do it. And you know, after doing a research project and publishing, it's you feel like saying, maybe not, I my place simple, but we went ahead and did what they asked, and we were happy to do it, so.
Jayson Davies
Yeah, and this article comes from about 2015 so about seven years ago. And I'm always, I guess the word is kind of careful. You know, when we're talking about ot outside of the United States, you never know what it looks like. You know, even within the UK or Canada, those civilizations that we kind of compare, you know, relatively close to civilization. In America, it's still very different. And so in Israeli, I I've never or Israel, I've never talked to an OT there, and it's probably very different, actually in this study. And I don't know if you have the answer to this, do you know what school based ot in Israel even looks like?
Julie Bissell
You know, I didn't, but I got a glimpse of it when I was working on this project, and it's very advanced, I would say, in terms of, I'm not so sure about their educational system and how OT is integrated politically into the system, but what I learned is that they have some amazing research and school based assessments coming out of Israel. One that I just love is the quality of life at school, and that's an interview where it's been shown to be valid and reliable, but you can interview a child about different factors related to their school day. And on another note, this handwriting self assessment was that had been developed in in Hebrew, was very interesting to us, because how often do we ask a child's opinion? You know, we we look at a child's handwriting sample, we see what the the teacher is saying. We do our own fine motor assessments. But then what is it that the child thinks about his own handwriting. And so that self assessment component, I thought was really, I think, powerful, and I think that's what the Israelis are doing a really good job with in school based practice.
Jayson Davies
Wow. So it sounds like there is actually some some good work coming out of there. So I made note of those resources you just talked about the quality of life at school resource, as well as the handwriting self assessment and Hebrew. And we'll make sure to link back to those in the show notes, so we will find those and track those down. But yeah, so let's go ahead and continue on, because that actually shares with us. You know, there is stuff going on in Israel related to school based occupational therapy.
Julie Bissell
And just one thing to add to that if you put the link for the handwriting self assessment. So what Dr Cermak and I did was to translate their work into English. So we have an English version of this child self assessment, which is a really fun card game that you play with the children, and you show them is your handwriting look more like this or like that. And then they self assess what they think their handwriting is. And then you ask them if they would like to change their handwriting, or if they're happy with the way it is, or whatever. And then you get them to buy into yes or no I want to write a goal on it. So, so we translated their you. Work into English. So that's available too, if you want to add that link as well.
Jayson Davies
Yeah, definitely. We'll make sure to add both of those for anyone who maybe is in Israel listening, they can get the Hebrew version, and anyone here get the English version. Awesome. All right, so this article, it wasn't exactly your traditional research article. It wasn't like you were comparing one group to another group. It was really more of an informational article for occupational therapists. I guess your target audience would technically be like Israeli occupational therapist, but you still have to do research no matter what, and you guys have a ton of articles listed in your reference. So what did you do? You know, just kind of what information, what research were you looking for to ensure that you would be putting together an article that really did reflect everything going on in school based ot in America?
Julie Bissell
Well, what we did was to look at some of the seminal work in occupational therapy that that describes our role as occupational therapist using the A ot a practice framework. So that was a core model that that we used, we used idea our education laws that describe what an occupational therapist is or does in school based practice. And then we looked at the California Department of Ed's guidelines for OT and PT in the California Public Schools, and a number of other guidelines as well throughout the country, to see what was happening with individual states, and kind of put all those models together. And included the World Health Organization, which model of function and ability, which also inspired the A ot a practice framework, and is also mentioned in the California Department of Ed guidelines. So we included that as well. So we took some of the more important frameworks that are used by occupational therapists and referenced those and tried to explain how that all related to school based practice in the United States.
Jayson Davies
Yeah, definitely. So you guys had to really find some foundational, I guess that's foundational knowledge from ot A and then also looking at some of those models or whatnot that have developed over the, you know, 3040, years of school based ot being a practice. Now, I honestly wasn't going to ask these questions so a little bit later down the road, but you started to talk about some of those frameworks and models, and so I'd love to jump into that a little bit. There's two particular models that you actually really mentioned within the document, within the article itself, is the ICF, the International Class of functioning Disability and Health ICF, and then also the educational framework for child success. I want to discuss both of those. I'll let you choose. Which one do you want to dive into a little bit first?
Julie Bissell
Well, let's start with the World Health Organization model, because that's used universally across the world. So that might be a good place.
Jayson Davies
There we go. Let's start there.
Julie Bissell
Right, And so this was a way of looking at ability versus disability worldwide, and how to even measure outcomes form assessments. It's it's a way of just looking at a human in terms of participation. Because I think in the past, what had happened is that a person was looked at in terms of their disability and what they can and can't do. And this turns it all around and says it doesn't matter what disability you have as much as how are you able to participate in your daily life? And so key to this model is the concept of participation in whatever setting. So we're in school based setting. So our gold standard, based on the World Health Organization model, is participation in the curriculum which is really consistent with idea and all the school laws as well. So participation is key. And then if you, I know, you'll be posting the link to this model. It's in the article, and it's also in the California Department of Ed guidelines and models all over the place. You'll see it all over the place, but next to participation, on the same line, almost of importance, is activities. And what we find so many times is that a child can do an activity, but they're not participating. So what's that all about? Like we've seen them do it, but why aren't they playing? Why aren't they getting their work done? Why doesn't it happen in this context and and so I think that's interesting, to value the activities and verify that a child can or can't do an activity. But how does that matter in terms of his participation, like make sure child's participating, and that's why I love sometimes in assessments, the P, E, D, I that pediatric.
Jayson Davies
I can't think of it either, but I know what you're talking about.
Julie Bissell
The PEDI is a an assessment that you can send home to a parent in a link, and they answer a series of questions, but the questions are getting at you know, there's mobility and there's social and and then there's a participation scale that looks at is the child actually doing these and how much support does the child need for participation? So we're starting to see assessments now that actually help us tap into that participation level in our work. But and then, so you have participation, then you have activities, and then you have the foundations or the core body functions and structures that support those activities. So, for example, does child have use of their limbs? Are they mobile? Can they? Can they walk and talk and have range of motion? And can they? Can they access, you know, physically or through their sensory systems, can they access those activities and therefore participate? And then underlying that whole model is environmental factors and personal factors, because each person is unique in their own culture, their own setting and their own families. And so you look at environmental factors and personal factors as it relates to their body functions and structures activities and then their participation. So that's, in a nutshell, the World Health Organization model.
Jayson Davies
Okay, great, so that's the WHO World Health Organization, and then I know another one was the educational framework for child success. I personally love this one. I kind of view it as like the PEO model for schools, in a way. But I'll let you explain a little bit how that ties in everything, including the curriculum, which we talked a little bit about earlier.
Julie Bissell
Sure and that educational framework for child success was developed by a group of therapists that were nominated through the California Department of Ed to write the guidelines for OT and PT in the state of California. So we had, probably, I would say 15 therapists or more that were from preschool to high school in their expertise. They were from urban and rural areas. They were from universities as well as clinical practice and school based practice. So we had a number of therapists working on a team to develop the guidelines, and this is what came out of it. So this is the child's educational framework for child success. And what we love about the model as well is that the whole focus of the model, core is the child. The Child and Family is is at the very center of all this. And then you'll see on the link there are three concentric circles that that have curriculum assessment and intervention, with progress monitoring going between the assessment and and the intervention. So it's nice that curriculum is such a huge part of the child centered, school based practice, yeah, and that we're taking a close look at how this all relates to curriculum. And then there's a larger circle going around those three concentric circles, which is everything is evidence based, and team collaborated, so that you're collecting data and you're collaborating with the team. So it's a very comprehensive model with an arrow that shoots out to two boxes, and the first box, the top box, is the annual goals and the ongoing annual outcomes, and then the second box is post secondary outcomes. And you ask how practice had changed over the years, and I think this is one big way in which it's changed, and it's nice that it's reflected in in this model is that that back in the day, your goals were pretty much annual, that you wanted to see annual progress, and it wasn't as future oriented as it came out in later years, and reflected in the guidelines so that that in the second box is all those really important post secondary outcomes of education, like if you look at all the mission and vision of educational. Systems, whether it's national, state or or local, it's that children will reach post secondary education, get as many children into college as possible, and they would have competitive employment. They're not just, you know, sorting things or folding napkins or whatever, but try to find competitive employment for students and then find not only community participation, but independent living. And so when it makes you really think, when you look at this model, because when you are writing an annual goal, you have to say, how does this matter for getting a child into college, or how does this matter for a future employment or community participation, because it helps us prioritize the goal and the work that the child's doing on an annual basis, if we have our eyes down the road.
Jayson Davies
Definitely, yeah, and, you know, sometimes I have sat in IEPs and I've had that kind of conundrum with myself and with team members, because you're trying to think of an annual goal, and sometimes you kind of get stuck in that one year from today, and we forget to look out three years, five years, 10 years. How is the goal that we're producing today that is supposed to be met one year from today, supposed to impact the student for the rest of their life, right? And I think that's important to remember. When we're creating those individual annual goals, we have to think about the long term. Where is this goal actually going to lead to down the road? Sometimes you can even just say, oh, right, if I create this goal this year, what might be my follow up goal. Assume he meets that goal. Assume she meets this goal in a year from now. Well, then what? What's, what's that next step? And you know, if you kind of keep going, what's the next step, what's the next step, what's the next step, then you can kind of see where that student might get to, you know, five years, 10 years from now. So it's important not to only look at the the here and now, but as you mentioned, you know, the educational framework for child success, EF, CS, as I know us common with it, we'll call it. Those post secondary child outcomes are are extremely important, especially when you're starting to work with kids in middle school and and you're having those transition meetings, really making sure that we're looking beyond just this year and looking into, you know, meaningful college experiences, meaningful work experiences, and, as you mentioned, independent living, super important. All right, let me switch back to my notes here. We've been jumping around a little bit, and that's totally fine, because I like to go where the conversation leads us to another another. Sorry. Did we cover all the do we cover all the frameworks? We did the who?
Julie Bissell
One that is that is not exactly mentioned, it's or folk. It had a minor focus in the article. Was the, was the Universal Design for Learning,
Jayson Davies
Okay.
Julie Bissell
And, you know, that's a really important framework, and I think that kind of defines the occupational therapist role in school based practice. And I think most people are familiar with the the UDL guidelines and UDL framework of the core value of in helping a child with engagement, yeah, the activities, and then finding multiple means of action and expression to demonstrate their knowledge. So that's been a really core, a model or framework that's been guiding what we what we do in schools. And an occupational therapist could have been the author of that. I know it took, like a national team, but it's.
Jayson Davies
You know, funny story about that actually, is that, you know, in college, you know, I graduated in 2012 and I remember universal design being like a big topic within school. And then, you know, jump in fast forward, you know, three years into school, and all of a sudden we add the four learning at the end. I was like, Oh, I know what this is. I learned all about universal design. Now we just add the four learning, which just means it's related to education. Basically. I was like, Yeah, I know this. That was an easy, easy transition. So, yeah, I think you're right, easily. OTs could have, have been a part of that. Now, as we talk a little bit about UDL, I often, and you might do the same tie UDL within the same frame, per se of RTI, MTSS a little bit we're talking about that preventative model, as opposed to the wait to fail model. So with that, can you go a little bit further in talking about how you can tie in UDL a little bit potentially, with the MTSS, and how that became more that getting away from the way to fail model, I guess.
Julie Bissell
Right. And I just loved your question about, how have things changed over the years? Because it's really taking me back on the road of. My whole career to see how things have changed, and that's another wonderful change in the educational system is going away from that wait to fail model. It used to break my heart to see a child who I know was struggling in kindergarten needed special help. But no, let's wait till first grade. Let's wait till second grade, and then, you know, occupational therapy as a related service could not get involved until the child had had a modified diagnosis, as in a special education qualification. So so our hands were really tied, and the MTSS and multi tiered systems of support and Response to Intervention. Movements have really opened the door for children to get really good services, whether or not they need special ed, but to give early access to help. So that's been a wonderful development, I think, in education, and I think most people listening to the podcast know forwards and backwards. I don't think you know what RTI is and what MTSS is like. The RTI model came about, I think, in response to individuals with disabilities, act that said that children needed to be identified and that, as you know, whatever level of of help they needed there used there needed to be some kind of a universal screening early on to determine if a child needed help or not, and then it divided those children who ended up not needing help, and filtering out the children who needed a little more help into more a targeted approach in groups, and then those children that still weren't making progress would get help at the third tier, which would be more individualized help and instruction and may end up in a special education referral. But it's that's the RTI process. And and the RTI process is that came earlier than the multi tiered systems of of approach, because the RTI process itself started out to be more academically focused, to see if children were making progress in reading and math curriculum and and then we're tested every six weeks to see if they were making progress, and if the progress wasn't happening, switch gears and try to teach the child in it in a different way. So it was more academically focused, although it was still in those early days, taking it into consideration the behavioral component and the self regulation and the ability to be ready to learn. But that was more informal. And then when MTS, the multi tiered systems of approach, became more popular. You know, five or more years later, RTI became a component of that, and the multi tiered systems of support embraced, not only that, but really looked at behavioral components and social emotional components as as well the regulatory things that that get a child ready to learn.
Jayson Davies
Yeah.
Julie Bissell
So did I answer your question?
Jayson Davies
Absolutely, I mean, I'm going to go a little bit further. I because, first of all, I typically use the term RTI, RTI when I probably should use MTSS, because, like what you said, RTI is kind of a component of MTSS these days. I use them interchangeably sometimes, but I understand, yes, MTSS includes that behavioral, social, emotional, even mental health aspect a little bit which, as we know, is so important, and there's a lot of funding right now also going for mental health. So it's important to include that. I didn't realize, though, that MTSS came a little bit later than RTI, but yeah, okay, now everyone breaks down those three tiers of RTI a little bit differently. I know this can depend on what district you're in, what school you're in, what state you're in, per se, if you could Starting with Tier One, what are some examples that you would consider tier one interventions, and maybe a few that you've even been a part of yourself?
Julie Bissell
Okay, sure, I have a couple of good examples. One is in tier one. It's addressing the whole population, everyone and all the classrooms, all the teachers, general ed. And one example is staff development. So we've been involved in a lot of teacher training regarding how to have a comfortable classroom, to look at the ergonomics of the desk in the chair, to make sure there are some sensory tools that children are getting enough sensory breaks just to make the learning and. Environment comfortable so a child can be ready to learn. And so many times I'll go into a classroom and there will be a desk that is up to the child's neck, and the feet are dangling on the floor, and the teachers are reporting that the children are squirmy. They can't sit still. They're sitting on their feet. And I I said, Well, how would you like to sit in a bar stool all day, you know, that not and have the table up to your neck, you know? And so when I showed them a few things about how to make sure a child's comfortable during the day, and then, you know, we've had a lot of ideas about alternates, you know, sitting to go sit on a bean bag chair during the reading time and things like that. So just that, the staff development was a big one. And then one year, I had a really fun project in a kindergarten class, and it was a universal screening of all the kindergarteners, and we did a mini version of the print tool, where we had them write the letters of the alphabet. And this was, I think, in January of the kindergarten year. So they had had, it wasn't just kindergarteners coming in that that had not had any experience with writing. This was January of the of the kindergarten year, and there were some children that could write the whole alphabet, and there were some children that couldn't. And so we had after this screening, we grouped the children into targeted groups for those that that needed more specific help, and then we also got permission from the administration to send, luckily, Handwriting Without Tears was presenting in our area, so we sent the kindergarten teachers to that specific training, and we had the targeted groups on the Handwriting Without Tears program for six weeks, strategically Teaching them handwriting. And then from that group emerged only, like three or four students that really needed specialized help, because even with the targeted teaching in small groups, they still weren't getting it. And so that we knew these children needed more targeted help. So it was kind of a universal screening that kind of drilled down to the tier three.
Jayson Davies
Yeah, yeah. And actually, you know, you didn't use the words as you were talking about it, but you just shared tier one, tier two and tier three. And that that short story, right? Because, so let's just break it down really quick, you know, expand it out. Tier one was you doing the screening. It was also the teachers going and getting that that specialized training from Handwriting Without Tears. You know, personal development is also tier one. In my opinion. Even though they didn't send the whole school, those teachers were still improving their education so that that goes back to the, I think they call it first best instruction, right, making sure that everyone has first best instruction methods, okay, so that's tier one, and then from that screening, that tier one screening, you moved to tier two, which brought out some of the kids that needed a little bit more instruction, right? And so what did that look like? Was that you working with a teacher? Was that just them coming to you? What did that look like?
Julie Bissell
No, it was I went in once a once a week for the the core lesson, following the protocol from Handwriting Without Tears, and then they followed up the other days of the week. So I would go in and demonstrate using multiple means of action and expression. We were using the the chalk and the wet towels and the Play Doh and the magnets, and we were using the whole instructional protocol, and we were doing it in the order in which the handwriting and without tears specified. And then I would demonstrate, and then they would continue with those letters that week, and then next week, I'd bring in the next letters and and use the protocol that handwriting with OTs had. And then, you know, that's another important, very important, component of the RTI process is whether it's a teacher or an occupational therapist, when you are giving instruction or intervention, you need to use the fidelity to the treatment that you are implementing or to the instructional method. So So, for example, since I chose Handwriting Without peers, I wasn't hop, skipping and jumping to my own creative or I think I'll try this and I'll throw in this letter, or I'm going to throw in this or that or the other. It's like I use their protocol, and the only way we're going to know how to help students is by keeping fidelity to the program that you're testing out with them. For example, the teacher. Teachers learned a lot during the RTI process because they were doing that piecemeal language teaching. And so some children are auditory learners, some are visual learners. And if a child after six weeks is not getting your instruction, you couldn't tease out which part of it, if you just used a hodge podge. So what you needed to do is I'm going to do this particular program to the fidelity of the program, and then if this is not going to work, I'm going to switch to a different channel, like the auditory channel versus the visual channel. But if this concept of fidelity to the treatment or the intervention is such an important concept and and I use the fidelity to Handwriting Without Tears. So I would go in once a week, and then they would have small group instruction with the instructional assistant at one table, and the teacher was at another table, and I was at an at another table with the small group instruction.
Jayson Davies
Gotcha so. So you weren't going in for the entire classroom. You were just going in for that small group. Yes, okay, and you were following the fidelity of the handwriting without tears. Model. I want to pull that out a little bit, because that is something that I have never had someone talk about on this podcast before, 100 and whatever episodes in, and I don't think we've ever talked about following something to the fidelity, you know, following a program, whether it's size matters, whether it's Handwriting Without Tears, or some other program, following it to to the T I think when we see a student individually, you know, we really rely on our personal evaluation, and we have that leeway to mix things up a little bit, maybe not follow a program to the T but I'm understanding what you're saying. As far as when you are doing RTI, that's more important, maybe because you haven't done like a formal evaluation, and because, like you said, you want to be able to determine, you know, if the student is not making progress, where was the disconnect, per se, did what I say sound accurate, or was there anything that?
Julie Bissell
It sounds accurate, and I think I know where you're going with this is that, of course, occupational therapist is dependent upon for that professional leeway, because when you see a child struggling, you have to try, you know, this, that and the other. But what I meant by the fidelity, say, like using handwriting without tears as an example, is that, you know, the first letters that you teach are the the letters that started the, you know, the top left, the D, the E, that.
Jayson Davies
straight lines, nice, easy lines to make, and so.
Julie Bissell
What I meant was that I I used that sequence as they recommend, and I didn't jump like, oh, well, let's try the the F. Now let's do an S, or let's do us a lower case, or let's do like, I stuck with the letters that they recommended in that motor planning, easy to more complex strategy that they have set out for the success of their program and so, so you can stay with the fidelity, but make those modifications as as you need, like, pull in some, you know, different things that along the way. So, you know, because I could have used, I could have used those same letters and used finger paint, or I could have used which, you know, is not really sold by Handwriting Without Tears, but I could have used finger paint or a salt tray, or I could have used a, you know, a bunch of different things, but I would stick with those letters as they have different letters of of the week and a progression.
Jayson Davies
Yeah, and you're still using the multi sensory approach, Which is important within, within handwriting, thought, tears, using the different senses, not just strictly look at a board, watch what I write, copy it. You know, you're including that finger painter that Play Doh, or whatever it might be, the little wet sponge, yeah. So, okay, great. Well, thank you for for going a little bit further on that. And then so we talked about tier one, we talked about tier two and the next step, you said there's, you know, just a handful four kids, maybe that needed even more, and that's tier three. I know some people consider tier three being a ot evaluation, and going from there, others consider tier two, tier three a little bit different. In your practice, what has tier three looked like?
Julie Bissell
Tier three has looked like strategic support for the teacher, if the child has not been identified as a child that OT is permission to assess, because we were very careful not to assess without permission or screen. But what I had the teachers do is have them, for example, have the child draw the shapes that you would see in the VMI, the visual test of the very visual motor. Test, test of freedom, motor innovation.
Jayson Davies
I know, again, with the with the evaluations, I can never remember what they're all called, but we know that one.
Julie Bissell
The formal, the formal title of of that one, which I use all the time, but, but you can have the teacher, have the child draw the shapes. And from that, you can tell that developmentally, based on the shapes that this child can and can't draw, that they're probably functioning at the two to three year level, and somehow they're in kindergarten, and it's never been picked up before that the child has that that developmental delay. So the tier three would look more like an informal screening with no name on it. It would be more of a of helping the teacher help identify and then go to the school psychologist and try to go through the proper channels of the system to get to get the assessment.
Jayson Davies
So potentially leading helping the teacher to make that referral. Per se. You know, because you went through tier two, you saw that developmental delay while you were trying to work on, you know, the easy, tall, straight line letters, you saw some difficulties. So then you work with the teacher, potentially to go to the psych, make that official evaluation so that ot services can potentially begin. Does that sound about right?
Julie Bissell
Yes, exactly. And what the beauty of this process was, is that when the teacher went to the psychologist, she had more to say than I think this child has problems. We had a lot of data on the child. We had that first screening I did with everyone that the child just made squiggles, and then we said that we've had strategic teaching using valid and reliable program, yeah, and a six weeks program of that, and progress was not made. And here, here are the work samples. And now here are the shapes the child can, can't do in the psychologist could see right away that this is like, what a two or three year old does, you know? So that it really helped with a portfolio of referral data.
Jayson Davies
Yeah, yeah, absolutely. I think the same exact thing every now and then I would for tier three, I would be as I would be part of an SST or a step meeting for that child. So before they, I don't know, they're called different things in every school, but it was kind of a one step below an IEP. It was still a team meeting, but it wasn't, you know, an IEP. The student didn't have an identified disability per the school, but the teacher would be a part of it, maybe the administrator. And at step three, I may not work directly with the child. I may be working with them, you know, at tier two, but I can provide the teacher with some, I mean, pretty specific strategies I haven't evaluated the child, so I can't, like, you know, narrow it down completely, but strategies that I would try with anyone I can provide to the teacher to try with this child, and oftentimes I've already expressed that to the teacher, because, like you said, you know, during tier two, maybe the teacher sees what you do, or maybe after you do your small group, you have a debrief with the teacher, and you say, hey, you know what? You know, the kids did really well today when I use finger paint, or the kids did really well today when I use the wet, dry try and they'll maybe they carry that over. But yeah, I know tier three is always a little different depending on what district you're in. And yeah, it's a little messy sometimes, but yeah.
Julie Bissell
You just have to be careful with with identifying strategic activities individualized with the child's name on it. And I love what you said about that you find activities that would be important for that child, but that you could give to anyone, and it's wasn't like therapeutic treatment activity with a name on it.
Jayson Davies
Right? I think the best way I've described it is it's a general strategy for a specific student, because, you know, it's any It's a strategy that you would just use for any kid. I would use it for my child, but I'm providing it to the teacher to use specifically for that student. I guess.
Julie Bissell
That's good, right?
Jayson Davies
Yeah, all right, we kind of went into RTI MTSS, really hard. I love it. I love RTI and MTSS, and I want to dive in beyond the RTI and the MTSS. We just kind of actually scratched the surface with this a little bit with tier three potentially leading to a referral. Have, I mean, I've seen it. I'm sure you probably have the increase of referrals for occupational therapy. What have you seen over the years, and how do you think it has impacted ot at this point?
Julie Bissell
Well, that is, I think the number of referrals has accelerated over the years. I think we've we're getting more and more referrals out every year, and I think it's impacted occupational therapy in a way where. Yeah, I think, come to think of it, it kind of was one of the things that ignited my interest in advocacy for occupational therapists, to be able to have a voice at at higher levels of administration to help manage all this. Because, as you know, I've been involved with the Occupational Therapy Association of California and for the school credential initiative and based on occupational therapists and physical therapists not having a credential and not having access to leadership positions that deal with budgets and managing referrals. I think sometimes occupational therapy is left out of solutions to this problem based on a more systemic problem of not being at the bargaining table with the other administrators. So I think we're handed large caseload sometimes and handed referral processes that we could probably better manage if we had higher level leadership positions.
Jayson Davies
Yeah, I agree. I mean, at this point, if I'm getting flooded with referrals, the only thing that I can do is let an administrator know. I will often tell people, you know, if you don't tell an administrator, your boss, whoever might be, that you're drowning, then the burden is somewhat on you, and you're going to feel like I'm not doing enough. I can't stop because I need to do more. But if we let our administrators know that we are getting flooded, and we have the data to show our administrators that, you know, every year there's two more evaluations, or I'm averaging an extra three evaluations year after year after year, it's only growing. It's growing. It's growing. And you can show that to your administrator, then it's somewhat on them to help fix the problem. You're taking the burden a little bit off yourself. That is part of their responsibility is to figure out staffing, to figure out workloads and case loads. And I think sometimes we let we we kind of put the burden on on ourselves, and you know, we need to do something about it. But, you know, unless we can get to that administrative level, or unless we can convince our administrators to change something, then our hands are a little tight. I mean, let's just be honest, we don't have the ability necessarily to say caseload cap of 45 or workload cap of 20 hours per week, or whatever it might be, of treatment. So yeah, I think that's important. And as you know, I'm working on the on the credential with you as well, trying to get California to figure that out so that we could potentially have more of a say within within the school district.
Julie Bissell
Yeah, one thing about referrals in in our district, what we have done is to limit the access to who can refer to. Ot so if you look at the educational or the organizational structure of a school, you know you've got the administrators, and then you've got this school psychologist, and then you have the speech therapist, OTs, PTs, and then in also you've got the the teachers, etc, if a teacher is able to refer to occupational therapy, you have the potential to have hundreds more referrals than you would if you limited the referral process to the school psychologist. So what our teachers have to go through the school psychologist to get access to us. They can't just say, oh, somebody in my classroom is having a problem. They're walking on tiptoes, or their feet are turning in or, can you come take a look? Because that just, you know, drains the flow of our of our workday. But if that, but the child could be doing very well on the participation scale. Like, everything's fine. They just their feet are turning in or something like that. But if, if a teacher, there's hundreds of teachers, and there's probably, like, 20 or 30 psychologists, say, or whatever, a lot less, a whole lot less psychologist than you have teachers. So yeah, so if the teachers have to go to their psychologist who already screens for a special ed need? They had the whole picture of what's happening with all aspects of the child's education, and they will know when is a good referral for OT and PT. So that that really kept a lid on ot referrals at a time when we were just being caught in the hallway, you know, from a teacher, a principal, like just, I don't know, we were way too accessible, so we, we narrowed it down that way that helped.
Jayson Davies
That's one way to do it. Also, I think RTI. I think RTI and MTSS also helps because, you know, I had a conversation with Sarah Leon or Lyon. She has another podcast. Cast ot potential podcast, and I was on her podcast recently, and one term that came up, or a little analogy you could call it, is, you know, you can go upstream to prevent those downstream evaluations. And that's exactly what RTI is. You know, you're going putting it right. You're going upstream and you're taking time out of your day to go upstream, and it is going to take time out of your day. But how does that impact your downstream evaluations? You know, I would spend easily. I mean, over the course of the entire evaluation, I would say it takes up a full day, you know, between the IEP, you know, the talking to the parent everything, right? It takes up eight hours or so. But if you go upstream, you know, and maybe you take two hours a week to do some RTI, then can you prevent three evaluations, which equates 16 or 24 hours? So yeah, I think that was a great analogy to kind of put it up going upstream to prevent some of those downstream evaluations.
Julie Bissell
Love that idea. Love it.
Jayson Davies
Yeah. All right, so let's go ahead. We'll wrap up the article. I still have a few more questions for you, and I know there's so much more in this article, so please, please, if you're listening, go read the article. We're not going to get to everything, but we're hitting some of those main points. And Julie, I want to ask you one last question really related to the article is what stood out the most to you when working on this article? I know you had been a school based ot for a long time, but was there something that really like just hit hard as you wrote this article?
Julie Bissell
I think what my take home from the article was that that ot matters in school based practice, and that that the emphasis of using those models and and frameworks really helps in an organized way to help a child and to target a child. So each, each one of those frameworks and models really served as a as a roadmap for not only addressing the needs of the child, but but helping to explain what we do in a either theoretical or, I don't know, research backed way of of the value that we bring to the student, and it just gave, I don't know, comfort to my practice to have it all in one place and to really reflect on different conversations I've had with administrators or parents or attorneys or what have you that these models and frameworks that have been developed over the years in the United States have really been useful in doing, explaining and delivering what we need to do for children.
Jayson Davies
Yeah, yeah, you know, and models and frameworks, they're they're so helpful. I think as OTs, we often forget to go back and look at them. You know, we went to OT school. We know everything, right? But no, that's not the case. We have to remember to go back and look at whether they're old models that we haven't looked at in a long time, or things that are evolving. And if we don't go back and look at the research, we don't see that stuff, all those models, those frameworks that you know people have taken time and actually put evidence into to develop. We don't know they exist, and we don't know that they can be helpful, not only in our own practice, but also explaining to other people our practice and what we can and also, I like to say we have to know what we can do as well as what we can't do. But those models and frameworks can be so helpful in explaining what we do to some of the people that can help us make decisions. And so understanding those models is is very important, and we need to, we need to go back and look at them every once in a while to confirm that we're, we're staying on the right direction. So yeah.
Julie Bissell
And what, what I loved, too, is that that World Health Organization model and, and how random was that the Israeli occupational therapy world was interested in United States, school based, based practice and, and how unifying that model is, and how nice it is to look at a person with a disability, whether it's an adult, a young adult, or a child in school, as a human being that is valued and is looking to participate in in daily Life. And it's it's a universal language across the world. So it's, that was a fun thing to reflect on, I think, as well.
Jayson Davies
Yeah, absolutely. Now I have one last question to follow up. Not to follow up, really, actually, a whole new question. The article was published about seven years ago, personally, as we've had a discussion today. I don't think too much has changed since 2015 when this published was published. I know RTI and MTSS are definitely more ingrained than they were seven years ago. And it's it's more common, right? Someone you say RTI, they typically know what you mean now versus in 2015 that wasn't necessarily the case. I don't think where do you see school based ot going beyond 2022 and and, I mean, what do you anticipate? Do you think there's going to be changes? Do you think we're on a on a straightforward trajectory, or do you see something changing?
Julie Bissell
I think the future is bright for occupational therapists going into school based practice, because over the years, there have been some rough patches. You know, we talked earlier about some of the more litigious years, or the new quest for data driven services and all that. But I think that as time goes on, it's easier and easier to have more efficient, comprehensive, easy to implement assessments. I think it's easier to have the data driven services with some of the new assessments that are, that are coming out. And I think that, well, like One example is the easy the the air sensory integration test, and the PD cat, yeah, these are, these will all be computer assisted technology that will, it won't be these long, you know, two hour tests. It'll be tests that are computer assisted with artificial intelligence that you can be giving a test and find out the key factors that that describe the child. And you can, you know, stop testing after a few items, versus, like, 20 items or something. But I so I think assessments going to get easier and more comprehensive and and give us more to go on to more specifically help children. And I think that it will reduce the burden of us, of our some of the guesswork that goes into our clinical reasoning. It'll will have better tools, and I think, more, hopefully, more time to play. I think that the more efficient you can be with your collecting of the data, the more time you have with the child on the playground or in the therapy room or in the, I don't know, cafeteria area, wherever you're you're able to to play. So I think there'll be more time for play easier assessments. And I think that around the corner, occupational therapists across the United States will have the professional equity of of a credential. So we'll be at the decision making tables that will open up increased access for children to have more occupational therapy and for OTs to have more reasonable caseloads and workloads and things like that. I think the future is bright, but it does take a lot of work. There's a lot of research that goes into some of these assessments and and a lot of volunteer work that goes into getting.
Jayson Davies
White papers and attendings California Department of Education meetings and, yeah, all that good stuff. Yeah,
Julie Bissell
it takes work, and I encourage people to, you know, step up to the plate, because it's a nice thing to do, and it's, it's easy once you get involved. But I think the future is bright, and I think there will be more time to play and and less worry about I don't know, all the extra work.
Jayson Davies
The extra stuff, yep, yep, great. Well, Julie, thank you so much for coming on and again. Congratulations on your retirement, I know you have several grandkids that you get to spend all your time with now, right. Rolly, quickly though, I do want to give you the opportunity. If there is anyone listening in out there and they're just, you know, thinking, hey, I have one question that I would love to ask Julie. Is there somewhere that they can find you? Maybe on LinkedIn or something like that.
Julie Bissell
Um, I have retired, you know, no, I love to be available, but I'm not sure how. Maybe they could email you, or I'll think about it, and then we'll put a link on the links.
Jayson Davies
Sounds good. Well, thank you so much for for being here. Thank you for just opening up a little bit about your your career as an occupational therapist, and also sharing a little bit about your work. This is only one of the several articles that you have helped to get published. I know you have been very busy within the SI field. You've written several articles, or CO written several articles within that and so thank you so much for your contribution to to occupational therapy in general, especially here in California too. I know you've been on the board that has worked on credentialing and making sure that OTs are advancing within schools. So thank you one more time again. And yeah, I appreciate you for being here. Thank you so much.
Julie Bissell
Well, thank you and thank. You for all you do. I just love ot school house and your podcast and your easy communication and bringing us all the resources that you so readily share. So thank you so much.
Jayson Davies
All right, and that is going to wrap up Episode 108 of the OT school house podcast. Thank you so much for being here. Don't forget to earn your professional development for listening to this podcast over at ot schoolhouse.com/episode, 108 there are also a ton of links over there. Julie gave me links to so much that she talked about today, including that PD cat assessment, as well as the Israeli handwriting assessment and the translated version. So go ahead check that out over at ot schoolhouse.com/episode, 108, thank you so much again, Julie for coming on and sharing your wealth of knowledge. Congratulations one more time on retiring from a very fulfilled career, and I hope you get to enjoy this next chapter in your life, spending time with your family, and especially those grandchildren that you have for everyone listening. Thank you again, so much for being here, especially for listening all the way to the end. I really do appreciate that. It means the world that you find value from second one to the final ending, not even a credit, but whatever. This is the end of the podcast, I appreciate you being here. Take care and we will see you in episode 109, have a good one. Bye.
Amazing Narrator
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