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I recently had a conversation about feeding goals on an IEP with a colleague, and it raised a question that comes up more often than many school-based OTs would like to admit: What are we actually being asked to do when feeding shows up in an IEP? The situation was complicated. This student was new to the OT, and they were unsure how to proceed with the feeding goals related to accepting new foods, oral-motor skills, and feeding strategies. There was also a history of outside therapy and professional language that sounded clinical. Together, we wondered: What assessment data supports these goals? How is the concern affecting the student's participation at school? What part of this belongs in school-based OT, and what part requires someone with more specialized training or a different role? So, after some research, I wanted to help my colleague and you. A student can absolutely have a feeding goal on their IEP. But that doesn't mean they should have one. If you have ever been in a meeting where someone turns to you and asks, "Can OT help with feeding?" you have probably felt the unmistakable tension that follows. You want to support the student in front of you, but you also know the cafeteria is not an outpatient feeding clinic, and you may not have advanced training in feeding or swallowing. So, what do you do? Let's talk about what we can support, how to think through feeding goals on an IEP, where the boundaries are, and how to explain all of that clearly to your team. Why feeding concerns belong in school conversations I'm reminded every morning as I pack kids' snacks that lunch and snack are part of the school day. If a student cannot safely, efficiently, or comfortably participate in those routines, the impact can spill into regulation, energy, attention, peer interaction, and learning for the rest of the afternoon. That makes feeding-related concerns 100% relevant in school. However, it does not automatically mean that all feeding concerns need to be turned into IEP goals. It also does not mean that you must be the person to address every lunch problem The entire IEP team is responsible for taking the issue seriously when it affects educational access or participation. Of the included team members, teachers, administrators, and parents are not feeding specialists. So it often comes down to OTs and SLPs to address feeding concerns. ASHA has a page dedicated to explaining how SLPs support pediatric Swallowing and Feeding concerns. It even has a full section on school-based SLP and how the SLP can lead the team on these matters. AOTA Plus and Premium members can access a School Mealtimes to Enhance Participation book chapter and CE for free. That Chapter ends with the following statement in the summary: "Interventions provide strategies as well as food and equipment, modifications, adaptive equipment, environmental adaptations for safe eating and drinking habits, and education or training for families and others." In addition, a 2025 AJOT scoping review on oral feeding management in school settings found that school-based OT has a real role, especially through collaboration, assessment, environmental support, and policy development, but it also noted that evidence and training are still limited. In other words, this is an important area of practice, but not one where we should pretend every OTP is automatically a feeding specialist. If your state has Guidelines for school-based OT, I would also check them to see what they say about your role in supporting school mealtimes. If your state has guidelines, you can find them here. Get your free copy of our Feeding Reference Handout to help guide you when a feeding concern arises mid-IEP. Work emails often filter out our messages. To ensure you get your handout, please use your personal email address. What the J.Z. case suggests about school-based OT feeding services In addition to what AOTA, ASHA, and your state guidelines say, it's also important to look at the law and court cases that have resulted. IDEA says virtually nothing about supporting feeding. But there was a recent court case on this matter. In J.Z. v. New York City Department of Education (not THAT JZ 😅), a federal district court issued a preliminary injunction requiring the district to implement stay-put services for two students. For one student, the order included 1:1 occupational therapy and 1:1 feeding therapy five times per week. For the other, it included 1:1 feeding therapy twice per week. The court focused on the district's failure to provide services that had already been ordered through the special education process and on the immediate harm caused by continued non-implementation. That case is relevant to school-based OTs for two reasons. First, once a feeding or OT service is part of the IEP, a district cannot simply leave it unimplemented while it searches indefinitely for a provider or feels like it doesn't apply. Second, J.Z. should not be read to mean that IDEA automatically requires every district to provide intensive feeding therapy, or that every feeding goal must be delivered by an OT. The decision relied heavily on the existing orders and the district's failure to implement them. It did not create a universal rule that all food selectivity, oral-motor, or feeding goals belong to school-based OT. The practical takeaway is to separate two questions: What does this student need in order to receive FAPE and participate safely at school? What services has the team or hearing process already required the district to provide? If you inherit a feeding goal or service: Review the evaluation data, the current IEP, amendments, etc. Do not make the goal or service disappear as though it never existed. Provide the service to the best of your training and scope. If the service appears outside your training or scope, raise that concern promptly with your supervisor and the IEP team. Share the J.Z. court docs with your supervisor so they know why you are concerned. If applicable, discuss with the IEP team whether the goals are still needed, and offer to evaluate the student's need for support during meal times. Start with participation, not food variety Okay, now let's assume a feeding concern is arising for a student who does not already have feeding goals. When feeding comes up at school, the first question should be: What is getting in the way of this student's participation during lunch or snack at school? In a school setting, your goal is often to support the student in eating what they already can and will eat at school, as safely and successfully as possible, so they can access the rest of their day. Our goal should not be to increase diet variety, treat severe food selectivity, or run a full feeding protocol in a crowded cafeteria with limited time and limited control over the environment. That school-based lens also keeps the work grounded in what we already do well: Analyze routines Identify environmental barriers Support regulation Increase independence Collaborate with staff And connect intervention to meaningful participation. You don't need to attend an SOS training to do any of those! What to Assess When There Is a Feeding Concern When a student is not eating well at school, I would start with three broad areas: the environment, the routine and regulation demands, and access or independence barriers. 1. The environment Cafeterias are overwhelming. They are loud, bright, crowded, fast-moving, and full of smells, visual clutter, and unpredictable social demands. For some students, the problem is not the food itself. The problem is that the lunch setting is so overwhelming that eating becomes almost impossible. This is where a school-based OT lens is especially useful. Ask: Is the student overwhelmed by noise, smell, lighting, or crowding? Is the line too long or too chaotic? Is the seating arrangement making the student feel trapped, distracted, or dysregulated? Is there a quieter alternative that still preserves dignity and appropriate social access? Usually, a cafeteria walkthrough and observation will tell you more than any IEP conversation. The environment may be the biggest barrier. 2. The routine and regulation demands A dysregulated nervous system does not make lunch easy. If the student arrives to lunch already overwhelmed from transitions, classroom stress, sensory overload, or social anxiety, then they may not be ready to eat - even if they are hungry. By the time the tray is in front of them, they may already be in survival mode. That means your OT questions might be: What happens right before lunch? Does the student need more transition support? Are there predictable patterns of overwhelm? Would a visual lunch routine, preview, or calmer entry help? Is the issue starting during lunch, or before the student ever gets there? This is also where you want to avoid overcomplicating things. A single calm and repeatable routine that helps the student settle enough to begin eating can be enough to promote lunchtime participation. 3. Access and independence Can the student open containers? Manage wrappers? Use utensils? Carry a tray? Reach food comfortably? Sit in a position that supports eating? Finish in the time they are given? Clean up independently enough to stay with peers? We often look at similar types of skills in the classroom, so why not in the cafeteria? These are functional school-day tasks, and supporting them is very much within the school-based OT wheelhouse. Sometimes the issue that looks like "feeding" is actually: Poor seating fit Limited hand strength for packages A tray setup that is too hard to manage Pacing that does not match the student's motor or regulation needs Too little time to complete lunch Or a lunch sequence that changes faster than the student can process it. That does not make the concern less important. It just makes it more workable. Get your free copy of our Feeding Reference Handout to help guide you when a feeding concern arises mid-IEP. Work emails often filter out our messages. To ensure you get your handout, please use your personal email address. What intervention can look like in practice? Once you identify the barrier, choose one reasonable participation-focused support and trial it with the team. That might look like: adjusting where the student sits to reduce traffic, noise, or strong smells trialing a quieter lunch location temporarily while preserving peer contact when possible using adapted containers, utensils, or tray supports building a visual lunch routine so the student knows what to expect giving a short transition support before entering the cafeteria allowing a little more time to eat when scheduling makes that possible; coaching adults to reduce pressure and focus on calm, safe eating documenting which environmental factors help and which make lunch harder. This is also where collaboration matters. School-based OT rarely "fixes" lunch by dropping in once a week and hoping for the best. Lunch support works better when you collaborate with the teacher, SLP, paraprofessional, food service staff, family, and maybe even the nurse. Research on OT-led mealtime supports in school settings points in that direction too. The Comfortable Cafeteria program, for example, showed promising outcomes when occupational therapists worked to build staff capacity and improve student participation and enjoyment during school mealtimes. That's a helpful reminder that sometimes the most meaningful OT contribution is not intensive one-to-one treatment. It is improving the environment and the adults' response to it. Know the lines you should not cross This part matters, especially when a feeding goal is already on the IEP, and the team assumes that you should be the one to provide the service. If a student has signs that suggest swallowing problems, frequent choking, suspected aspiration, recent aspiration pneumonia, significant weight or hydration concerns, major medical instability, or a need for formal meal modifications, that moves beyond a simple school participation conversation. These should be red flags for you to ask for help. Professional guidance from ASHA's pediatric feeding and swallowing shared above makes that team approach clear. In school settings, feeding and swallowing support may involve SLPs, OTs, PTs, nurses, physicians, dietitians, and families, depending on the concern. If the concern is primarily about food variety, oral-motor treatment, or a specialized feeding protocol, pause before translating the request directly into school OT minutes. Ask yourself and the team what the student needs in order to participate at school, what expertise is required, and whether the school team has the information and training needed to proceed safely. Sometimes the appropriate OT contribution is environmental support, positioning, access, or collaboration. And other times, the next step is a referral, updated evaluation, or coordinated plan with an outside provider. Your district may not know what you're trained in or what your state's practice act says you can and can't do. So, you may need to be prepared to inform them. So if you are asking yourself: "Is this a swallowing safety issue?" "Does this student need medical nutrition or meal modification guidance?" "Am I being asked to treat food variety in a way that exceeds my training?" That is your cue to pause and collaborate rather than improvise. School-based OT can still support participation during lunch. But participation support is not the same thing as independently managing medically complex feeding concerns. A simple script for IEP and 504 teams Sometimes the hardest part is knowing what to say in the moment. If feeding concerns come up in a meeting, you can use language like this: At school, our goal is participation and access during lunch. Together, we can problem-solve the environment, routine, and accommodations so [student] can eat what they are already able to eat here as safely and successfully as possible. That script works because it does three things at once: it acknowledges the concern; it gives the team a path forward; and it keeps the conversation grounded in school-based participation. It also helps prevent overpromising and sounding like you are refusing support altogether. Neither of which helps the student. Wrap Up Let's put a neat little bow on the 3 questions that likely had you reading this article. Can you provide support for feeding goals in school-based OT? Yes, as long as you follow your state practice act and guidelines and work within your means (e.g., whether or not you have specialty training), you can support both basic and complex feeding needs as a school-based OT. Should you provide support for feeding goals in school-based OT? It's amazing how one word in a question can change the entire answer. I have been, and would be, cautious about evaluating and intervening with more complex feeding needs. I would work with the team to suggest and provide accommodations. I would share my limited training in this area with the team and let my boss know my limitations under my state practice act. I would encourage school-based OT supports to focus on routines that can only be addressed at school. How would you address feeding goals on an IEP new to you? I laid that out above, but to reiterate, I would provide services the best I legally could, and I would ask a lot of questions about whether this is a necessary IEP goal. I would also try to evaluate the concerns with feeding participation. I hope this article helps. Please remember that while I do conduct research and look up case law for these articles, I am not a lawyer and I do not hold any advanced certifications in feeding. Do your own due diligence before acting on anything I have noted here. Thanks for reading and thanks for putting in the work and effort to support your students! Resources & References Accommodating Disabilities in the School Meal Programs: Guidance and Q&As Let’s Talk Lunch: School Occupational Therapy and Speech Language Pathology Perspectives Oral Feeding Management in the School Setting: A Scoping Review The Comfortable Cafeteria Program for Promoting Student Participation and Enjoyment Pediatric Feeding and Swallowing J.Z. v. New York City Department of Education Recommended next OTS 201: School Lunch Struggles and Sensory Processing in School-Based OT Six Strategies for Impactful School-based OT Consults What Teachers and Admin Really Think About School-based OT (OTS 175)

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 209 of the OT Schoolhouse Podcast. What if the way we've been supporting autistic students is missing the mark? In this groundbreaking episode, Jayson sits down with Kieran Rose—autistic advocate, researcher, and author—to tackle the tough questions school-based OT practitioners submitted about autism, masking, stimming, and neurodiversity-affirming practice. Kieran challenges core assumptions about behavioral interventions, handwriting goals, conformity in classrooms, and what "support" really means for autistic students. You'll hear why masking isn't just "acting neurotypical for a bit," how monotropic attention changes everything about learning, and why occupational therapy is uniquely positioned as the most important profession for autistic people—if we return to our justice roots. Jayson and Kieran also discuss the moral injury many school-based OTs feel when trapped between what they know students need and what the system allows, the problem with ABA's grip on schools, and practical ways to create "islands of safety" even within flawed systems. This episode tackles the hard questions. Kieran doesn't offer quick fixes — but does offer frameworks, permission to rethink your goals, and the reminder that holding space for one hour a week might save a life. Listen if: You've ever felt trapped between what a student needs and what the system demands. Listen now to learn the following objectives: Learners will understand the difference between impression management (context switching) and masking, and describe its impact on autistic students' long-term mental and physical health outcomes.
Learners will understand how masking can impact autistic students' long-term mental and physical health outcomes.
Learners will understand the concept of monotropism and how deep, focused attention can make frequent school transitions difficult for autistic students.
Learners will identify common school-based demands that may unintentionally prioritize conformity over meaningful participation, such as forced eye contact, suppressing stimming, sitting still, or handwriting expectations. Guest Bio
Kieran Rose is a published mainstream and academic author, international public speaker, trainer, researcher and consultant to organizations all over the world with a specialism in Autistic Masking, Autistic Burnout and Autistic Identity. He was diagnosed Autistic in 2003 and is a dad to three autistic children. Quotes “They’ve got to feel safe at school before they’ll learn at school.”
— Jayson Davies
"Occupational therapy is the most important profession in terms of any professional that can engage with an autistic person."
— Kieran Rose
"You might have a child that you work with just for an hour a week, but the impact that you have on them is felt across their whole life."
— Kieran Rose
"Sometimes we can change our language and still not change our understanding. It can be quite performative often."
— Kieran Rose
"If you, as an occupational therapist, have drifted from your justice framework, you need to drift back again. It's really important that you do."
— Kieran Rose Resources 👉The Autistic Advocate (Kieran Rose's website) — Training, blogs, free resources, and consultation on autism, masking, and neurodiversity-affirming practice
👉Autistic Advocate 👉Autism: A Collection of Essays
👉Autistic Masking: Understanding Identity Management and the Role of Stigma
👉Inside of Autism training
👉Star Institute 👉Monotropism animation 👉Double Empathy Problem animation 👉Masking animation 👉Virginia Spielman, Star Institute

Episode Transcript
Expand to view episode transcript Jayson Davies Hello and welcome back to the OT Schoolhouse podcast. I'm your host Jayson Davies, and I'm going to be very upfront with you right now. This is one of those episodes where I had to check my own comfort level at the door before hitting record, but I'm really glad I did, and I hope maybe you will if you feel the need to, because sometimes a little bit of discomfort can really lead to a lot of personal growth. When I went to OT school, I was taught one way of thinking about autism, and over the last decade, so much of that has been turned on its head. Because for the first 50, or really a lot more than that, 50 plus years of autism research, the people who actually live with it weren't part of the conversation, but now that's changing. And sitting with that change, really sitting with it, has been uncomfortable for me at times, and I'm sure it has with maybe you. Even something as simple as shifting from using person-first language to confidently using identity-first language can be really difficult. That's why today's guest is Kieran Rose, aka the Autistic Advocate. Kieran is an autistic author, researcher, and educator based in Newcastle, England. He's on faculty at the Starr Institute. He's written extensively on autistic masking, and he's spent years training practitioners around the world on what it genuinely looks like to support autistic people. What makes this episode really special and really unique is that we've built it around your questions-the ones that you sent in several weeks ago, the same exact ones that you probably have after a tough IEP meeting, or maybe on the way home after a long day at work, and even the ones that you might be a little afraid to ask out loud. Now you're about to hear me ask Kieran about masking, stimming, transitions, handwriting. Yes, even handwriting, diagnostic rates, ABA, and even the moral injury that we could tell from your questions that so many of you are feeling when trying to practice in a way that actually aligns with your values inside a system that sometimes doesn't always make that easy. Kieran doesn't offer easy answers, but he does offer a framework that I think every school-based OT practitioner needs to hear, and I'm really excited to get this episode started, so that you can hear that, this is episode 209 of the OT Schoolhouse podcast. Let's get into it. Amazing Narrator Hello, and welcome to the OT Schoolhouse 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 Kieran, welcome to the OT Schoolhouse podcast. It is a pleasure to have you. This is one that I've been excited for, and I'm really happy to have you here. So thank you so much for being here. Kieran Rose It's a pleasure, Jayson. I'm delighted to be here. I've been looking for. We've been talking for months, haven't we? So I've been looking forward, really looking forward to this, Jayson Davies yeah. And this is a special one. We actually reached out to our community through the podcast, through our email list, through social media, because we wanted to have listener questions. And this is something that you and I talked about, and I think we're both excited for this because there's a lot of different ideas out there, and and we're going to talk about them today. So it'll be a good one. Kieran Rose It will. Jayson Davies Yeah, and one other thing that I kind of want to just right off the bat say is that as I was looking at your website, I was looking at your trainings, and something came across, and I'm excited for it because you specifically said in there that anyone you work with should expect to be challenged, should expect to you know have all their thinking challenged when it comes to autism, and again, what better medium than a podcast to do just that? So. Kieran Rose Exactly. Jayson Davies You ready? Kieran Rose I absolutely am. Jayson Davies All right. So rather than asking you to introduce yourself here, I want to instead ask you what you are most excited about right now, professionally, both in your you know research and your advocacy, and why it is that you're so excited about that right now. Kieran Rose Wow, that's a huge question. You've caught me off the hop there. The thing that I'm probably most excited about right now, and it's the thing that I've been excited about actually for a while, so it's a kind of an evolving thing, is the direction of travel that we are going in, in terms of research, because it's kind of we've gone back to being like the wild west in terms of all of lots of the things-not all of the things, but lots of the things that we thought we understood well-are now being directly challenged and kind of pulled apart and put back together again, and that's a really exciting time because I think obviously there's a there's a certain group of people who've been missing from the autism research narrative that will be autistic people, you know. And now autistic people are firmly embedded in that narrative, and we're getting all sorts of exciting concepts and new ideas and. New understandings, and and I think that's that's I'm really excited about where that goes. There's there's lots of things that are still wrong, obviously, but that little pocket of change, and I think we're already reaping the rewards from that. The kind of the reframing and the the the kind of new understandings around kind of attention and behavior and and motivations and and all of those kind of things, like sensory things, and how our bodies are working, like all the stuff that OTs love, like that's really at the heart of all this change as well. And I think that's just-it's such a fascinating and exciting place to be. So, so yeah, that's the that's the really big thing that I'm I'm excited about. Jayson Davies Perfect. And to kind of a follow up on that, you know, when I was in OT school, you know, 1012, years ago, person first language, you know, was the the like gold standard. Kieran Rose Yeah, Jayson Davies and now we are using more of that autistic language. Is that something that actually kind of came out of this new research that included autistic people, or did that come a little bit before, Kieran Rose I think that's been that's been there for quite a while. The autistic community that I think there's been about a shift over about the kind of kind of 25 last 2530 years, and then as we have discovered more and more autistic people, and or recognize more and more autistic people, I should say that then the narratives around that have become bigger, and the the momentum has grown around that. And I think it's it's always it's it's such a fascinating thing because I've done a few research papers on like the language that we use around autistic people and neurodivergence, and and there's still disagreements. There's still about how people personally like to kind of refer to themselves and be referred to, but the overwhelming majority, time and time again, we're talking about like 75% of all research samples lean towards identity-first language, and I think I think that shows the shift how we're shifting from this kind of medicalized behaviorist place into this more identity framed and recognition actually that that there is a valid experience going on here that doesn't necessarily need to be intervened with or changed, or you know, doesn't mean that people don't need support. But changing people fundamentally can be problematic, and I think the language is a driver for that. So I think it's really again, it's one of those exciting places to be where those changes are happening, which can also be scary for people who have been using certain terminology for a very very long time, and now feel like they're tripping over themselves all the time, probably, and it's hard. Jayson Davies Happens to me. Yeah, yeah, it will. And you know, there there's also been times, and you know, as professionals, these are things that we think about, right? We think about how we address people, but then we sit in IEP meetings or parent meetings, and you know, they have they don't look up autistic research, autism like research on these things, right? And so when we sit in these meetings, you know sometimes they are using a particular type of language that you might not want to use, and I feel like this comes up in the sense of like, how do you address that? Is it something that we should educate parents on. Oh, I think you should actually call your child autistic as opposed to a child with autism. Or do we just let it slide? Or do we just like? Is it even is it something we should be addressing? Kieran Rose I think it's something you should be thinking about very very strongly. Whether you actually do the addressing or not obviously depends on the context and the situation because some parents just aren't in a space to even hear that because they're they may be struggling immensely or you know they may be going through that that I hate to call it a grieving process but there is a grieving process often that parents are set up to grieve I think we have a question on that maybe later don't we around that kind of that kind of the feelings that this kind of all invokes and the stigma that's related to it but yeah, I think it's a it's a very contextual place. Psychoeducation is always important, and often the language that we use can be an indicator of our understanding or our lack of understanding of a certain thing, or at least the lack of nuance around that thing. So, so I think if the timing feels right to be able to step in and say, I've just noted that the language that you're using. Like, like, could we talk about that for a second and think about what that means? And because at the end of the day, if we're talking to parents, parents only adopt the language that they're given, and they are given that by professionals and academics. And and and, but that language is changing, and it is changing. But it takes a long time for that change to get into culture and to get into society, and and you know, so so it's I think the only thing we have to be cautious with with the language change is sometimes we can change our language and still not change our understanding. It can be quite performative often, so so just just kind of recognizing that as well. There there's so much depth and richness to all of this, and sometimes we're pushed down very very superficial and fast routes where we just take quick decisions, or or we learn something very quickly and think we have a grasp of it, and actually we might not really have a grasp of it. Just using the language isn't always enough. So, so yeah, so it's that within itself. That's a podcast within itself. Having a conversation about that, isn't it? Jayson Davies I'm sure we'll have many of those moments today, and. But but you made you make a really good point. Like a parent who is sitting across the table from us and calls their child either autistic or my child with autism is only saying that because that's what they've heard the doctors say and that's what they've heard the neuro you know the neurologist say or or whatever that is. So that's a really good point. You're right. Like even if we don't you know, address the issue in the moment, just by using that language, we're in a way letting the parent know, like, hey, it it's okay to use that language. Yeah, this is the the language that we use. So. Kieran Rose and I always I always hold the kind of the thought that I'm someone who needs to model, and so the language that I use would be the language that I would like other people to use. That doesn't necessarily mean that they have to adopt it, but I will even if someone's in a space where they're talking about a child as a person with autism, I will still be using they are an autistic child. So it's it's kind of that as the conversations go on, sometimes the osmosis effect kind of works, and and people just pick up that new thing and just have a think, or sometimes they get curious and they ask questions about that as well. Like, why are you using different language to me? So it's it's that modeling is a is a really important thing as well. Jayson Davies Yeah, yeah, such an interesting topic. But again, let let's continue on. We had some questions that came in around masking, and they weren't like what is masking. So before we actually get into the questions, I do want to give you a moment because you have an entire book about this to discuss just a little bit about what masking is, what it looks like, and the impact that it can have on a child. Kieran Rose Yeah. So this is this is a huge topic. Obviously, like you said, I have I have a book on the entire subject on that book. That book wasn't long enough. So there is often a big misconception. There's lots of misconceptions around around masking, and firstly, like the usual kind of pushback that when when autistic people talk about masking or parents talk about their children masking is, well, everybody masks, and yes, everybody changes their behavior in small ways. Everybody does context switching. Everybody acts a little bit differently in certain situations around certain different groups of people, and that and that's that's that's a that's a known thing that all humans do. But when we're talking about masking, we're talking about something very very different. We're talking about those behavior changes, but we also need to understand about how identity develops. So identity management is a little bit different to impression management. Impression management is that context switching, that changing, but identity management is the chronic effect of being in environments where you are constantly having to hold yourself in a certain way because of the expectations that are being placed on you, and the impact that that has. So, that that that kind of behavior switching, it might impact you you in kind of energy ways in in small ways. It might impact on your mental health in small ways. But when you are doing that consistently, and your whole identity development becomes framed around that, that's when that's going to have massive impacts on your mental health, on your physical health, on things like burnout and stuff like that. So so they're the they're the kind of longer term kind of impacts of this. And really, what is at the heart of this are two two factors: a stigma and a lack of safety. And when I'm talking about a lack of safety, I don't necessarily mean being at risk of physical harm, but felt safety, psychological safety. So, being in environments where you know that the the sensory environment isn't quite right, where people are maybe invalidating you or correcting you, or there's expectations of you that you know that they are wanting you to meet, but you aren't able to meet always. Being in environments like that is unsafe, and a lot of those environments are environments that we are mandated to be in, like schools, workplaces, like like the places where we spend lots and lots of time. Sometimes even the home, because home isn't always a safe place for everybody. Even well-intentioned places can be very unsafe. So when you exist like that, and if you think about the ways in which autistic people are basically subject to correction, pathologization, invalidation, all across every aspect of being a human being. Around how we communicate, how we move, how we eat, how we sleep, how we think, how we feel, how we emote, how we play. Everything about being an autistic person is up for correction in some way. And even if that's not being done to you in a direct way, you know, in an open way, still subversively, people are affecting your behavior and expect making expectations of you. So you, as you grow, you adapt to that, and your identity becomes formed around meeting other people's expectations. And those expectations might be for you to conform. It might be for you to display big behaviors, big emotional outbursts, like whatever's expected of you, whatever framework people hold of you in their heads and their expectation of you, you are constantly trying to meet. And this, this, this works for autistic people who are speaking, autistic people who are non-speaking, autistic people who have physical disabilities. All humans are engaging in this, but when you are subject to that level of stigma. And unsafety, then you are more likely to be engaging in this. So, and what that does for you over the long term is obviously it has, like I said, a massive toll on your mental health. It takes enormous amounts of energy to do that, and we have a massively. I'm sorry to talk about this early on, but trigger warning. I'm going to mention suicide. We have massively high rates of suicide amongst our community, like more than any other group on the planet of human beings. And when you look at life outcomes for autistic people, we are up the top for the worst outcomes across pretty much every single life outcome that you can think of. Our biggest killers are suicide, like I said, but also strokes and heart attacks. They're the three biggest killers of autistic. Yes, statistically, the three biggest killers of autistic people. So when we talk about masking as children, this is something that we are also taking into adulthood as well. The impact that is felt on us as children is being impacted across the lifespan. So, you know, like I always say to educators and people who work in education, you know, like you might have a child that you work with just for an hour a week, or you know, you might only know them for a year, and then they might move on to a different class or a school, different school or whatever. But actually, you hold the impact that you have on them is felt across their whole life. So that's that's a huge amount of power that professionals wield over autistic children, but also it's it's an opportunity as well, so yeah. So so most people think masking is I'm going to stick on my neurotypical mask and I'm going to act neurotypically for a short period of time and then I'm going to take it off again. But actually, this is something which is a whole body experience and is a chronic lifelong experience as well. Jayson Davies Yeah, you know, as you were talking, I was thinking like, yeah, we all change our behavior a little bit, right? Kind of as as you started that off with, but I, I mean, in this particular context here, in a school based occupational therapy podcast, we're primarily talking about you know those kids, those younger kids, and when we think about kids, we don't think of them doing as as much as you know your your businessman, your your adult, like that isn't something that kids normally do. I mean, at least not to an extent that adult does. And as you kind of alluded to, right? When you're doing it at such a young age, that that becomes a part of the identity, and and that is unfortunate. I think of one one kid who I worked with, an autistic. He was probably about I think like second grade, and you know we were just walking to the OT room, and I said, "Hey, what's up, dude? And he says, "I'm not dude, I'm his name, and like I was so thankful that he had the ability to tell me like what he actually wanted to be called, what he appreciated, and that then leads me to think about all the kids that we work with who don't have that ability to express themselves. Like that's that's really hard to know how they're feeling. Kieran Rose Yeah, yeah, it absolutely is, and that's that's, I mean, that's that's a perfect argument for total communication. Firstly, isn't it, and and and having the opportunity to communicate in different ways, but also that's an indicator of some children feel more safe than others. Some children, all all of these children are subject to stigma, but some of them feel it more than others. Jayson Davies Yeah. Kieran Rose So some children have the ability to advocate for themselves. Some have don't have that ability. So so this it's a mixed smorgasbord of things that are going on, but it's important to hold that in our heads because we miss children for certain. We miss the quiet children. We also miss the big the children who show the big explosive behaviors because we usually put them in a completely different box. And it's you know so so so these behavior changes are happening and this identity shifting is happening and masking is happening in all sorts of different ways, like the class clown is a mask, and people who fit different social niches. All of those things are aspects of masking. But so we need much higher level thinking and critical thinking when we're when we're looking at stuff like this, and not just going straight to oh, masking means small and quiet, and you know, like like those things are real, but also other things also exist at the same time. It's it's a much bigger, and there is a big irony in this narrative. Having having been part of the academic narrative of kind of understanding masking for for about a decade now, the existence of masking that we are talking about negates the theory of mind, the lack of theory of mind argument. So, because in order to in order to be able to project a version of yourselves that other people expect, you need to be able to sense what other people are expecting of you. So that requires theory of mind to do it. And it's so yeah. So again, like like we could go off in 200 different directions around things that hold much more nuance than we think, or are misinterpreted or misunderstood. Jayson Davies Yeah. So the question here that we have was, how can we support students who mask all day at school and then you know go home and melt down? And we and we hear this right with parents, right? Like, oh, they hold it together at school, but. And you should see them when they get home. Yeah. So, kind of like two parts of that, I think, is like, a, is this something we can screen for? Can we identify who's masking, who's not masking, and then b, what you know, like, what do we do? Is it mostly education based, letting everybody know around that student, or is there something an intervention we can do? T Kieran Rose The biggest intervention that we could do is change the entire way that we educate and hold space in education. I think, like, like there's a there's a whole conversation there about actually the way that we do things is really quite problematic, and the way that the I mean, the British education system, the American education system are very similar, and Westernized education is is very so it all comes out of a kind of an English model of education, and the world has moved on far beyond what the education system currently looks like, and our understanding of humans has moved far beyond, and how humans learn has moved far beyond how the education system works. I don't want to go too much into that because we'll spend the next hour just talking about how we can deconstruct school systems and reconstruct them, which I would love to do. But so we have a problem where we are existing in a flawed system, and that system doesn't recognize its own flaws, or at least maybe recognizes them to an extent, but doesn't have the ability to make much change around those things. So we are asking then children to move into a system which is problematic and which doesn't recognize the way that they learn. To be to be frank, I might throw out some terms, and if you want me to kind of dig into, like, give a little kind of definition of what they mean, because not everyone will be privy to those, but they're like my bread and butter. So, children who are monotropic. So, monotropism is a as a theory around the way that autistic and ADHD children use our use their attention. How autistic and ADHD people use our attention, in that we have an ability to kind of focus on something to incredible depth, and that is an incredible tool for learning, our current school systems don't allow for us to kind of focus to that incredible depth because there's constant transitions in school systems. So, and even in a an hour long class, there's like hundreds of transitions within that hour long class, and it doesn't it doesn't support monotropic learning. Now we celebrate monotropic learning in certain environments, and so so if you think about academia, and someone who's developed a PhD has spent literally three to five years answering one question, that's literally like all your attention is on one singular thing. But in a school system, the school systems that we have, there's there's lots of different pathways that we are expected to take simultaneously, so it doesn't allow for that kind of singular kind of focus and that that deep rich learning focus. So if we were going to on a very big way make an intervention, I would say we need to look at the curriculums that we use and how the school day is built. Is it built to facilitate that kind of learning? And if it isn't, your your autistic children in that space, and your ADHD children, that space automatically have a massive barrier, and that's the biggest barrier that you can put in front of them. Your brain isn't allowed to do what it's designed to do. That's a huge issue. So we might not be able to change the whole school day, but there's little ways that we can maybe flex in there. Like, can we change the structure of individual lessons? Can we diminish the amount, or reduce, or mitigate the amount of transitions that we're expecting a child to have, and that doesn't just necessarily move like movement from classroom. I know in the US, teachers move from classroom to classroom, don't they? In high schools, sometimes here in the UK, the kids are moving around constantly, which which is like corridors are constantly filled with children every 45 minutes to an hour. And oh yeah, that's in high school, middle school. That's yeah. That's our right to there. Yeah. So so so there's big things, but there's all sort of micro transitions. Like how is a child expected to change their attentional style within a classroom, within a learning environment that's like there for a subject. So play based learning is is amazing for that because that means that a child can just go and explore and be creative and curative and and do lots of things. And self directed learning is often something which autistic young people like like like are very very good at. But if we're not facilitating those things, then we're actually denying them their learning opportunities, and then we wonder why we have big behavioral outbursts, or we have children who can't use their attention or can't focus in the way that a teacher requires them to focus or a school requires them to focus, and and actually because we're not setting up the day to actually facilitate their learning needs, so big interventions and small interventions within that would look like actually how can we reflect on the structure of what we're doing, the actual whole synthesis of everything, and how can we flex within that if we can't change the big things? What are the small things that we can do to facilitate this more and more and more. Jayson Davies Yeah! Wow! Wow! Yeah, we're gonna everybody just go purchase every single one of Kiran's courses, his books, and get all the knowledge. We don't have enough time here, but we're gonna do as much as we can. We did have a question specifically about masking in females. Autistic females. I don't know if you want to go specifically. We've done masking a lot here. If there is anything specific to females, go for it. But you have one daughter, and you have really-I mean, everything autism is you. Something in our planning call you also surprised me about was like diagnosing, and so maybe these questions might go together a little bit: overdiagnosis, underdiagnosis. But I want to give you an opportunity to talk about autism and females, as well as a little bit about diagnosing. Kieran Rose Sure, sure. So, in about 2015, there was a shift in attention in terms of across genders, and rightly so, because autistic women and girls have been missing from this narrative forever, going all the way back to the published work. I'm going to say that's very specifically the published work of Asperger and Canner and and the kind of those people who who kind of laid the foundations for everything that we we do now and everything we think now. Although they had girls in their clinics, an equal number of girls in Connor's case publish work focused only on the boys. And think about that. Think about that contextually in the kind of the 30s, the 40s, the 50s, even through to the present day. To some ways, who's more important, or who is deemed to be more important? The person who is going to be go out and be the breadwinner, and and you know, boys and men are you know from a misogyny kind of point of view are more important. That that's how things have been framed historically. That's not me saying that. That's how things have been framed. Correct. So, autistic women and girls have always been there academically and statistically. We can look back and we can see autistic women and girls have always been there in equal numbers, but the attention was put on the men. So in about 2015, that started to shift, and rightly so. Like I said, because there's been a huge amount of anyone who isn't who doesn't identify as male has been missing from all of this. Unfortunately, though, and there is an unfortunate kind of side effect to this. At the same time, the academic interest in masking kind of kicked off and sparked off. Even though the autistic community has been talking about this stuff for like decades, academia only took notice around the same time. So it became a very convenient thing then for academics to turn around and say, "Well, we've just figured out this masking thing, or we've just realized that this masking things exist, and we've just realized that all these women and girls have been missing from this narrative for the whole time. So they put two and two together and came up with 474. So they basically the narrative that spun out of that then was that autistic women and girls have been missing from this narrative, not because we haven't been looking for them, but because they were all hiding from us, there they are. Like there's one behind the table over there. There's one hiding, like a sneaky one behind the tree over there. Like literally, that's the narrative that evolved out of this. And then the secondary narrative, which is something called the female autism phenotype, which I hope you won't be offended when I reduce it down to its an acronym, which is fab. So we're talking about a sexist and misogynist narrative, and all of a sudden we have an acronym, which is obviously in American parlance means something very, very different. So, so there's a little bit of sexism and misogynism still wrapped up in this too. So, what the female autism phenotype basically states is that there is a whole different version of autism, which only women and girls experience. Female autism, and the ridiculous thing that's evolved out of that is that now we have lots of boys who, on their diagnostic profiles, it says presents as having the female autism. What? It's just meaningless. Absolutely mean. This is the problem with phenotyping across genders. So what's actually happening? And I've got a little quote that I always use, which I stole from a colleague of mine, Eleanor Broadbent, years ago, and I use it everywhere because it's the most amazing thing. What she said was, when boys line up toy cars or nuts and bolts in a perfect logical order, we call that autism. When girls line up stuffed toys and clothes in a perfect logical order. We call that good housekeeping. So the presentations are actually exactly the same, but the way that the frame of reference, the lens that we look at different genders through, is completely different. The expectations that we have of different genders is completely different. Now, that's not me saying that that boys and girls are identical. Obviously, because like in terms of anatomy, there are going to be different experiences. Absolutely, people who are assigned female at birth are going to be biologically experiencing something different in terms of periods and hormones and body changes and stuff like that. That's very very real. So there's going to be different autistic experiences through that. But fundamentally, the baseline experience is exactly the same across genders. Jayson Davies Yeah. Kieran Rose So, the other interesting thing about this is that because in a kind of an oversteer and a course correction from oh my god we've been missing all these autistic women and girls for years and and now we need to change that is that we've dropped the ball on everybody else, including the boys and men. So women and girls are now overrepresented in autism research. So, which is which is just like like I mean it's good in a way because we're playing catch up. But if we're playing catch up and we've taken the R I off of everybody else, then what are we missing and what aren't we learning? We've just completely oversteered in the opposite direction. So so yeah. So it's there's there's a again, but this is this is why I keep using the word nuance. There is so much nuance required to understand these narratives, and there's so many different threads to all these narratives that actually pulling them all together and being really critical about them is really really important. Because otherwise, we just blindly accept what somebody tells us. But historically, we've done that. We've spent 120 years listening to academics who have been observing autistic people, but haven't actually been co-producing and talking with and spending time with, and and and actually working with autistic people in that sense. So you know, or allowing autistic people to lead. So there's so much missing, so much that we don't know, and we fill the gaps, and we what we fill the gaps with, we believe is concrete, but actually it's not concrete at all. Often it's putty, and it melts in the sun, and it's flexible, and it moves, and we have to dig it all out and replace it with something else. And so we're still we're still at the very early stages of understanding all of this, and yet we say things with such certainty, and we create interventions with such certainty, and we do things to people with such certainty when actually we are missing boatloads of information and context. Jayson Davies Wow, wow, yeah. You know, we actually had a few questions about overdiagnosing, Kieran Rose which was really interesting because I think there is like this over there's this belief that there's actually overdiagnosing that maybe people who actually have ADHD are being diagnosed as autistic or other learning disabilities are being diagnosed as autistic. But it sounds like from from the research that you've done, it's actually more under diagnosis of we're missing still large numbers of people in terms of diagnostic kind of profiling, and also thinking about that in context of you know how things are done in different countries and how people are accounted for in different countries. Like here in the UK, there's very little actually tracking of diagnostic rates, and the way that the NHS, the health service, works here is that it's independent. Each each NHS area is independent of another, so they all track data in different ways, and they look for different things. So there's no uniform way that people look. There's no no one person sitting there counting the beans of how many autistic people are getting a diagnosis. And then obviously outside of like the UK and North America and Australia and New Zealand, that side of the English-speaking countries, things are done very different differently culturally. People have different expectations and ideas around all of these things. So there is not a single way that we can say that diagnosis is skyrocketing because it might be within a certain limited context, but outside of that context, when you bring back the nuance again, you recognize that numbers are going high in terms of diagnosis because we're actually catching up in addressing the fact that people have been missed all this time. That's a thing, but actually, when you look at the baseline numbers, the the escalation of it is actually very stable. The the when you dig into the numbers, the amount of people being diagnosed and the amount of people being recognized actually isn't abnormally going off in any direction at all compared to population levels. So you know it's there's a there's a context here of we are understanding things better and we are getting much better at recognizing people who exist in a certain way, and now we're getting to the point where we're being we we're getting better at recognizing adults who have been missing predominantly from this narrative. So of course those numbers are going to change, and it's going to look in a very singular way very dramatic. But when we apply context and nuance to it, actually, it's not dramatic at all. It's it's to be expected. Jayson Davies Yeah, yeah. All right. Well, we're going to take a quick break, but when we come back, we are going to address the most asked questions about stimming, regulation, and participation, and how those go together. So we'll be right back. All right, we're back, and I'm not going to to take one particular question here because we had a bunch of questions about this exact same topic here, and this is the idea of how do we address STEMing while also remaining neurodiversity affirming and supporting these students when there are these academic expectations. A lot of our, you know, listeners, they asked us, "I have this student who, you know, we're trying to get them to do one thing, and they just want to stem, and I want to let them stem, but I also understand they're in school and they need to learn. I'm sure you have plenty of thoughts about this, and I just want to let you let you talk. Kieran Rose I do. It's it's interesting actually because obviously you sent. Sent through a lot of the questions before, and I never really look at them, and I did this time. I just had a quick skim read, and I, I felt really sad because I could see the moral injury that was being experienced by the people who were asking these questions. That that being in that dichotomy of I know actually what this child needs and what I need to do for them, but I'm restricted because the system that I'm working within does not allow me the freedom and the the curiosity and the creativity to be able to actually meet those needs because the system has a whole different load of expectations and objectives, and so, so I don't have a perfect answer for how do we how how do we do this? How do we fix this? Other than burn it all down and restart again, you know, which is which isn't a helpful answer. But again, I think it comes back to recognizing how can we flex within the system that we are trapped within, and also how can we look after ourselves within this as well? Because I think there is a bigger question around kind of people who are working in this system who are also being traumatized by the system as well, and working with one hand tied behind their back and not able to do those kind of things. So, but that's I'm not going to go there because that's like well, it's also why we lose a Jayson Davies lot of people. Well, it is, yeah. People burn out of it Kieran Rose Yeah, because they can't do what they know that they need to do and what they're trained to do as well. You know, like like nobody, I don't think, goes into being an occupational therapist, which, by the way, I think is the most singular, most important job that you can do, working with an autistic person. You're the occupational therapists are the most important professionals who are secondary, slightly secondary of speech and language, but pretty close. But but in terms of you know the way that we live our life is fundamentally important. I think so many people devalue or don't understand what occupational therapists do and what occupational therapy actually means. It's a very misunderstood profession, and the vitalness of understanding occupations, the things that we do, of understanding the way that our body relates to the environments that we're in, our sensory profiles, the way that our you know in terms of praxis, how we move, and and all of those things, how our internal mechanisms work, and how that relates to the pressures that are put on us, and like there is so much to hold as an occupational therapist. So I just wanted to kind of shoehorn that in there. Of your jobs are vital. So anything that you hear me say is critical of systems and and professions, not of you as actual practitioners. But in terms of things like stimming and stuff, and and and also learning, I mean, I've got a little very very quick anecdote, which is a very singular thing if you just looked at it that way. But actually, it's representative of a much broader narrative. I've got a client who I've worked with for a number of years now, who runs a language franchise, so teaching young children how to speak French and Spanish and Mandarin and things, and and often does community classes. And in one of those community classes, they had an autistic child who would not engage, would not come and sit down, would not come and sing the songs, would basically run up and down the back of the hall for every single session, and wouldn't wouldn't engage, would flap and spin, and and all of those things. And they came to me and said, like, what do I do? How do I get them to engage? And I said, how do you know they're not engaging? Just because they're not conforming to your idea of engagement doesn't mean that they're not actually taking part in the session that you're doing. So I said, just run with it. Like they were building up to a kind of like an assembly at the end where they would be singing and things like that. I said, just run with it and see what happens when you get to that assembly. Just bear in mind, like hold space for the fact that things might not look the way you expect, but the outcome might be magical. And when it came to that assembly at the end, guess which was the one children that knew every single word to every single song and performed it at the top of their voice. It was the child that would be running up and down at the back of the hall. So you know, so so we have an expectation of conformity, and our educate. This is why I was talking about Westernized education again. That's built this idea of conformity. We sit at a desk. We look at the front of the room. The teacher stands at the front of the room. The teacher points to a board. Teacher tells us what to do. We do it and we wrote and we repeat. And that's that's called learning. And it isn't really learning. That's conditioning. That's a very different thing. Learning comes from curiosity and from being able to explore and play. That's real meaningful learning. There's different ways that we can learn, but that that will be my kind of core basis for learning. So, when a child, I am getting to stimming. I promise. When a child stims, and when an autistic child stims, well, when any child stims, because this is a human behavior that we're talking about. All humans move our bodies in regulatory ways. When when is that good stimming or bad stimming? Jayson Davies I'm playing with a foot cushion right now, like in between my two feet. I'm just like rubbing it around. Yeah, so Kieran Rose Yeah, so yeah, it's like like me from the bottom down. Like you can't see what I'm moving out onto the desk. So because all humans stim, we do not only stim for regulation. We. System is a form of communication as well. This is where all the speech and language therapists are like, so stimming is a way of communicating how we're feeling. It's a way of helping us absorb information. When you have a group of children for whom the sensory world is fundamental to their existence, autistic children, obviously the sensory world is fundamental to all humans, but in a much richer, deeper, we have a much richer and deeper connection with the sensory world, and a much it impacts us in far more obvious ways, negatively and positively. So, when you have that rich level of sensory information that your brain is mining into and is using to kind of assess whether you're safe. Assess whether there's good information out there. Assessing whether you can focus on things and all of that stuff, which is rich and meaningful for your existence, your body, your stimming, the way that you move and the way you regulate is going to be more obvious. It's going to mean bigger movements, jerky movements. It might mean spinning and it might mean flapping. It might mean playing with pens. It might mean having little little things that you fiddle with all the time, and like I have a whole bank of things here. So it's that's important. And the more we suppress that, the more we're actually suppressing learning. We're suppressing safety. We're suppress. We're impacting negatively on all the things that we actually think we what we intend to actually positively impact. So, I think we need to hold space for the fact that autism. This this is the thing. Like, we diagnose autistic children and we define autistic children as being different in a variety of ways. When an autistic child expresses those differences. We all go. They can't do that. They shouldn't be doing that. We need to stop that. Why are they doing that? That's really confusing. So there is a dichotomy between we recognize difference and then we basically look at difference in horror. But that difference is a meaningful difference, and that difference means we need to adjust what we're doing. We need to adjust our frame of reference. We need to adjust our expectations. We need to understand the motivations of that person because they're different. But we don't do that. What we do is actually look at them and say, "How do we make you more like what we want you to look like? Jayson Davies Yeah. Kieran Rose And that's a really problematic way of doing it. So I think in terms of stimming, we need to be encouraging it. We need to have more movement. We need to recognize that a classroom doesn't have to look like children sitting down and looking straight ahead and being very still, because that might look like learning, and that might look like the teacher is having attention. But believe you me, if I'm sitting in that classroom, my brain is gone. I'm somewhere else. Even if I can hold myself in that still way, I am not able to do that and pay attention to what the teacher at the front of the class is saying. I need to be moving. I need to be doing things. I need to be up and down. I need to be fiddling, and that's why we have this this whole thing about like like if we stop that, that's great for teachers in terms of they have a quiet class, and they may the rest of the you know the class generally might need the objectives that the teacher wants them to meet, but we're also not meeting the needs of certain children in those classrooms, and we're probably not really meeting the needs of any of the children in those classrooms meaningfully. So I would say we need to change our objectives and our targets again in that big picture way. That's the thing that we need to do. A frame of reference for how we teach and what learning looks like needs to change fundamentally. Jayson Davies Okay. Follow up pushback just a tiny bit here. A lot of what we do as occupational therapy practitioners is very physical. It's handwriting. It's using scissors. It's manipulating items, and so I mean, just hand flapping. We go with that sort of stem at this point. Really, does is not conducive for having to do things like that. So, in that sense, does that mean we a allow the student get all the movement out, wait until they are in a moment of calm to work on that. Potentially, do we in the moment try to prevent the hand flapping? Do we just say, "Hey, you know what? Handwriting isn't important right now. Let's look at other forms of written expression. Kieran Rose Yeah, it's interesting because I was talking to my kids about coming on the podcast before we were having dinner, and I I read out some of the questions to them, and they were like, "You can't stop them doing that. And like, why do they need to write things down when there's 100 different ways that we can record information? And so, again, it comes back to actually, we need to look at yes, we do things in a particular way, and we may have done those things in that particular way for a very long time. And what that has done is created an expectation that's the only way we can do things, but again, we need to step put our one foot back in our curiosity and our creativity, and we need to reflect on this might not be a meaningful activity for the person that's in front of us. And if it's not a meaningful activity for them, what is a meaningful activity for them? Sometimes we can reach the same place by taking a completely different. Sometimes we can't reach the same place, and that's okay. That's a that's a disability narrative. That's a normativity narrative. You know, we don't. Why should we all end up in the same place doing the same things? Yeah. Some people have the ability to learn incredible things that I can't do. There are things probably that you can do that I cannot do. Does that make me more problematic than you? Does that make me disordered? No, it doesn't. It just means that we've got different skill sets. So that doesn't mean that we can't try, and that doesn't mean that we shouldn't try, and we shouldn't introduce people to different things and different ways of doing things. But when we get trapped in these singular paths of these are our targets and objectives, they have to do ex cursive handwriting, they have to use scissors. They have to do this and do that. And I mean, actually, when you think about, like, I very rarely use a pen anymore. So you know, I type. Everything I do is type is either typing on a keyboard or it's typing on a tablet or a screen or you know, like like. So actually, pens are becoming less and less relevant. Handwriting is bigger, and that's not me saying it's not an important skill, but it's not a skill that everybody necessarily needs to have to the extent that we are pushing them to, and I think that's also an education narrative where you know kids don't do science at school; they're young scientists. Kids don't do maths; they're mathematicians. You know, like we're creating roles for them. Like the expectation is that if you follow this line well enough, you're going to become this thing, and actually, that's not right for everybody. It's absolutely not. So, while again, I need to reiterate that that it's important that we introduce lots of things and lots of opportunities for doing different things. Absolutely, like things like handwriting, and because those are some beautiful, and handwriting can be an art form. You know, like it can be beautiful, but it's not necessarily right for everybody. So if you are hitting that many walls and that many barriers, maybe the timing isn't right, or maybe the methodology isn't right, and maybe we need to be curious about that. About what can we do differently? Jayson Davies Yeah. One thing that that I come back to was you know one of the first things you mentioned on the podcast, and I don't want to butcher the word, but it was the mono. Say it one more time. Kieran Rose Monotropism. Jayson Davies Monotropism. Yeah, and so I think about that because I mean we've all worked with students or worked with autistic individuals where yeah they don't want to copy an agenda from the board, but you get them writing about Mario and my goodness, and it goes yeah yeah Kieran Rose yeah. So you can you can incorporate interests and things into things, and sometimes that can be a motivator. I think you have to be careful around that because sometimes you know, like when people turn the hobbies into jobs and then they lose the passion for it because it kills it. So sometimes you have to be cautious about that. You can over overkill it and kind of over saturate it. But also, I think there's different things that we need to consider here as well. Is and I bet there is not an autistic child that you haven't that you've worked with that hasn't shown a kind of skills development that's looked like that, and then all of a sudden they've gone like this. They pick something up out of apparently out of nowhere. They've just suddenly started doing something, and that isn't because they've suddenly just started doing something. That's because their brain has been maybe whirring on it in the back in the background, actually trying to figure out the mechanisms of what this is. How do I train my body to do this without outwardly doing anything? So you can't see inside those children's heads. So you don't know actually what skills they're working on, and what their brain is prioritizing at any given moment because it's working differently to yours. It's literally there is a huge empathy gap between autistic people and non-autistic people because our mechanisms are completely different. We're all human and we're all similar, and we can all kind of work towards each other's kind of the way that we do things. But there's going to be fundamental differences. So if we're not accounting for those fundamental differences, those kind of spiky profiles, those non-linear kind of skill development, and like we should be expecting those things rather than being thrown by them and and being shocked by them and surprised by them, because like like I said, like there is not an autistic child in the world that doesn't have a spiky skill development profile, you know. But and we know that, but yet we're still surprised by it, and we still work on how do we make it non-spiky. And actually, why don't we just lean into the spikiness? Jayson Davies Yeah, I remember. I don't hear it as much, but we used the term splinter skills was sometimes kind of associated in that way, right? Like this student had a quote-unquote splinter skill in this particular skill set, and and yeah, like I mean, there's been times where I'd sit in an IEP and I say, let's lean into those strengths and use those strengths to accommodate some of the areas of difficulty, right? Like if they are good at typing, let's use typing to our advantage, or if they are really good with one particular thing, let's use that to our advantage. Kieran Rose Exactly, and I think it's it's a healthier way of thinking about human development as well, because again, I think it's and you know from a from from a justice perspective, which I know occupational therapy comes out of, it's purely comes out of justice. The occupational therapy, at its heart, recognizes that every single human on this planet is absolutely unique in the way that we. Learn the way that we develop our skills, the the things that we do. Yet we are being asked in educational terms to work within a conformity environment where all those children are the same, have to go through their different skills development sets and targets and objectives. They all look the same. The outcomes have to look exactly the same. That's not how humans work at all, so we are actually working counterintuitively, and again, that brings me back to the moral injury that I know so many occupational therapists face, because you know this in your gut, but yet you are expected to work in ways which are actually counterintuitive to the way that you know you need to work, and that's a hard place to be. Jayson Davies You know, if if you had one hour, if you were an occupational therapist, you're at a school, you know it's a K through six school, whatever it might be, and you've got one hour that you can provide a professional development to everyone on the campus about autistic individuals, what would you spend that hour on? Kieran Rose An hour's not very long. An hour's not long enough. What is it? I don't even do al-on training anymore. I refuse to do it because it isn't long enough. But um, but I think I think probably I'd focus on three things. Now this is this is me coming at this as obviously I understand these three three things to a significant degree. I'm by no means an expert in anything. I don't actually believe in the word expert. I think it's a problematic term, but masking, monotropism, and the double empathy problem. I think they're the three key things. Lots of things fall under the banner of those things in terms of communication, in terms of sensory processing, in terms of praxis and and motor movements and and like there are lots of things that come under those things, but I think they're the three kind of headlines that you can encapsulate everything with. Jayson Davies All right, so there you go, everyone listening. One hour, one hour, one hour. Go go learn from Karen and then take that back to your back to your school and say, hey, I want I want to provide a professional development, you know, for for everyone on campus. I mean, you could, if you really need to, maybe narrow it down to less than the entire campus, right? Maybe you're focusing on those individuals who work with autistic children, but ideally, it'd be great just to provide this professional development to as many people on campus that you can. So, yeah. All right, we're we're getting closer to the end of our time together, but there, whenever, especially in school-based occupational therapy and any occupational therapy, the mention of ABA just like makes people cringe, and I'm wondering because you have mostly you just have such a vast network of autistic individuals that you that you work with that you know. Why is it that ABA has become kind of like the go to, or I mean, really, it's becoming called autism autism therapy. Like, why has that become a thing? Kieran Rose I think ABA is very. Its marketing is superb and has been superb for a very long time. I think it's the way that it markets itself plays often to the grief that parents feel and the stigma that other professionals experience towards the idea and the concept of autism, stigma plays a massive role in all of this. And and I think the ABA industry preys on that. So they prey on fear, basically, that if your child doesn't do X, Y, and Z by certain times, their life's going to be over. You know, like it's not worth living, and and so so it is your role as a parent to dive in and rescue your child. I think certain charities and organizations, not naming any names, in the US have played a massive role in the promotion of that ideology as well. The kind of the crisis, the grief, the negativity, the stigmatize you, the you know like it's out to get you and it's going to steal your children and all of that kind of narrative. And what I don't want to do here is kind of dismiss the very real fears that parents often have, particularly parents of autistic children who have co-occurring physical disabilities, who may be non-speaking or minimally speaking. Like those children are are have a very specific need set, which often isn't met. So that often comes with that that kind of extra panic and worry and fear. And as a parent, we all worry about our children and what what's going to happen to them when we're not here, you know. But for children who have very high support needs, that that becomes a very very overriding factor. So I think ABA has specifically preyed on that. I don't even know if it's done it intentionally. It's it's there's a market force going on there as a capitalist kind of thing, but but there was a here's a huge gap in the market. Let's fill it by fixing these kids. Basically, the irony of that is that you know ABA has been around since the '60s. It's more formalized since the '80s. But if it actually worked, we wouldn't have any autistic children left. So you know, like, like, like it, like, like it's, it's not actually what it does doesn't do what it says on the tin. And what also we don't know with because there's no there's no real meaningful long longitudinal studies into the effects of ABA. You know, like we don't know in terms of life outcomes how much this plays a role. What we do know anecdotally, and and sometimes with with academic research, is that behaviorism is a fascinating beast because behaviorism preaches that it understands human behavior, and actually, often I think it completely misunderstands human behavior. It simply oversimplifies human behavior often. ABA does this specifically, you know, like with the four functions, and you know, it's it's a very very superficial narrative, and it hasn't moved with the changes of adopting these more contemporary narratives that we're seeing now coming out of research. You know, the the understanding different attentional styles, different motivations for communication and behavior and socialization; those things are all missing from the literature around this. So, I think it's become easy for other people to grasp onto because it's sold as the fix. Firstly, but second, it plays into the narratives that we've been speaking to, particularly education narratives around the idea of conformity. You know, the idea that you do things in a particular way, and if you don't do it in a particular way, you're a problem, and your life is going to be over, and you're not going to get a job, and and things like that. And so, it all kind of feeds around this this kind of like a whirlpool of things that it's feeding into, and I think I think that's why it's so got such a firm grip on on everything, and it's infected everywhere across the world, in terms of either ABA specifically or behavioral frameworks, and we have PBS and Positive Behavior Support in the UK, which is an ABA behavioral framework, which is utilized in health and social care and education, and so literally the ideology is everywhere. But it's all about actually control and conformity and keeping people in their place, and I'm not an advocate of doing that at all. Jayson Davies Yeah, yeah. And and you you talk a little bit about the fear and playing on the grief that that parents might have, and we did actually have have some questions about that. Unless your listeners really asked about how families emotionally process autism identification and how practitioners can communicate in ways that honor acceptance, grief, cultural values, and concerns about stigma. So, I think you kind of discussed this a little bit, but anything else you want to talk about that? Kieran Rose Yeah, I just I think you know, as an autistic person, as a professional, we have to hold space for the fact that people hold fear and that stigma has played a role, massive role in in why they feel the way that they do. We also have to hold space for the fact that autistic people don't just spontaneously manifest in families. That actually there is a lot of there are a lot of unrecognized autistic parents who may kind of superficially recognize that they are, but don't have the capacity to be able to explore that because they're busy supporting their children, and so they will have experienced lots of stress and trauma. They will have experienced masking, and all of those things will be very, very real for them. They might not cognitively, consciously be aware of that, but that will have still happened to them, so we have to hold space for the fact that there are intergenerational dynamics going on here. That there, there is, there is obviously all of this cultural and social narrative around autism and the stigma that's kind of fed all of that. And so, holding space for that is really important. But it's also really important that people don't get trapped there, and that we support parents to move out of that space. And that isn't me saying that again. You know what many parents often do, unfortunately, is is oversteer again. Use that term again, where they go down. They go from like here's this massive deficit and disorder narrative. We're going to stop using that one, and we're going to go down the superhero route. You know, and it's like, look at my child with their super, and it's ridiculous. Like it's, we need to be looking at this from a neutral perspective. That autistic people exist, non-autistic people exist, ADHD people exist, black and brown people exist. If we were, if as a as a species we were better at actually looking at things neutrally and not loading them up with stigma and fear, things would be a lot better for all of us. And and they're the conversations that we actually need to be having with parents. We need to validate their experiences. We need to recognize the things that they have gone through. We need to think about if they're fearful of their child's future. Is that also because they were fearful of their own the future when they were children? You know, like the things that they grew up in. So we take on a role often as therapists, and I mean, like mental health therapists. You know, where you're having to psychoeducate, you're having to hold space for people's trauma, you're having. But that's the reality of our jobs, and I think our jobs need to evolve and recognize that this is actually what we're doing now. It's a huge. Part of what we do, it's not just about we go into a house or we go into a school and we work with a child. There's a whole system around that child that also needs to be educated. It needs to be understood. It needs to needs to be taught. It needs like like there's so much that needs to go on there, and and neuroaffirming practitioners will recognize that, and we'll be working towards that. And you know, no one's ever at the end goal of being the perfect, perfect professional. But that's the pathway that you should be on if you want to be an affirming practitioner: is recognizing the interactions of all these systemic layers, and then realizing that parents, and then autistic people, and children are right at the heart of all of these systems, and those systems are soaked in stigma. So, how can we destigmatize as much as we possibly can, and create a bubble of safety around them, where they can feel a little, have a little capacity to to learn, to feel safe, to explore, to be creative, to think? You know, like they're the things that we really, really need to be doing on that very macro level, and then we need to be advocating out obviously for all the other systems as well. So, so yeah. So I don't actually know if answered your question there, Jayson, or if I went off the complete tangent. But I feel like it went in a big loop. Jayson Davies but in this whole conversation, though, like you know, I'll apologize to everyone listening because I think that people probably started pressing play, thinking, man, there's going to be a bunch of things that I can do with my singular student, and I think what we've learned today is that yeah, there are things that you can do with your singular student, but there's also a lot more that you can do from the macro level. You know, supporting the entire school to better understand autistic students, not just trying to support your individual autistic students that you work with on your caseload. Kieran Rose Absolutely, and that's big. One thing, one thing to add there to kind of to make it a bit smaller, is because of that can be really overwhelming to think like all of this has got to change, like, and it does. All of this needs to change, but that can also leave us powerless. So one thing I always come back to is that if we look at this this need for change as a civil rights movement, and you think about other civil rights movements that have been that have been happening in the world for decades, and how in some ways they have moved forward immensely, in other ways they've stood still. Like change has not happened in so many other ways. So the same things are happening here, and we are right at the beginnings of understanding this and recognizing this as a long-term war, basically, or a game, or however you want to look at it. That that we need to look at objectively and say, I, as an individual person, cannot change the world right now. There is nothing I can do to influence everything, but I do hold a pebble of power, and that pebble of power for some people might be like a little, little, little bit of grain of dirt. For other people, it might be a boulder. So when you drop that pebble, and what that pebble is, is actually you. It might be, I don't know, if you work in a school, it might be that you model to everybody to stop slamming doors. That might be one thing that you can change, or that you influence the score so that they're not having buzzers going off when there's a change of lesson or a bell going off or things like that. Like like just little simple things. Like they're little pebbles that you can drop. You make a change, and you find someone else who holds a pebble of power that wants to make change as well, and then they drop their pebble, and then all of a sudden you have ripples converging. And what happens in water when ripples converge? Chaos. And the more pebbles we drop, the more chaos there is. The more change is going likely to happen, and then the ripples get bigger and they turn into waves. So, so one narrative that I always push for in this is something that I call islands of safety, which is anybody that's ever done anything in kind of mental health, you know that that's that's a term that's often used there. And basically, what that is is that you have a child who has been dropped in the middle of this really problematic and flawed system and this this environment that is effectively harming them. And there is very little you can do to influence change in that, but what you can do is hold space for that child, and that might mean you only might be with that child like for an hour a month or an hour a week. But how much safety can you create in that short period of time? That might mean that you go in with targets and objectives that other people have met you, given you, and you rip them up and you say no. What I'm going to do is validate this child for an hour because that's the only time that they get validation. That this is an opportunity maybe to explore what it means to be autistic for them, to explore their sensory profiles, explore their communication identity. Like there's so many opportunities there. It might be just a space where you just come together and you just sit and you both look out the window together for an hour. Now that doesn't sound like work, but that might be meaningful time for the child that you are working with, who is going to go out of that room with you or out of that space with you, back into an ocean of unsafety. So, holding space is sometimes the biggest thing that we can. Do even though it feels like we're doing nothing, so you know, and that's hard advocating out to your bosses and to teachers and to parents or whatever that that's what you're doing is going to sound ridiculous, but that could be the difference. I'm going to go back to those statistics I talked about at the beginning. That might be the difference. You, as someone who created an island of safety, might be the difference between them being alive and dead by the time they're 40, and that sounds like a dramatic thing to say, but that's a very, very real thing to say. All of us, all humans, we remember the people that were kind to us. We remember the people that hold space for us. We remember the people that were good to us, and if you can be that person in a world where they have very little of that, where they have very little understanding from other people, where everything is pressure, if you can be that person for them, you could be the difference between them being alive and not, and that's huge. Jayson Davies Yeah, yeah, I 100% agree. You've got that permission, you know, to to rip up the goal for this week, and you know, just focus on that student safety. You know, kids have to want to go to school before they're going to actually, you know, learn from school. They've got to feel safe at school before they'll learn at school. And as you've already talked about, a lot of kids aren't feeling safe. They're not feeling like they want to be there. And so, if the OT is the person that can help promote that, and maybe if the OT is the person that can help drop one pebble into another classroom to help that classroom understand that. Kieran Rose yeah. Jayson Davies that that's that's big, that's really big, it's huge, yeah. Karen, I'll ask you one final question, and and that is, are there any questions that you're expecting today that I didn't ask you, or that you didn't see on the list of questions that I sent over you, that you were actually kind of shocked that you know what a school-based OT didn't ask me this. What the heck? Kieran Rose Um, no, but the one question which you haven't asked, which I thought was absolutely fascinating, was the one about what does the autistic community think of occupational therapists? And I thought that was such an like I've never ever seen a question like that before. Never like that's such a reflective question, and I think it was such a beautiful question as well because I think I've already kind of alluded to the answer in terms of what I think. That's why it works. Jayson Davies but yeah. Kieran Rose Yeah, and I think so. I think firstly, like I said earlier, occupational therapy is the most important profession in terms of any professional that can engage with an autistic person, and I think speech and language is is slightly secondary to that. Apologies to any speech and language. Very important, but just not quite as important. Yeah, you're all important, but you know, like, but I think it's a, it's, it's a fundamental mental role because of the fact that the framework that occupational therapy comes from is a justice framework, and I think that's that's that's fundamental to any work that you do. If you, as an occupational therapist, have drifted from your justice framework, then you need to drift back again. It's really important that you do. The other thing that I was going to say, because I think this is a really interesting question, and you know, Jayson, I do a lot of work with the Star Institute and Virginia Spilman, who kind of runs the Star Institute. We have this conversation all the time. Is in that occupational therapists are really. I'm going to go back to marketing again. You're really bad at marketing because nobody knows what you do. Yep. Like it's like a mythology around like like what do they do? Is it a bit woo? Is it a bit this? Is it a bit that? And I think one thing I think that would better serve occupational therapists is a greater promotion of the fact that there are different types of occupational therapy and different styles of occupational therapy and different roles within occupation. Because I think autistic people often look to occupational therapy and think, "Oh, an occupational therapy therapist can help me with my sensory stuff. But actually, not all occupational therapies would be able to do that. So, so I think there's a there's there's something there around kind of actually differentiating different roles within occupational therapy and what they mean, and and I think that's really important. Jayson Davies Yeah, Kieran Rose but I think just overall, I think the autistic community looks to occupational therapy as an allied community, and you know, as as you are a group of professionals who kind of get it and are kind of safer, and there's lots of ableism within all sorts of other professions. Lots of ableism within speech and language therapy, and and and it saddened me to see that behaviorism has started to creep into occupational therapy. It's not unexpected, but it really kind of saddens me because I think that is diametrically opposed to what occupational therapy is. So, if anything, I would say that that if you don't want to lose the the good feeling that you get from autistic people and the autistic community, then then reflecting on that. And thinking about, well, actually, why are we so highly thought of, and why, out of all the professions, is that the one that's usually the first one that's first turned to? The safer profession, the safest profession, the justice profession. I think getting back to the roots of that is an important thing that occupational therapy should be doing. Jayson Davies Wow, justice, justice. That that's that's not the answer I was expecting. Like, you know, research maybe or yeah, that we get it right. We we understand autism a little bit better than some of the other professions. But justice is that's big. That's big. Thank you for sharing that. We appreciate that. Kieran Rose You're welcome. Jayson Davies Yeah. All right, Kieran. To wrap this all up, where can everybody go to learn more about you? Kieran Rose Oh, my website really. You can follow me on social. I'm on pretty much every social media platform, but I'm not very good at social media. I core everything together on my website, so there you will find training, lots and lots of blogs and articles and resource free resources and things and signposting and stuff like that as well. So that's kind of the hub of everything that I do. So just www.theautisticadvocate.com. Jayson Davies Absolutely, and really do go over there and look at his trainings. If you one time today were like, man, Karen said that perfectly. I need to learn more from him. Everything he says is golden, right? Go over there. He's got his trainings up there. They even says right on the training pages. Like I try to keep them as cheap as possible, and he really does. And so they are very affordable. I'm not quite sure how how long is your average training ish. What do you try to do? Kieran Rose Oh well, I have a big, I have a big core training that's about six or seven hours long, and comes with a massive round of resources. But generally, kind of between the one to kind of two hours mark, and I've got a, I've got a few more that will be coming out over the next few months. So some around employment, others around kind of masking, and I've got the training coming on islands of safety, actually. Yeah. So that's that's all framed up with ecological systems and stigma and stuff as well. So, so yeah, just little stuff like that. Jayson Davies But is it the inside of autism? Is that the longer one? Kieran Rose That's the big one. Yeah, yeah, Jayson Davies yeah, and very affordable right now. It's listed for under $100, even way less than that. So go check it out and learn more from Karen. And yeah, find him on all the podcasts that you can. Find him everywhere that you can because he's got a lot more to share than we can do in this overtime hour and 12 minutes that we did. So we appreciate it, Karen. Thank you so much for your time, your energy, your knowledge, all the experience that we that you bring. We really appreciate it. Kieran Rose Appreciate you too, Jayson. Jayson Davies Thank you, Kieran. Thank you so much for this, for answering the tough questions and for being able to see that internal struggle that so many school-based OT practitioners are having as they try to navigate the school-based OT system, this was definitely a conversation that I did not take lightly, and I'm really honored that you allowed us to bring our real questions to you and answered in such a kind and genuine way, we really appreciate that. The autistic students that we work with, that that we are trying to help navigate this tough world for them, that wasn't built for them, and that data that Kieran shared with us today isn't just sobering. It it's a call to action: suicide, stroke, and heart attack-you know, those are the leading causes of death in autistic adults. And the work that we do in that one half or that one hour a week that we have with our students, the safety that we can create in that time, and the validation that we're able to offer within that short period of time-it matters, and it matters more than we know. So, if you leave today with nothing else, please leave with this. You have power. Use it wisely and use it kindly. Thank you so much for tuning into this episode and asking your hard questions. Keep asking those difficult questions and keep sitting with yourself and answering those questions. And thank you for caring enough to keep learning and to show up every day for your students, for your autistic students, and all the other students that you serve, being a school-based OT practitioner is not simple. It is tough. It sometimes feels like we are getting nowhere, but know that you are. Every moment that you spend with them, you are helping a student that that needs that support. That that maybe needs someone to actually care about them, genuinely care about them, and hear them and understand them. I'm Jayson Davies, and this has been an episode of the OT Schoolhouse podcast. You can find Karen over@theautisticadvocate.com, and I really do hope that you take the time to explore his work. It really is amazing. Check it out, theautisticadvocate.com. We'll see you next time. Take care and keep serving those students that you see at school. Amazing Narrator Thank you for listening to the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until next time. Class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 208 of the OT Schoolhouse Podcast. What if occupational therapy wasn't confined to pullout sessions and IEP goals? Nicole Pfirman, M.Ed., OTR/L, shares how she brought an OT lens to every role—designing multi sensory environments for behavioral regulation, creating prevention and wellness teams that operated outside of special education, and reframing the "mental health crisis" as an intensity crisis that demands systems-level change. You'll learn why sensory regulation and mental health can't be separated, how to advocate for OT involvement at tier one and tier two, and what it takes to shift from waiting for an IEP to meeting student needs proactively. This conversation will challenge you to reclaim participation as the core of your practice and see new pathways for OT leadership in schools. Listen now to learn the following objectives: — Learners will recognize the distinction between a "mental health crisis" and an "intensity crisis," and explain how this reframing reflects the current reality school-based OT practitioners are seeing in students' behavioral presentations. — Learners will identify that sensory system regulation and mental health outcomes are directly connected, and that trauma responses impact the sensory system — meaning trauma-informed care cannot be effectively delivered without also addressing sensory dysregulation. — Learners will identify how OTP's core focus on participation and meaningful occupation applies across all MTSS tiers — from tier one environmental and policy conversations to tier two consultation — not only at the point of IEP eligibility. Guest(s) Bio
Nicole brings extensive experience as an educational leader in school-based mental health, with a unique occupation-based perspective that recognizes meaningful engagement in daily activities as foundational to identity, connection, and overall wellness. Throughout her career, she has focused on aligning educational and medical models through collaborative, multidisciplinary approaches that support the whole child.
Quotes “We are more in an intensity crisis than we are a mental health crisis, meaning that the intensity of the anxiety, the intensity of the trauma, the intensity of the behaviors is showing up in a different way. And that's what our teachers are feeling.” — Nicole Pfirman M.Ed., OTR/L "Because you have tier three behavior doesn't mean you're a tier three student." —Nicole Pfirman M.Ed., OTR/L "We can't do trauma-informed care if we have a dysregulated sensory system." —Nicole Pfirman M.Ed., OTR/L "We don't often hear sensory integration and mental well being or mental health in the same sentence, but you just kind of align them together and and that's unique” — Jayson Davies Resources MindPeace Cincinnati Holding Space Collaborative Snoozelen Environments OT Practice Article: "Advocating for a Seat at the Table"

Episode Transcript
Expand to view episode transcript Jayson Davies On this podcast, you have heard me time and time again advocate for OT practitioners getting into administrative and district level roles. Today, I'm excited to talk with an OT who has actually done just that and then some. Nicole Pfirman started her OT career in the same place we all did, on the floor with kids, maybe you know in that isolated OT room, sensory plans in hand, in fighting for meaningful participation one student at a time. But over the last two decades, Nicole has moved from school-based OT to behavior coach to special education supervisor to director of prevention and wellness, and now to the executive director of Mindpiece, a nonprofit supporting mental health systems across 250 schools in Southwest Ohio, and while none of these jobs had the familiar OT initials in their job title, Nicole never stopped thinking like an OT or using what she learned as an OT to best support the teams that she supported. In this episode, Nicole and I dig into what it actually looks like to bring an occupational therapy lens into an administrative leadership position. Why she believes we're not in a mental health crisis, but actually an intensity crisis, and how OT practitioners belong in tier one conversations about discipline just as much as they belong in an IEP. If you've ever felt like OT is being overlooked at the table, or wondered what's possible beyond a traditional caseload, this one's for you. I'm Jayson Davies, and this is the OT Schoolhouse Podcast. Let's dive into this episode with Nicole Pfirman. Amazing Narrator Hello, and welcome to the OT Schoolhouse 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 Hey, Nicole, welcome to the OT Schoolhouse podcast. I am excited for today. We have been planning this for a while. I'm glad that we finally have a chance to sit down with you. It's summertime, so yeah. Thank you so much for being here. Really appreciate it. Nicole Pfirman Yeah, thank you. I am so excited to be here. Definitely love the opportunity to come on and talk about occupational therapy, which is not necessarily something I get to talk about as much as I would like these days. Jayson Davies Right, and it's you have had a lot of different roles in your OT career. We're going to get into some of those because I love how you have transitioned now from 13 years as a school-based OT to kind of in this more supervisory and now even administrative role. And we're going to dive into all that. But you sent over your bio to us, you know, just for the reason for the podcast. And there was one line that really stood out to me, and I wanted to get more of your take on that. You said that you have focused on aligning educational and medical models through collaborative, multidisciplinary approaches that support the whole child. Now, I just want to get your idea on that because a lot of times we don't see focusing on educational and medical models in the same sentence. A lot of times, people are trying to actually differentiate the two. So, I'd love to get your thoughts. Nicole Pfirman Yeah. So, I think one thing that I found out pretty quickly in my career, starting in the medical model setting and then switching over the educational model, was just the disconnect or the misunderstanding between how those two systems need to be integrated to really support students, youth, adults, but you know, in the medical model, everything was about treatment. It was about diagnosis. It was about specific goals. And yeah, those things were true in the schools as well. But the real truth around educational model is understanding how all of that then integrates into a classroom setting, or onto a playground, or into the cafeteria, and so I feel that throughout my career, a lot of the conversation that I've had with other colleagues is how do we bring what works in the medical space into the educational space, and vice versa, so that kids are getting consistency and continuity and care, and not something completely different in medical model than they are in educational model. Jayson Davies I really appreciate that answer because I've long said like that you know a lot of times the difference between educational and medical model to a degree is like the goals, right? Like in in school based OT, our goals are more educational versus in clinic based. Typically, you know more ADL and and functional living skills, but the way that we go about developing our treatment plan and the modalities that we use aren't necessarily confined by the setting that we're in. I don't know if you want to follow that up or if you have different names. No, Nicole Pfirman I agree with you. I think I mean when we look at it from like the goal perspective, yeah, obviously we have educational goals, we have medical medical model goals, but I think the other piece too is that oftentimes I felt like in either setting there was a silo in working on and achieving those goals, and that in a school setting you really had the opportunity to bring what you know from a medical. The model lens into an environment in which kids naturally progress through a variety of different areas during the day, and the goals can't just be siloed to what are we doing to work on fine motor in the classroom setting? What about what are we doing to work on fine motor in the cafeteria and outside? And how is that generalizing to the community environment? And then how are those goals also helping to achieve maybe the private OTs goals that are being worked on in a medical model setting? So, really, just the integration of systems, I think, is so important. Jayson Davies Yeah, yeah, absolutely great. Well, thanks for for for answering that one. It was just something I was reading your bio, and I was like, this is a great place to start because I think a lot of OT practitioners struggle with that. Whether we, you know, it's one of those things where even when you believe something, you still question yourself all the time about that. I feel like, and so it's always a good discussion. Now we're going to talk about your, you know, supervisory and administrative roles first. But you were a school-based OT practitioner, you know, in the thick of it for 13 years, and I would love to hear a little bit about those days and how that shaped who you became as a leader. Nicole Pfirman All right, yeah. Well, that's something I love to talk about. So, actually, you know, I started my career. It definitely was not a linear path, starting in adult rehabilitation and psychiatry. In my short period of time of doing adult rehab and adult psych, I quickly realized that pediatrics was something that was a calling of mine. I wanted to do that type of work, focusing on mental health and behavioral concerns, but with younger children. And at the time in 2003, 2004, there really wasn't a space for being able to provide what I felt like was mental health or psych treatment or care to pediatric in pediatrics unless you were in a school setting. And so when I made my shift over to the school setting, I I was pretty particular that I did not want to be a traditional school-based therapist. I wanted to be a school-based therapist that was working towards changing systems, that was working on program development, that was really being able to improve youth and young children's mental health outcomes through participation in meaningful occupations. And how does that look different than how historically OT was provided in a school setting, so I spent about eight years in the space of specialized programming for kids who were in a classroom of about six kids to one adult, severe to profound autism and other neurodivergent disorders, working mostly on behavior modification and sensory integration, so that was the core of the work I was doing as a clinician before moving on in my career. Jayson Davies Gotcha. And now you did have that, you know, emphasis in mental health and behavioral support. And in 2003, like that was the big, you know, autism rates were just climbing, and so I heard you say you wanted to focus on mental health and behavioral support. But then on the flip side, kind of at the end there, you really talked about doing a lot more sensory and fine motor type of stuff. Was that a bridge that you kind of had to like gap from the from the sensory fine motor to mental health, or is that kind of something that you've managed to kind of just seamlessly do together? Nicole Pfirman Yeah, I mean, honestly, I would probably say that it was a seamless integration. I think working on fine motor and sensory skills and isolation really didn't mean much to kids who were struggling with intense behaviors, who had a loss of connection, who had difficulty participating in normal occupations or routines during the school day, and so I actually probably functioned more in the mental health and wellness space and integrated fine motor and sensory activities into those spaces. So, for example, I used a lot of multisensory environmental approaches, a lot of vibration, a lot of low lighting, a lot of vibroacoustics, and in doing that, also worked on fine motor skills, but in a very calm and and sensory based setting versus in a sterile classroom setting. And I think you know at the time, as you mentioned in 2003, autism rates were really starting to climb. Schools were struggling with kind of what what was the programming that would be successful for students. And I think in in designing a program that worked for some of our most severe to profound students with autism, we also found that so many of the things we were doing and specialized programming also would benefit kids who just were having behavior or mental health concerns in the general education environment. And so, then, how did we start to integrate those things in a way that you didn't have to be in specialized programming to benefit from these environments, the sensory activities, the other types of mental health supports, and that really was the catalyst to a lot. The work that I continued to do over the last 20 years. Jayson Davies Wow, I'm struggling right now because I want to continue on. But one of the things that I that I kind of gleaned from this last response here, sensory integration and mental health, like those are honestly, when you think about it, sensory integration, your your sensory processing absolutely impacts your mental well-being, but that said, we don't really see that. Like it's not; those aren't two terms that are often put together. Whether it's in the research, in the IEP room, you know, in professional development, we we don't often hear sensory integration of mental well-being or mental health in the same sentence. But you just kind of align them together, and and that's unique, I think. Nicole Pfirman Yeah, well, I think that is a huge miss in our profession in general. Honestly, to not be tying those two things together more closely. When you think about kids with significant mental health concerns, often trauma difficulties with resiliency, difficulties with regulation, low participation and engagement, and then you think about sensory integration, and you think about the heightened trauma response also impacting sensory integration, the intensity of behavior impacting the ability to regulate and or and vice versa, and so really, if we're talking about improving mental health, we also need to make sure that the sensory systems are working appropriately and in the same lane as we are when we're working on mental health outcomes. We can't do trauma-informed care if we have a dysregulated sensory system. We can't teach kids how to regulate if their sensory system is dysregulated, and so why are those two things not more commonly talked about? I'm not sure. I did often wonder when I worked with kids with severe behavior. One of the first things I did was implement a sensory diet, and these were not kids with sensory integration concerns. They were not kids on the autism spectrum, but I knew that if we found the right regulation activities, we could get generalization in the classroom just from traditional behavioral approaches. And it, I think, was one piece for me that anytime I'm looking at a student with mental health concerns or behavioral concerns, the first thing I'm thinking about is: Are their sensory systems regulated? Jayson Davies Yeah, yeah. Wow. You know, we've been talking all of seven minutes, and I can already kind of feel an answer to this next question here. But you know, you were realizing all of these things pretty early on, and then you started to look toward program development and supervisory roles, and and now even administrative roles, so I'm curious how you feel that your background as an OT really prepared you and maybe even incentivized you or made you the best candidate for some of those supervisory roles. What are your thoughts on that? Nicole Pfirman Yeah, well, I think that's a question I get a lot. I think the through line of participation and engagement in meaningful activity or meaningful occupations really is what has led me in all of the positions that I've had. When when you're talking about working one on one in a clinical setting and you're talking about meaningful occupation and participation. What does that look like? But then, as I moved on in my career into more administrative roles, it really was about participation at a classroom level, or at a building level, or at a system level. And even now, in the work that I do, looking at it at a regional level, it's the idea of looking at participation, trying to determine what are the barriers to participation, and then how are we focusing on meaningful occupation to get the results that we want from kids, regardless of the concerns that maybe are arising? Jayson Davies Yeah, and you're in Southwest Ohio. You have your master's in education. Was that a requirement for you to get some of these positions, or what made you decide to to get your master's in education? Nicole Pfirman Yeah, that's a great question, and that was also by chance. So when I started my OT education, I was actually at Indiana University, and throughout my time there, I found that Xavier University offered a dual program, and I had enough transfer credits to get both my post baccalaureate and OT, and also my master's of education administration at the same time. And so I transferred during my educational career to Xavier so that I could end my four years with both a post bacc and masters in education administration. At the time, I actually thought that it was hysterical that I was going to have an education degree, and I think some of my college colleagues would say the same because I was like, I will never use this. But it was I wanted the master's degree, so I ended up getting it. And what was so. Interesting to me about that connection is that the second I stepped into the school setting and really got into the work, I thought, "Oh my gosh, it is so great that I got that education administration degree because it's going to help me in these leadership positions that I'm interested in. But I will tell you that even moving from clinician to behavior coach was not easy, regardless of having the education administration degree. It was a position that I had to advocate for. It's a position that I had been told no to multiple times. In fact, there were two people that were hired in that same position prior to me basically begging at the time, like please, I know I'm an OT, but let me try it. I'm telling you, I can do it in a different way than what you've seen before. And it was because they were coming at it from traditional, you know, ADA approaches to behavioral concerns in the school environment, which is great for some kids. But really, it wasn't a system. It wasn't a system move. And so, yes, I think having the educational administration degree helped. It was not a requirement in Ohio, but it was a requirement once I got to central office leadership, and so that was definitely a benefit there. But in the early days of moving through leadership, it really was about advocating for what OTs could bring to the table. Jayson Davies Yeah, yeah, so interesting. Did the original, you know, the first two times that they posted that job description, did it have something in there like must have teaching experience or anything like that? And did you have to eventually get that removed? Nicole Pfirman You know, it's funny. The original job descriptions were very ABA based in that you needed to have been a behavioral analyst, or you needed to have been a teacher, you needed to have direct classroom experience, and the pushback that I always had with that was a as an occupational therapist we do analyze behaviors. It's something we do for a living, regardless of the setting. Jayson Davies Absolutely, Nicole Pfirman and also I had spent eight years in and out of classrooms, I didn't need to be the teacher to be able to understand how the system worked, and so helping them to redefine the scope of occupational therapists in a school setting was really what had to be done in order to for them to see me in that role. Because I think you know, as you would probably agree, historically our role has been pretty siloed in a school setting. There are very few school administrators that I work with that, if I ask them what is the scope of an occupational therapist, that they can actually answer with the scope of work we do. And so it was it was definitely convincing the school that my OT lens would be beneficial in that space, Jayson Davies yeah. You were at the district for 13 years, I think, before before you moved into a supervisory role. How many of those, you know, how many years at the tail end was you trying to convince them this is a job that you could do? Nicole Pfirman Yeah. So I I was actually probably treating for 11 or 12 years, and then in the next two or so years, I was in what I would consider like a trial period of being a behavior. It wasn't a trial in their mind, but in my mind, it was like, no, I I need to take these couple of years and prove to them and prove to myself that really this is the role for an occupational therapist, and so it was during those two to three years that I think it was my proving the worth of an occupational therapist in that space that then really helped me get into the actual leadership positions that I was in the last eight years that I was at that district. Jayson Davies Well, two things come to mind. One, that's kind of you know a benefit to staying in one job for a while, right? People get to know you, they get to see you, they get to see the work that you're doing. And two, they often say like, dress for the job you want, not the job you have. It's like you were kind of doing that, right? You were you were doing the job you wanted, not necessarily the job that you were assigned to at the point, and and you had to prove to people right that that you wanted that, and I think that is something that that we have to do to advocate for occupational therapy sometimes, and we have to be willing sometimes to have that short term pain per se of you know trying to do something while also having a high caseload. And I know it's not easy. I've done that, you know, but it's amazing what can be on the other side of that when when we're you know put the effort energy time because it does take a lot of time to do that extra work and to show people hey we we can support behavior and we can support teachers and yeah Nicole Pfirman and that is something I would love to see OTs do more of right is that we advocate for why we have a desire to be in the room, or a desire to have a seat at the table, and I think so many times we limit ourselves by not bringing our skill set and occupation to every conversation. You can tie occupation into every single career, every conversation that happens. You can tie in occupation, and so why are we not doing? Jayson Davies Absolutely, absolutely, yeah. But let's just end the podcast here. No, all right. We're going to take a quick break, but when we come back with Nicole, we're going to start to talk about some of the programs and the systems that she's developed over time in her various different roles. Okay, we're going to start to get to this transition where you, you know, became that behavioral supervisor. But before we do, were you already starting to create programs in different you know formats while a quote unquote traditional school based OT? Nicole Pfirman Yeah. So a lot of the programmatic work that I was doing as a school based OT was with a team. So it was with an incredibly talented special education teacher that I worked with. It was with a speech therapist. We also had PT and we had school counselors and school psychs. So of course, I was one of the individuals helping create programming. But I think what was my specialty really was multisensory environments and how we could use multisensory environments to change behavior, and that was something that really hadn't been done before. It was like, oh, this child is struggling. We're going to take them to the sensory room, or this child sensory diet, and we're going to maybe do this a few times a day, right? But the idea of creating programming in which preventatively we were using multisensory environments to stimulate the sensory system, so that when we sent kids back into the classroom, that their sensory systems were regulated in a way that they could stay there, participate meaningfully, and not have behavioral concerns that were getting them removed from the classroom. So my time as a clinician really was spent on developing multisensory environments more so than specific programming or treatment modalities. Jayson Davies Okay, but when you say creating multisensory environments, what what did that even look like, and how did it kind of get started? Nicole Pfirman Yeah, well, it was probably about 2006, I would say. Really, it was pretty early in my career, and I had read a research article on a snoozeling environment. And at the time, snoozeling environments were being used in adult psych or nursing home type settings to help to regulate adults who were in crisis. And the idea of a Susanne environment is to use vibration and vibroacoustic lighting to stimulate the nervous system in a way, in whichever way you want to stimulate it. So there are activities that you do to rev up the nervous system, and there are activities that you do to calm down the nervous system. A lot of proprioception, a lot of vestibular input, and I kept thinking, why is this not being used in a school setting? I mean, it was bright lights, it was colorful activities, it was you know equipment that looked fun, and I thought kids would love this. Like, how come we're not using this in a school setting? And so, at the time, Ohio had a grant at the Ohio Department of Education, that was for preschool, in particular, and so the special education supervisor and I at that time were struggling with a lot of kids who had just they were in general education, but they were being removed from general education consistently. You know, every day at 12 o'clock, this child's being removed from the class because they've escalated in their behavior, and so we wrote a proposal for this grant funding to bring a snoozlein environment to our school building, and we got the grant funding. We spent about 35 or $40,000 that first year creating a state-of-the-art snoozelin' environment. Everything was, you know, snoozling designed, and we used a company up in Canada actually that helped us to design this for a pediatric setting. And for that first year or two, we just took data on general education students' behaviors. So we identified students across grades preschool through second grade who were being removed from class, who were being disruptive, who had trouble with peer relationships or trouble regulating, and we started scheduling them in our snoozle environment in 10 minute increments once or twice a day, and then watching their behavioral change over time, and we saw incredible behavioral change. Things like 60% reduction in classroom disruptions, 40 or 50% of reduction of needing to be removed from the classroom, increased participation and engagement just after being in the environment. And what's so unique in that programming space is it really was about the environment, so that was a no-talking environment. We would take a child in one-on-one. They would move through a rotation of the activities in a very dark space with vibroacoustics that lit up in response to different types of stimulation. So we would use stimulating music, or we would use calming music. Based on which behavior we wanted to come out of that environment, but we as the therapist were really just supervising. We were making sure that the child kind of rotated through these activities, but but we were not actually working with them. You know, we weren't doing hands on. There was no hands on. It was just environment itself that was being used, and that to this day is still being used in that district for kids every single year with the same types of benefits and outcomes, and I think that that was really the the catalyst for me that we were waiting too long to give kids the supports they needed, whether it be for sensory or behavior. And what if we just started giving kids the supports they needed when they needed it, versus waiting until a diagnosis came, until an IEP came, until we had to sit down and write a goal, and that environment really allowed for that. And so that that then was kind of a throughput, and still is in the work I do in meeting kids' needs when they have the needs, and not waiting until there's such a significant impairment that we are working backwards, Jayson Davies and even after that, it took the district like another five years to figure out that they should make you a supervisor some kind. No, I'm kidding. You said it still exists there. Is it still the OT supervising, or have they transitioned to the OT training someone else to supervise? Do you know, or even so, Nicole Pfirman by the time our like pilot of the room was over, we had transitioned it to paraprofessionals, to teachers, intervention specialists, speech language pathologists, anybody who was working with a student that felt that the student would benefit from that environment. Now it is a scheduled environment, so if you go at 12 o'clock, you go at 12 o'clock every day. Okay, so it is like who's with you at 12 o'clock as a younger child. That's the person that's likely going to take you to the room. Um, it's not the type of room you would take someone to in a reactive state. Um, you get the benefit from that proactively. Jayson Davies Yeah, so interesting. Um, thanks for sharing that. That that's really cool. But it it's really awesome to to hear that you were already kind of doing this stuff before you had to take on an administrative position. Like this is something you took initiative on and got started with it. And it sounds like it was a tier one, maybe a tier two type of MTSS thing before MTSS was even a thing. So yeah, that's really cool. And then it sounds like eventually you kind of parlayed this a little bit, you know, this experiences and grant writing and all that fun stuff into the behavior support role. That was the next role, right? Nicole Pfirman Right. Yep. So after being a clinician, I moved into a behavior coaching and then a behavior supervisor role. And in that role, really, what I did was respond to kids in crisis, and create behavioral support plans. And if you would read a behavioral support plan of mine, you would say this is an OT plan. So much of it is proactive sensory supports. It's about the time out, time Jayson Davies out, time out. Are you are you free? Like august 12, we're gonna have to do a podcast just on behavioral support plans. Like we'll have to do that again sometime. But go ahead and continue. Yeah. Nicole Pfirman So, so much of my role there was just a continuation of the OT and sensory work that I was doing programmatically to say when we're responding to kids' behaviors, are we seeing the behavior as a behavior, or are we seeing the behavior as a symptom of something else? And if we're seeing it as a symptom of something else. Our role is to do a root cause analysis. Our role is to figure out what is causing the behavior, and then put in the supports proactively to prevent that behavior from happening. So, really, in my behavior coaching and supervisor role, it was just that. It was designing behavioral support plans that were heavily sensory based and proactive, and then also designing response plans for what it looked like to respond to a student in crisis, what it looked like to remove them from the classroom. How are we consistently following systems so that students have come to an expectation of what we need from them to to regulate and to calm down? And so that was then my work for the next two or three years, was really just putting systems in place to change behavior, but not change the behavior just based on what we were seeing in the classroom. Change the behavior based on the root cause. Jayson Davies Yeah, and last time I checked, you don't have a BCBA after the end of your name, right? Nicole Pfirman I don't. Jayson Davies Just the just the OT and the MED. Awesome. Okay, so a few episodes ago, we actually had a colleague of yours on the show, Brianna Lynch, and she shared that she was on one of your teams and and worked along with you. I believe it was on the prevention and wellness department team that you put together, and so I would love to hear a little bit about that. Was that around the same time during the behavioral time, or was that at a different point? Nicole Pfirman That was at that was actually when I was a special ed supervisor for the district. So once I once I moved on from behavior coaching, I moved into special education supervision and oversaw elementary special education for a group of our students. And it actually is kind of funny. So. Brianna Lynch was actually applying for a traditional school-based OT role. Jayson Davies Yeah, Nicole Pfirman and she was new grad, had only worked a couple of years, I think, and we're sitting in the interview. And I already had this idea of creating this prevention and wellness team, but I wasn't sure that people were going to buy in that, and by people I mean administrators. That they were going to buy in that OTs should be on this team. I think they were thinking it'll be school counselors and it'll be school psychologists and it'll be other support professionals, which of course even Jayson Davies after Nicole Pfirman even after even after Jayson Davies all the work you had done, Nicole Pfirman yeah, this is this has continued for the last 20 years, really. But um, she sat at that table for the interview, and she walked out of the interview, and I was like, "Okay, yeah, we are going to hire her as an OT. And then I turned to the other supervisor in the room, and I said, "What if we actually offer her the job of prevention and wellness coordinator? And she looked at me, and we said, "Let's go find her. We like ran out into the parking lot. We were like, "Hey, we know you just interviewed for this OT job, but what would you think about interviewing for the prevention and wellness work, but bringing your OT lens as the core to the position? And Brianna was super excited. So she was the first OT that I hired in prevention and wellness work, and lucky for me, she's also going to be joining me in my new organization as well next year on a on a part time basis to help me bring OT back to the space in other places. Jayson Davies Awesome, congratulations! That man loves. It's a small world. It's always fun when you get to work with good people and find good people and and keep them around. That's awesome. I love it. Awesome. All right. So we talked a little bit about your original the the original room that you developed, very much behavior centered. You did become the behavioral behavioral coach, writing support plans, coaching teachers, and then you became an administrator, and you were still focusing on mental well-being, mental health, all that. Were there other programs that we haven't discussed yet that you know, or things that you're just really proud of, and things that you were able to kind of do during that time with the school district? Nicole Pfirman Yeah, I think I mean honestly, my biggest passion area or success that I had in school-based practice really was the development of the prevention and wellness team. The idea that when I was a special education supervisor, I was always questioning why we wait until kids are on an IEP to receive services. But at the same time, I was struggling with the fact that mental health really was becoming a concern in schools across the country, and mental health and wellness and behavior were often tied to the special education systems, and to me, that was the completely wrong way to view mental health, wellness, and behavior. Every human has mental health. Every human has behaviors. Every human has a need for wellness. And so, to keep that siloed in special education really meant that our systems were going to be reactive or responsive in nature, versus looking at prevention and wellness in a proactive, foundational way, in which that is what drives outcomes, and so we can't say that we actually care foundationally about student mental health and wellness if we're waiting to address it until there's a problem, and so that's something for me that I am very proud of in the work we did. I worked for an incredible school district with incredible leaders who believed in the work that I was doing, and also had an innovative mindset to say how can we do something different. And I think that that team in in itself was just a continuation of great work that was already being done. All these folks that were in this school district were already doing the work, but how do we systemize it? How do we systematize it? How do we take something that works for one kid and take it to scale so that it works for all kids? And that really was my goal with prevention and wellness work. And I think what I'm grateful for is to see that so many other schools across the region, across the country, have moved in that direction over the last eight years as well, to really say that mental health and wellness should be foundational to what we do in schools every day. Jayson Davies Yeah, and let's talk a little bit about that that team a bit more. You had Brianna, an occupational therapist, acting as a coordinator. What other professionals were you, you know, looking to bring on and be part of the team, Nicole Pfirman yeah. So the prevent the idea behind the prevention and wellness team really was to make it a multidisciplinary team approach. I feel that kids get the best care when there are multiple disciplines sitting around the table, all with the same common goal and theme to improve outcomes for kids, and so on. That team. My initial team was a school social worker. Brianna was an occupational therapist. A one of the other prevention and wellness coordinators was a intervention specialist who had worked specifically with kids with severe behavioral disorders. We also had a school counselor on the team, and then let me think the last oh and then we had a resource coordinator so somebody that could work with families to just provide the connection to the community which is something that I felt like schools really had a gap in we put a lot of things in place for kids at school or we put a lot of place things in place for kids in the community but who's connecting that to the life outside of school so we used this team to kind of make a three-pronged approach of the student, the environment, and the community. Jayson Davies Sounds a little bit like the PEO model, a little bit, right? Okay, so so you had this team. Was this also grant funded? Nicole Pfirman No, actually, we when we started this team, it was through reallocation of supports. At that time, our district was willing to invest in the work of student mental health and wellness, which was a huge help. But really, what we did was we reallocated some roles. So we didn't do excessive hiring. I think we only actually hired Brianna. The other roles, we just took roles that were already in place, and then kind of redesigned what they were going to be doing during the day, and and what that looked like from a support model instead of a direct service model. And that is a unique difference too. Is that the prevention and wellness team really was support model versus direct service model. So we were supporting also staff who were directly servicing kids. So how are we working with the school counselors who are seeing the kids? How are we working with the therapists who are doing direct service? Really, from a consultative and collaborative standpoint. Jayson Davies Yeah. So I imagine there might have been like a few stages or like a an action plan, right? I'm assuming that some of these team members needed to get some education. I'm assuming they brought some of that education back and shared it. Was there kind of a plan laid out, and is that something that that you can share a little bit, or the ultimate goal? Nicole Pfirman No, I don't. You know, I'll be really transparent in that initially the plan was to create a team that could support mental health and wellness outcomes for all students, all students, all staff, all families, and it was a build the plane as you fly it type. That's Jayson Davies what happens sometimes because Nicole Pfirman all of us were skilled in our individual professions, and all of us, I would consider experts in the work that we were doing. But then to come and sit around the same table and say, okay, but how are we going to change the environment? How are we going to change these huge systems like discipline, attendance, homelessness that have historically really negatively impacted kids for the most part, and how are we going to take our collective expertise and try to change these systems? So when I think about our initial plan, it really centered around behavior and mental health, and and what I mean by that is aligning partnerships, bringing outside partners into the school, providing education, providing training to staff, providing training to parents, connecting families to resources-that really was the initial plan. And then COVID hit, and when COVID hit, the multidisciplinary team went into overdrive, and we really became the connection for a lot of families who were struggling with kids having behavioral crises at home? Kids who were struggling with the routine change, the inability to participate in meaningful activities, and so then we became kind of an extension of a social service model during that period of time during COVID, in which we really were helping families to navigate something that none of us had walked through. Yeah, and everybody Jayson Davies was struggling with. Nicole Pfirman Yeah, and and I mean, and I think that then became a lot of the goal of the team moving forward was that we wanted a multidisciplinary team that supported the whole child, and it needed to be both in the school environment and in the community as well. Jayson Davies Wow, just happened to have this team available when. Yeah, Nicole Pfirman honestly, honestly, I think back, and I'm like, it was by fate that we had this team in place before COVID hit. Now, of course, all of our other professionals took a huge lift during that time too. Right, teachers were incredible, counselors were incredible. Psychologists were incredible. We just had this bonus in our district to have an additional team to support families during that time. Jayson Davies Yeah, yeah, awesome, love it. All right, well, we're going to take our final break, and when we come back, I want to talk more about your current work with Mindpiece and how you're kind of using that to expand a lot of the work. You've done at the school district to other districts. All right. During the break, I had one more thought that I wanted to ask you. Now, you did have Brianna come on, and she was kind of your pseudo OT, not working as an OT, but as an OT. Were you going to use one of the district OTs before you found Brianna? Nicole Pfirman No, honestly, I wasn't. Initially, I thought, well, I'll be the OT representative. Jayson Davies Ah, okay. Nicole Pfirman So because I wanted a multidisciplinary team, I thought, well, I have the OT lens. But what became clear in choosing Brianna was that as the leader of the team, I was able to remain neutral, and she was able to have the OT voice in most of the conversations, which I think was a healthy balance in leading a brand new team. That that I myself was not the only OT voice. Jayson Davies Gotcha. Yeah, I wanted to ask that because I have often, you know, and I have no research behind this or anything, but I often have this feeling like the last people that a special education director is going to reach out to for a team is the OT, because typically the OT is also and the speech therapist are also the people that are screaming from the rooftops. My caseload is too high. I need more support. Like, and it's fair, right? All of our caseloads are high, but that's also going to prevent people from asking us for help when it comes to like programs like this, and so that's why I wanted to ask you. And I don't know if you have any thoughts on that idea. Well, that Nicole Pfirman that really does go back to what I always say, which is OT deserves to have a seat at the table or should be advocating for a seat at the table. And when we talk about OT caseloads, yes, they are high. So are a lot of support professionals in a variety of fields. But in some way, I would push that thought to say, are our caseloads so high because we wait too long to get the OT involved? And when we actually think about occupation, and we think about participation, and we think about the real skill set of an OT. I think we could mitigate a lot of high caseloads by accessing, allowing students, families, staff to access the knowledge base of an OT at a much earlier time. And when we do that, I think truthfully, a lot of the skills could be generalized in a way that other professionals could be working on them, and we're not waiting till the moment of crisis where we have to go through an ETR or an IEP and diagnostic criteria, and that that's the piece that I think to me is where having the OT having a seat at the table in early planning conversations is vitally important, but doesn't have a lot. Jayson Davies Yeah, yeah, absolutely. And you have a unfair advantage that 95% of OT practitioners don't have that you have sat in a lot of district level meetings, you know, upper management meetings, and I mean, obviously, you're an OT. People, I would assume that you work with know your background is an OT. Some may not understand what the OT behind your name means. But when you sit in these meetings, a is OT even a conversation ever? And B, what are those conversations about? Nicole Pfirman Yeah. Well, to me, occupation is always part of the conversation, right? So when I sat in leadership conversations, I wouldn't necessarily always be calling out my lens of an occupational therapist, right? But I would be talking about things like if we're going to talk about attendance, why are kids not coming to school? Where is there a gap in participation? If we're going to talk about discipline, where is the root cause of the discipline concern itself? If we're going to talk about why kids are not achieving the way they should be, is there a lack of relational connection? Is there a loss of meaningful participation? And so, those are the words I would use in leadership conversations that brought the conversation back to OT. Yes, there are lots of conversations I sat in where it might have been unclear that I was an occupational therapist, but if they listened to me long enough, they would hear the common thread of participation, engagement, relational connection, sense of belonging, and when we had those things, outcomes improve. So honestly, I feel like having an OT lens really allows you to move system change at a faster pace than just having had an educational lens, where all I knew was the classroom environment. Jayson Davies That is a powerful statement, and yeah, with that, I'm going to leave it. I'm going to let that one sit. But I do want to talk about your newest work. You have now been at Mindpiece for a few years. You are the, I guess. The The executive director to be very very soon. Congratulations on that! And it sounds like you're really this is an you know you're bringing all your past work together now to not just support one district but to support all of Ohio or at least the southwest part of Ohio. Please let share a little bit about how Mindpiece operates and what you know what they're doing and what your goals are. Nicole Pfirman Yeah, so MindPiece is a nonprofit in Cincinnati, Ohio. We support about 250 unique schools, 36 school districts, and really the way that I explain at a 30,000 foot level is that we stand as a neutral partner between the educational and medical model, and our role at Mindpiece is to facilitate partnerships, expertise, collaboration to change systems that improve mental health outcomes for kids. That might look like treatment. That might look like bringing treatment providers into a school setting, into the natural environment to allow for more engagement and participation in the treatment plan. When they are in their natural environment, we know they're going to attend more frequently. We know that they are going to participate more willingly. And so, bringing the connection of mental health providers into the school setting in a consistent way is a core foundation of the work we do, but changing mental health outcomes for kids does not stop with just putting a treatment provider in place. It starts the second the child walks into school. It starts on the school at the school bus stop. It starts on the school bus in the cafeteria in the hallways. And so, really, our role at Mindpiece is to see system change. I often say when I it was a hard it was a hard pull to get me to leave the incredible district I was at I often still sometimes think like oh if I could just go back for a day how would I do things a little bit differently but really what MindPiece gave me the opportunity for was to just increase the size of my caseload and the reason I say that is my caseload was initially starting as a clinician. My caseload were individual students. When I was a behavior coach or a supervisor, my caseload was an entire building. When I was the prevention and wellness leader, my caseload was the entire district system. And now, what I've been able to do is have a caseload of the entire region to look at how systems are improving or inhibiting outcomes for kids at a regional level, and if we start to actually do things that are focused on system change versus trying to change the kids or trying to change their diagnosis, I really think we can change outcomes in a much broader way for kids, and I would say that my biggest question I still ask at Mindpiece is, what's preventing participation in school, Jayson Davies yeah, Nicole Pfirman or in the treatment setting, and oftentimes meaningful occupation. Jayson Davies Yeah, Nicole Pfirman that is what's preventing participation. Jayson Davies That's awesome. So, so have you have you kind of been taking the programs that you had done before you got to MindPiece and trying to implement some of those? Are you creating new programs? I know that you were the director of school-based mental health systems before you, you know, eventually are now the executive director. But in that, you know, the first role that you had with MindPie's was that helping districts implement programs to a degree? Nicole Pfirman Yeah. So MindPiece is not a direct service provider, so we are a consultant really in the work. So what my role was is to press on school leadership teams to create systems that were responsive to the needs of their students, and so it looked a lot like talking to school leaders about their current district policies and procedures around discipline, attendance, homelessness, chronic absenteeism, achievement levels, and then connecting that back to the mental health outcomes they were hoping to achieve. And so, looking at do you have programming to address these needs? Do you have partners that can come in and help? Do you have mentoring programs? Are is the community coming in and work helping you work towards these same goals? So it was it was more consultative, and it still is in helping schools to see how all of their systems that are working in silos will actually improve outcomes if you start to integrate them. I think schools, to me, have always figured out a way to integrate the child, but none of the systems are integrated. And so, what if we start looking at actually integrating systems, and then we integrate the child into that? Won't our outcomes be improved? So we we definitely are not a program provider, but I believe that wellness in a school setting is more than the wellness program you have or the wellness curriculum you have. Right? It really is about how all your systems work together to. Towards the same goal for kids, which is that we want healthy contributing adults when they leave the K 12 environment for whatever path they may choose. They need to have an understanding that there's meaning in life, that they have a choice in participation, that there are occupations that bring them joy. One of the biggest things I talk to districts about is what brings your kids to school every day? Jayson Davies Yeah, Nicole Pfirman you know what? Why are they coming? What's their spark? What's their joy? And if you don't know it, you really need to find it because that's what's going to keep kids engaged. Jayson Davies Absolutely. Again, you you have this unfair advantage. You talk to a lot of people in leadership here, and so I'm going to ask you this one: What trends are you seeing right now when it comes to districts and wanting to, not wanting to, not being able to afford whatever mental health services and being able to provide the best mental health services for their students. Nicole Pfirman Yeah. So, well, at MindPiece, one of our goals is to have financially sustainable models, independently financially sustainable models, to bring mental health treatment to kids in their school environment, but I would say that some of the biggest barriers continue to be funding insurance, private or public funding. Obviously, we've done a great job. I feel like in this country on decreasing stigma around mental health concerns, but we're not there yet. We still have a lot of stigma in in certain communities. I also still believe that there's a bit of a lack of understanding of how how to change the academic pressure that kids are under and change systems to be more proactive and upstream versus looking at academic outcomes as the goal. So I think those are some of the barriers. I think the other patterns that we are seeing in schools is what I would call an intensity crisis. And I I could have brought this up earlier, but I think that you know if you're talking to school leaders over the last 10 years, you hear constantly, "We're in a mental health crisis. We're in a mental health crisis. That kind of becomes a crutch in a lot of ways. If if everything is because of the mental health crisis, it's really easy to not change systems. I believe we are more in an intensity crisis than we are a mental health crisis, meaning that the intensity of the anxiety, the intensity of the trauma, the intensity of the behaviors is showing up in a different way, and that's what our teachers are feeling. That's what our educators are feeling. That's what we need to be responsive to. We've always had anxiety. We've always had depression. We've always had trauma showing up in our schools. We haven't always had every one of those with high intensity, and so what are we doing differently? What we were doing for anxiety seven years ago when we had mild and moderate anxiety doesn't work anymore. We now have severe to profound anxiety showing up in the classroom, and that includes escalating behaviors, more need for crisis prevention and crisis intervention. And so, how can we not change our systems to be responsive to that, and I think that's that's one of the biggest conversations that I'm having with school leaders, but also that I think about all of the time is that we are in an intensity crisis, and we are not going to move the ball forward if we don't change our systems first, and then look at like programs and partnerships and expectations. Jayson Davies So, if we if we kind of put this into an MTSS tier one, tier two, tier three, it sounds like we're saying we're seeing more tier three kind of in a way when it comes to anxiety and other mental health conditions. Well, I'll Nicole Pfirman interrupt there and say I I agree, but we're seeing tier three symptoms often in a tier one student, and that's something that we are not quite willing to look into. I think as an educational system, in that because you have tier three behavior doesn't mean you're a tier three student. Jayson Davies Yes, Nicole Pfirman because you have high anxiety doesn't mean that you're not also overachieving and a tier one student in all other aspects of your life, and so again, when we set these systems, sometimes it's like, well, if you're tier three, you get this support. Well, if you're tier two, you get this support. Well, what if you're a tier one student and you're just in crisis? Jayson Davies Yep. Nicole Pfirman Where's the support for that student? And so I think that you know it. It is a little bit of a upside down model in which tier three support should be also available for all students. Jayson Davies Oh yeah, I completely agree with that, and that's kind of where I was going with the question to to go a little bit further. Was like, do you feel like we have to do more tier one, more tier three, somewhere in the middle, and I would imagine. Obviously, the answer is all of the above, but it sounds like we need better tier one to start with to a degree, and then work maybe up from there. But yeah, wow, wow, that's yeah. I mean, Nicole Pfirman I believe, and and I know. Brianna may have alluded to some of this, or I have a lot of conversation around where we belong, right? As an OT, I think we belong in all tiers, right? At the tier one level, we we belong at environmental conversations, policy and procedure type conversations, activities or conversations around engagement and participation; those are all tier one activities, and we should be in the conversation at tier one, not necessarily providing the service. And then, really, when I look at tier two, we also aren't in the space of providing small group intervention in a lot of ways. That is just short term. That's addressing a short-term need. So I would love to see OTs at least be part of the conversation for all tiers of intervention for students. That would be my dream down the road. Jayson Davies Yeah, yeah, absolutely. We'll start to wrap up here. For anyone who is located in your general area, Southwest Ohio, and they're an OT, and they're like, "Man, we should really get in contact with you and with Mindpiece, and and make something work potentially, or at least you know connect with one another. Where's the best place for them to potentially start that process or reach out to Mindpiece? Nicole Pfirman Yeah, I love to collaborate with anyone from anywhere. I think being a thought partner in this work is so important. The best way to get in touch with us is honestly on our website, which is mindpeacincincinnati. com. You can find my information. You can find other team members' information. You can also find a lot of the resources that we use to consult with schools, but that would be the best way to get in touch with us. And please reach out whether you're an OT, a school leader. We would love to collaborate. Jayson Davies Fantastic! I just bookmarked mindpeacincincinnati.com on my browser because you said resources, and that is a that's an easy way to get bookmarked on my computer. So, all right. Well, Nicole, thank you so much. We really appreciate having you here. It's just, I mean, there's so many different things. We will have to have you back on to talk about behavioral support plans eventually. But I just love everything that you've done from from you know on the ground boots, school based OT, developing programs supporting students and kind of moving your way up is just so many things. It's so much good that that I see in the future for occupational therapy, and and you've done it, and you're helping others to do it as well. And so I just love it. Thank you so much for being here. Really appreciate it, and best of luck in your new role as as executive director. Congratulations. Nicole Pfirman Thank you so much. I appreciate your enthusiasm and time in this topic because it is definitely something that I am super passionate about. So, hope to connect again soon. Jayson Davies Absolutely, take care. Nicole Pfirman Thanks. Bye. Jayson Davies And that is a wrap on episode 208 of the OT Schoolhouse podcast. A huge thank you to Nicole Pfirman for joining us today and sharing so openly about her journey from school-based clinician to behavior coach to special education supervisor, and now as the executive director at MindPiece. I had never heard about MindPiece until I actually sat down with Nicole and learned about it, and it's just amazing what they are doing there. If you are in Southwest Ohio, please do look them up, find everything you can about them, and see if it's possible to somehow get your district in connection with them. If it will better support your students, your teams, and everyone involved, I've been really, really excited for you to hear about this episode. Not because you're in Southwest Ohio and can get in touch with Nicole, but I knew that this episode could be an inspiration to the many of you who love working one-on-one with kids, but also know the impact that you could have if you could just get into the educational system at an administrative level or at a district level, and even beyond just the students that you serve, but all the teams that you could support, and maybe even make an impact on the OT profession, and just so much more. So I really hope that this episode helped to kind of help you see that path or what it could look like if you decided to go down that path. And if today's conversation really did light up something for you, I want to make sure you know about the OT Schoolhouse Collaborative. The OT Schoolhouse Collaborative is our online community built specifically for school-based OT practitioners, where you'll find professional development, monthly mentorship calls with myself, a whole library of resources to support your practice, and so much more. To learn more about the collaborative, head on over to otschoolhouse.com/collab, and I hope to see you there. As Nicole reminded us today, OTs belong at every single table, especially in the educational world. Let's make sure that we're showing up. Let's make sure that we're advocating to be a part of those tables, to be a part of those tough conversations. I'll catch you next time on the OT School OTs podcast. Amazing Narrator Thank you for listening. To the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 207 of the OT Schoolhouse Podcast. What's really happening in school-based OT practice across the country? In this episode, Jayson sits down with Hannah Smiles, OTD, OTR/L, to unpack findings from a national survey of 331 school-based occupational therapists across 41 states, published in the open-access Open Journal of Occupational Therapy. Hannah and her research team examined the entire OT process — from referral through intervention — using the OTPF as a guiding framework, revealing that narrow referral patterns persist (handwriting, sensory, and fine motor still dominate), over two-thirds of OTPs aren't using formal environmental assessments, and most practitioners are operating in a "blended" workload/caseload model. Three major interconnected themes emerged from the data: role confusion, inconsistent leadership opportunities, and an incomplete transition to the workload approach. Whether you're looking for validation, language to advocate for your role, or a clearer picture of where the profession stands today — this episode is for you. Press play to discover where school-based OT stands today and what needs to change to move the profession forward. Listen now to learn the following objectives: — Learners will identify the most common referral patterns in school-based OT and recognize gaps in scope. — Learners will recognize the three major themes affecting school-based OT practice. — Learners will identify the unique value of school-based OT using research evidence. —Learners will identify practical ways to expand their role, advocate for involvement in MTSS/RTI activities, and move toward more leadership within their schools.
Guest(s) Bio
Hannah Smiles, OTD, OTR/L, is a school-based occupational therapy practitioner in St. Louis. She works with students across a wide age range, from kindergarten through vocational skills programming, supporting their development and independence in the school setting. Hannah is passionate about expanding the role of occupational therapy in schools and empowering OT practitioner leadership on school teams. In addition to her work on Perspectives of School-Based OT Practitioners, she has contributed to publications focused on health literacy and menstrual health management programming in schools.
Quotes "The role of the OT is misunderstood by the education team, but also by OTs themselves." — Hannah Smiles, OTD, OTR/L "Leadership can be getting in on a problem-solving team and advocating for yourself to be in the room." —Hannah Smiles, OTD, OTR/L "Some people feel stuck. Some people want to break out." —Jayson Davies, M.A., OTR/L Resources 👉Perspectives of School-Based Occupational Therapists - Open Journal of Occupational Therapy
👉Hannah Smiles on LinkedIn 👉OTPF (Occupational Therapy Practice Framework) 👉PEOP (Person-Environment-Occupation-Performance) Model 👉School Function Assessment (SFA) 👉Sensory Processing Measure (SPM) 👉Beery VMI 👉Sensory Profile 👉CHEC Assessment - Washington University 👉EFPT (Executive Function Performance Test) 👉Handwriting Without Tears 👉Zones of Regulation 👉Dr. Cahill's work on RTI/MTSS in school-based OT 👉OT Schoolhouse Collaborative

Episode Transcript
Expand to view episode transcript Jayson Davies As a school-based OT practitioner, there is something uniquely powerful about finding out that your colleague across the district and even across the country is struggling with the exact same things that you are. That referrals feel just as narrow, like sensory and handwriting, and that's it. That the workload feels just as impossible trying to squeeze 50 treatment sessions into a single week, and that the gap between what you know is best practice and what you can actually do feels just as frustrating. There's real comfort in knowing that you're not doing it wrong. That maybe it's not you, but maybe it's the system that is making things so difficult. If hundreds of OT practitioners across 41 states are running into the same barriers. That's not just validation; that is a signal, and that signal deserves a real, honest look. A team of researchers did exactly that. They surveyed 331 school-based OT practitioners nationwide and asked a simple but ambitious question: How are we actually carrying out the OT process within schools, from referral all the way through intervention, and how does that compare to what best practices actually call for? I'm Jayson Davies, and this is episode 207 of the OT Schoolhouse podcast. My guest today is Hannah Smiles, a school-based occupational therapist in the St. Louis area, and the first author of an open access study published in the Open Journal of Occupational Therapy. What makes Hannah's perspective especially compelling in this story is that she didn't just research this. After she conducted her research, she went straight into the schools and watched every finding play out in real time. Today, we're walking through what this data actually shows us, what it means for your daily practice, and why, despite all of it, one quote from a survey respondent just might reframe the way that you think about the value that you bring to your school every single day. Let's dive in. Amazing Narrator Hello, and welcome to the OT Schoolhouse 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 And welcome to the OT Schoolhouse Podcast. How are you doing today? Hannah Smiles Good. Thanks for having me. Jayson Davies Absolutely. And really quickly, where in the world are you joining us from? It's it's really awesome. I love the podcast. We get to talk to people from all over the country and sometimes even outside the states. But love to hear a little bit about where where you live on this great big earth. Hannah Smiles I'm currently in St. Louis, Missouri. So St. Louis from Chicago, but live in St. Louis. Jayson Davies Ah, very cool. And that's where you're working as well. Hannah Smiles Yep, I'm a school-based OT in a school in St. Louis. Jayson Davies Awesome, perfect. And now every few years, there seems to be an article that comes along talking about the perspectives of school-based OT practitioners. I don't know if this is unique to school-based OT. Obviously, I only look at really school-based OT stuff to see if there's perspectives to school-based OTs. I don't know if this happens outside, like in general outpatient Peds or in the adults world, but it seems to happen within the school-based OT world. And so, to kind of get us going here, I just want to know kind of like the why behind that. Why did you, Steve and Charlie and Lauren, who also worked on this article with you, say to ourselves, like, or say to yourselves, we need to look at the perspectives of school-based OT practitioners. Hannah Smiles Yeah, so we were kind of exploring the literature within school-based scholarship, and we were kind of seeing a lot of different literature surrounding different parts of the OT process, and there was a lot of information about best practice suggestions for OTs in schools, and we were kind of came up with the question of like, what is actually happening now? What are OT practitioners? How are they completing the OT process, and how does that compare to all of this literature in best practice? And we really couldn't find anything current that was the entire OT process and what that looked like in comparison to best practice to kind of see what it in our minds we were like in order to have actionable steps to move forward towards best practice we needed to know kind of where we stood, and so that's kind of how this this survey and this piece came about. Jayson Davies Interesting, because yeah, when I was talking about those perspectives of school-based OT practitioner research in the past, I know several of them have kind of been around the realms of caseload and workload. I know from Syria and Garfinkel, and I think that did come up in your paper eventually, but that isn't exactly what you necessarily wanted to look at, correct? Hannah Smiles No, yeah, we were looking at the OT process as a whole rather than individual pieces of intervention or evaluation or caseload with versus workload, for example. We wanted to get kind of a snapshot of how current practice trends are aligning with those best practice standards to kind of see because there's so much variation across the country and across school-based practice. We kind of wanted to see where we kind of stood in relation to all of these suggestions that come out for best practice to kind of start that ball towards moving us a little bit closer towards those best practice standards. Jayson Davies Yeah, yeah. And you mentioned that you're a school based OT yourself, right, in the St. Louis area. How did that impact? Kind of, I mean, was this something that you were wondering as a practicing therapist? Like, hey, best practices? Am I doing best practices? Am I not? Is that like why? What kind of led you down this road, or how did your actual practice lead into this? Hannah Smiles Yeah, so this we completed this kind of study while I was on Capstone, and I was working within a charter school actually, and we were kind of introducing OT as a more like population level work into this charter school, and so that's kind of how we got led down into this realm. As we were introducing kind of these best practice, and we were talking about how this is not how OT is being done in a lot of other district schools around the country. So that was kind of where that comparison started, was because we were kind of starting from the ground up for my capstone project and another person before me's capstone project. So we were talking kind of from the roots up of best practice standards, if that makes sense. And now, as I'm working kind of full time in in a in a different district, I'm seeing the realities of what our research kind of has presented, and I'm understanding a little bit more where everybody's coming from, and knowing where my focus and intentionality needs to lie based on kind of how how the respondents and all the themes and trends that kind of came out of this study. Jayson Davies Gotcha. You mentioned that this, I think, if I heard correctly, that this was kind of like a follow up to a previous project before. Is that correct? Hannah Smiles Well, there was another capstone student that was starting in before me in the charter school, and she introduced kind of the OT into the population level OT into the school, and then I kind of took like what she was seeing, and we talked about it together, and then we kind of took the project and ran with it. So, gotcha, yeah. So it it takes kind of building upon people upon people, you know. Jayson Davies Oh yeah, I've been there. I have advised master thesis students, and it's like a little mini capstone. And I've gone through that process with multiple groups of students, and yeah, like each time we built a little bit more on top of the previous project, and sometimes it's a project, and then the next one's a research to look at to see if the project was effective, and yeah, so it kind of goes back and forth a little bit. So totally get that. All right, well, every research, every article that gets published, especially within the OT world. Before you actually get into the the nitty gritty of doing your work, you've got to look backwards and you've got to see what's out there. and And you mentioned, you know, that there wasn't necessarily a research space that kind of looked at the best practices within the school based OT process. What were some of the themes, though, that you recall kind of coming out that that you were finding, and how did that influence where you eventually went? Hannah Smiles Yeah. So again, kind of like we touched base on, there's a huge growing body about workload versus caseload management styles and like approaches. So that was a big one, and then also there was we were looking at some information on MTSS and how research is beginning to arise on OTs role in MTSS, and we did a big kind of background on the legislation and how IDEA and ESSA all came into about and how this influences OT practice. So that's kind of all things that we touch on in our introduction because they're things that you can't leave out when you're talking about school-based OT. And then we continue to look at different intervention types. There's lots of research about specific interventions and maybe specific referrals as well that we were kind of finding, and we were kind of wanting to put it all together and see if, as a process, where people were kind of landing. So Jayson Davies pretty ambitious. Hannah Smiles Again, lots of bits and bits and pieces, and we kind of wanted to see the process as a whole. Jayson Davies Yeah, anything related to like the scope of school-based OT. I mean, right? There's this constant. What is our scope as school-based, as opposed to outpatient pediatric? And some OT practitioners really, really like being. In that, I do handwriting and sensory and fine motor, and then there's other OT practitioners who are really wanting to break out and do other things. And some people feel stuck. Some people want to break out, and some people are very happy with with where we're at. Any of that come out in that that research part, or maybe not? Hannah Smiles We didn't find a lot of like that perspective base. There was more quantitative research on like caseload size and service delivery type, and like implementation of implementation of workload. But there's less information regarding the OTs' role in like referral or evaluation and things like that. So we have found like that there's a couple bits and pieces, but not a ton of like the OTs like specific voice giving voice to their perspective on these things either. Jayson Davies Gotcha, gotcha. Okay. So as you kind of look back at the lit review, was do you feel like that there was one like one or two key things? I mean, you mentioned caseload workload. You mentioned MTSS. You mentioned IDA, ESSA, and and some of the other pieces. Was there anything that just like really shocked you and kind of led the direction a little bit, or was everything pretty much kind of you know things that you already knew as as even as a capstone student. Hannah Smiles I think none of it was super surprising. Okay, I think that there was like there's focus on maybe an OT referral or an OT collaboration with other team members in the school or even OT intervention, but there's also like a missing piece of that like larger contextual perspective of education and working within the system of education, and so it felt like there was like a missing piece in all this evidence of like how the OT process as a whole is implemented, if that makes sense, so we were seeing things that really like made sense of like okay, there's mostly this type of referral, and there's all like there's minimal collaboration, and once people are educated on what an OT can do, they feel like like they want the OT to be more involved, and that's that like collaboration piece, and all of that's like super important. And I think it's not something that we should discount. It was important. It's important for our lit review and for our study as well. But the seeing it as a whole towards like the OT process towards best practice as a whole is kind of where we wanted to kind of fit into that gap. Jayson Davies Interesting. Okay, so you've talked, you said the the phrase a few times, right? Like the OT process. That's what we wanted to look into the OT process. I want to give you a moment to kind of break that down a little bit. I'll kind of I think cue up a little bit here. Like, is that from the referral to going from the referral process to the evaluation process to the intervention treatment plan, and eventually, you know, exiting a student-is that what you mean by the process, or how do you define that? Hannah Smiles Yeah, that's exactly kind of what we were going with. We wanted to have basically questions from pre-referral, so before the referral, their involvement, so that's your MTSS, and then questions about referral, evaluation, intervention, and then kind of scope as a whole and things like that as well, kind of the larger picture as well. But yes, we kind of followed the OT PF and we followed the OT process and how we created the survey as well to kind of hit all of the pieces of what a school-based OT would be kind of working within, if that makes sense. Jayson Davies Yeah, you mentioned just there really quickly. You use like the OTPF to kind of guide this. I think within the process, we actually did an episode about this not too long ago, with where the OTPF requires an occupational profile, it basically requires the the assessment piece, the observation, the assessments if you're going to do tools or whatnot, and then a synthesis. Is that kind of what you're referring to here when you're talking about you use the OTPF to kind of define that process? Hannah Smiles Yep, exactly. Jayson Davies Gotcha. Okay, very cool. All right. Of course, now if we're talking about any research article, right? Starts with the the little abstract, goes through the lit review, and the next kind of comes the next parts that that methodology piece. Before we start talking about exactly what you did, you already mentioned survey or question. So obviously this was a survey, but break down the population a little bit here for us. I'm surprised you guys actually had a pretty decent number of people fill this out. But tell us a little bit about who it was and what your your requirements were. Hannah Smiles Yeah, so we were trying to get a wide span of OT practitioners to respond to our survey. We had. 331 responses from 41 states. So that was OTs across the country, and we were just snowball recruiting through social media survey boards. We emailed state associations to pass on to their members. We tried our best to get our hands on OTs in whatever way that we could, and that's OT practitioners. So we included OTAs as well as OTs, and I believe it was at least one year of experience was our our limit, and was our start. So we and yeah, 331 responses. We were very excited about that. We felt like that was a good like a representation of Jayson Davies yeah Hannah Smiles of different OTs across the country. Jayson Davies Yeah, definitely 41 different states. I I almost want to guess the nine states, but I'm not going to even try that. And it looks like I'm looking at the research study right now in front of me. It looks like you're at about 29 OTAs and 302 OTRLs. So yeah, I mean, I know how difficult. Like I said, I've done research before. I know how difficult this is. I mean, even when we send out an email to the list of 14,000 plus school-based OT practitioners that are on the OT schoolhouse list, it's still hard to get you know even a few, and so kudos to to all of you that were able to get 331 responses. That is just amazing. I'm kind of looking at this. By the way, everyone listening, you need to say thank you really quickly to Hannah and the team because they actually got this published on the Open Journal of OT keyword there open, and so this research is completely accessible. We will be sure to link to it in the show notes. But yeah, you can look it up right now for free. Don't need any subscription. Easy to access, and I'm looking at table one here where it just kind of breaks down and everything. Yeah, very very diverse, right? You you've got education level, you got years of experience. It looks like you did have some practitioners with zero to 12 months, so it might not quite have been one year. And Hannah Smiles yeah, it was. I guess it must have been less than one year. Jayson Davies Yeah, which which is totally fine. I mean, because you're breaking this down, which is which is great. Ooh, and I like that you also looked at the current practice setting, and you've got public school here, public charter school, private school, religious day school. So all the different types of school, and again, very diverse. I mean, it looks like 302. Surprising, that's the same exact number of OTRls, but that's just the way the cookie cookie crumbles. I guess we're in public school, but then you've got you've got a several that were in others, so oh, you know what? Did I just realize that? No. Yeah, it was Hannah Smiles a select all that applied, so you could yeah select like multiple schools if you were maybe working within different kinds of schools yeah as well. Jayson Davies Yeah, well, very cool, and and congrats on getting such a such a again on getting such a large number because that is that's not easy, and I will applaud you for for and thank you. Hannah Smiles Anyone's listening who took the survey, thank you. Right, we appreciate that, and I mean it was really important for us to make this accessible accessible to especially school based OTs because we are in it and we know that it's frustrating when things aren't accessible within the public schools. So that was something that was important to us as well. Jayson Davies Fantastic, fantastic. So okay, so we've got our population set. Let's talk about some. How did you go about developing the survey? And before I ask you those specific questions, was there like some key things in your mind? You're like, our survey needs to fit this criteria. Doesn't matter what the questions are; it needs to fit this criteria. Hannah Smiles We wanted it to be holistic. That was kind of our main driving point. Again, we wanted to kind of create a snapshot of what OTs at that time, were kind of doing, and we wanted it to be comprehensive so that OTs felt like their voice was heard. And I think through that, we ended up wanting to do both quantitative and qualitative data, so that we gave OTs the chance to add anything that was important to them that we didn't have specifically on a multiple choice question, so that was really important to us, and I feel like it was really definitely worth the coding and the effort that it takes for scoring kind of a qualitative type of responses. But we got to we got to hear from the OTs themselves in their own words, which was also really important to Jayson Davies us. Oh yeah, yeah, definitely. I appreciate that. And so, when we get into your your methodology a little bit further, it looks like you actually broke it down by referral, evaluation, and then intervention, which kind of makes sense in in line with what we've already talked a little bit about. Was the survey kind of broken down in that manner as well? Hannah Smiles Yep, exactly. So the questions flowed in that order, so that it would be the most it would make the most sense to the survey taker of okay, we're starting in our minds at like where we would start with a new student in the referral process, and then kind of go forward because that's the natural way that OTs think. So Jayson Davies yep, absolutely. That's that's exactly how I develop my course in the same exact system. Because yeah, you need to know the basics before you move on to pre-referral, referral. Yeah, it's just the way it works. Okay, so then, and I think it makes it a little bit Hannah Smiles less daunting. I think it makes it a little bit less daunting to someone who wants to maybe get involved in something like research. Like you don't have to reinvent the wheel, like it's OT already. Kind of has so much mapped out for you that even if it's scary to approach, like look what we did. We just went right through the OT process, and we use the OT PF as a guide. So it's also encouragement to anyone who doesn't know where to start. Jayson Davies Yep, yep. So then, when it came to questions, how did you? You said you use qualitative and quantitative. How did you all start to lay that out? And if you can, just kind of a few examples, maybe under each of the three areas of of what you wanted to to ask OT practitioners. Hannah Smiles Sure. So we started with referrals, and we had not only multiple choice but ranking questions and things like that, so that we could get a sense of what the most common referrals were. For example, so it was like rank your top three referrals, and so then we kind of got to see a wider span instead of just what's your most common referral. So that's an example of that, and then we kind of went into evaluation, and we were looking at the evaluation of the environment, the individual, and occupation. So we had questions related to all of of those. We also use PEOP as kind of a guiding like theory to help us remind us to hit on all of the different areas as well. So we, for example, had a question on evaluation of the environment. We had a question on individual evaluation, and then we had a question on occupation-based evaluation. And those kind of looked like what, which of these environmental assessments do you perform? And then there was an option to, like, we didn't perform any of these any environmental based evaluation. So that's kind of how the evaluation portion looked. And then an intervention. We again were kind of having people rank where they most commonly delivered interventions, and there was also like frequency of which six like intervention service delivery types, things like that. So intervention, it was like what intervention, but also like where and how you're intervening and things like that. Yeah, and we had we had some a question about kind of those formal intervention types like handwriting without tears or zones of regulation, like what the role of published intervention programs are in in school based OT as well. Jayson Davies Interesting. I am excited to learn a little bit about that because I do have this like whole conflicting notion in my head all the time about individualized type of I'm with that student I'm going to do what I know versus should we implement a 10 week design program of handwriting without tears or size matters or you know one of Kelly Mahler's program like do we just stick to what's being designed as a quote unquote fixed curriculum. So I'm excited to hear that, and we are going to start to dive into those results right after a quick break. All right, we're back, and we're going to dive into the results now of the survey, and especially I'm really, like I said, I'm really excited to see what you found about people using curriculums. But first, I want to ask: Looking back at this, right? Your this research is all done, written up, all of that. Was there any question that you felt like, man? I wish we would have asked that after you looked at all the data. Hannah Smiles Oh, that's a good question. I mean, I think there's there's many like looking, knowing what I know now, like yeah, like there's there's an infinite amount of more information you want from from your therapists. I think, I mean, we would love to have more information about like different comparisons of varying years of experience and things like that, and how that specifically can influence someone's how they intervene and how they evaluate and things like that. So that's just one. And I think, I mean, I personally would want to know more about like health literacy and. Management in that specific area because that's an interest of mine, but but yeah. So I mean, those are two off the top of my head. But when you're in such like a holistic like mindset, I think there's so many that we could have, so many different directions we could have gone, and that's why we needed those like structuring different items like within the OT process and the OTPF, and then PEOP, kind of to keep us on track and not and give us that holistic picture, rather than kind of getting segwayed off in different Jayson Davies oh yeah in Hannah Smiles different directions. Jayson Davies Plus, you've got to keep it short, otherwise you're going to lose people halfway through exactly through the survey. And so, yeah, no, totally get that. Yeah, I was just wondering. I mean, because you know, we live, we learn, and we we like you said, right? Like now you're into health literacy, and you would love to maybe go get your PhD in it. No, I'm kidding. Um, right, go that route. But no, you know, it's it's I don't know. There have been sometimes where we've done research. I'm like, man, it'd be cool if we had this. Now, you said that when you guys tallied up everything and looked at the results, you didn't do any like cross-sectional stuff. You just basically looked at basic statistics. You weren't looking at hey, the people who have been practicing from five to 10 years did more of this versus that, right? It doesn't seem like you went that detail, Hannah Smiles right? Yeah, no, we were kind of doing an overall snapshot picture. We didn't do that cross examination there, and again, that's something else that it would have been like cool to have that data and kind of see those two comparisons of like how different aspects of practitioners' demographics affected their OT process and how they execute the OT process. Jayson Davies Did you guys use Google Forms or like Microsoft Forms type thing, or did you use more of a specialized software? Hannah Smiles We were using Qualtrics, so that was the form the form base that we were working out of. Jayson Davies Okay, and then when it came to actually finding the results, did everything just kind of in a spreadsheet get averages and compare? Okay. Hannah Smiles Yeah, we were we were comparing like just basic statistics of what we were getting out of it, and not specifically through any sort of like statistician or anything. Yeah, we didn't have any access to that. Yeah, Jayson Davies yeah. I bring that up only. I mean, you guys published this, and you all published this in 2025 April. You know, I'm assuming the actual research itself was done 2024, late 2023. Hannah Smiles Yeah, Jayson Davies 2024. Yeah. So, and things have changed. Like I, I don't know. I just think of right now the way that if you a still have the data and if you b ethically can use that data based upon what is said in the IRB and all that fun stuff, it would be interesting. Of course, you know it's all de-identified to ask ChatGPT to actually do some of that stats for you because, like, it probably. I mean, again, we have to be careful with AI, but I do think that I would want to see that. I would definitely want to see how it compares someone who's you know brand new versus someone who's been working for five years versus 15 years. You know, who's using the curriculum? Is it the newer therapist or the the more experienced therapist? Like all of that would be amazing. So, for those of you out there thinking about a project, Hannah Smiles exactly. And there's so many places they could go. And yeah, you're right. I feel like when we did this in 2022 or 2023, like Jayson Davies okay, Hannah Smiles even AI has come so far since then. You know. Oh yeah. And the use of it has dramatically changed since then. So yeah, yeah, it's that's super interesting, yeah, for sure. Jayson Davies Yeah, and and I've worked with a statistician, and it is not like the easiest thing. And like now that we have access to a statistician on our computers with with AI to a degree, and at least a good an initial synopsis, you know, and and kind of of course you have to overlook it and make sure things actually line up and make sense. But but yeah, it'd be really interesting. All right, I got sidetracked. Let's talk about results now. You already we've already talked about how you broke it down: referral versus the intervention piece, the PEO, and then or sorry, the evaluation piece, and then the intervention piece. Let's talk about the referrals. What were some of the things that really stood out? Hannah Smiles Not surprisingly, the most commonly received referrals were handwriting, sensory processing, and fine motor. Jayson Davies Hey, I just wrote an email about that. All right, continue. Hannah Smiles Yeah, exactly. So that wasn't really a big surprise to us, and kind of showing us that the we're getting referrals for only a quarter of our scope. We only only two respondents reported that mental health, any sort of relation to mental health and wellness, were their top referral. So were their top Jayson Davies okay. Hannah Smiles Whether it was their as their top referral, or even within. Top three, and we also found that the majority of respondents like never or rarely received referrals for non-academic, extracurricular, technological, or vocational activities, and that stood out to us. Thinking about how all the things that happen on a daily basis in school, so that are non-academic and how OTs can have a role in that, and over half never or rarely receive any referrals for or in are involved in that at all. So Jayson Davies yeah, yeah, that was Hannah Smiles interesting to us. Jayson Davies Ah, shucks moment when you saw that. Hannah Smiles Yeah, I mean, I think, I mean, the other thing is that unless OTs are being are involved in this not formally, as an OT, I can say like I don't maybe even if I don't receive referrals for it, maybe someone's picking my brain or trying to get me involved in like a non formal way. I guess so. I guess that's where the hope could lie is like we could be woven in differently, but in specifics for referrals themselves, if someone's taking that as formal, maybe that's kind of how that could fall. Jayson Davies I of those ones that you've got here, we've got non-academic, extracurricular, technological, or vocational activities were the four that you were just talking about there, non-academic. I feel like that can definitely fit. I feel like there are people that get referrals for like feeding, and I feel that that's non-academic, and I think that there are some referrals for that. Extracurricular. I don't think it's happening, and that's frustrating. I also think that that is a very big access problem because I think if again not looking at any research here, but I'm going to assume that if you look at the population of those involved in extracurricular, you're going to see a big gap between those with a disability or an IEP versus those without an IEP in extracurricular activities. I mean, I worked at a high school, and I can only remember one kid who, you know, was on the special or with an IEP that was playing baseball, and it was very adapted and and whatnot. But at least he was doing it. He had access to it, and and that was awesome. So I would love to see that more technological. Like we do a lot of assistive technology. I don't know if that falls into the case of technological, but I mean, we're using technology. I don't know if that's the the reason for the referral, though. But but yeah. And then the one that I really want to see more of is vocational, like especially as we talk about transition planning and the impact that we can have on transition planning, that would be wonderful to to get more referrals for that. So, just my few cents, but yeah, anything else related to to the referral process? That anything related to the referral process qualitatively, or is that more separated how you do the qualitatively? Hannah Smiles I think there was a lot of sentiment of like the team doesn't know what we do, but then once they find out, like they like they feel our impact kind of thing, and I think that falls into kind of the referral, and we'll talk more about that when we kind of put all the results together and we synthesize it, but the lack of referral scope really impacts the role that OTs feel themselves playing. Is kind of the the energy that we got from both sides of the the questions. Jayson Davies Okay, and then another follow up, and I totally understand if you don't have the answer to this, but you mentioned that two respondents reported mental health and wellness referrals as their top. Please tell me that you had something qualitative from those people to share, like about that. I'm assuming not, but maybe I don't Hannah Smiles know. I don't know if we pulled out their specific survey. Jayson Davies And maybe they didn't. They might have just put NA for whatever answer. But yeah, it would be interesting. Hannah Smiles That would be interesting. I would have to go back and go find their specific surveys themselves. But Jayson Davies All right, if you're listening to this right now, right? If you're the person, if you're the one of the two people that put mental health as your top referral source, we want to hear from you. We want to. We want more information on this because that's awesome, and and yeah, we want to hear more. So, all right, let's move on from the referral process to the evaluation. And with the evaluation piece, as you mentioned earlier, kind of lined up PEO. You got environment, individuals, and occupation here. What did you want to look at, or what were some of the questions that you were asking people within this part? Hannah Smiles So we were kind of trying to feel out how, for evaluation, what evaluation was looking like. Are we like, are we doing formal assessments, informal? Jayson Davies Okay. Hannah Smiles Where are we assessing? Like, which parts of PEO are we kind of? Leaning on, I think this is something that we had some evidence coming out of the literature pool that there was a lot of individual skill assessments, and so we kind of wanted to we wanted to ask that question again, but we also wanted to ask other questions, like specifically the environment, like what like what are you using to assess the environment, and are you doing occupation-based formal assessments? Things like that, to kind of build off what the literature is kind of already saying. We wanted to get more of a fuller snapshot of that, and yeah, it was a bit shocking. Over two thirds of the OTs didn't perform any formal assessments of the school environment, so it likely looked a lot like homegrown tools or observations, something like that. Which was, I mean, such a big part of who we are as OTs. You just you compare that to the skill-based assessments that we're seeing, and it's very it's very different. But it does like OTs were doing informal assessments of the school environment. The environment wasn't left out; it just wasn't formally assessed. If that makes sense. Jayson Davies Okay. Hannah Smiles So yeah, and that was in the classroom, lunch room, and playground. And then the most common assessments that were administered were sensory processing measure, the BRE, BMI, and sensory profile. So that wasn't really surprising to us there. Jayson Davies No, well, although I will say only one of those are performance based assessment tool. The other two are not criterion, but they're they're surveys from somebody else doing them. So, I mean, my kind of takeaway from that, and of course, I didn't get to see number four through however many else there are, and and you may or may not have more insight into that. But I think that OT practitioners are trying to save time any way they can because of their high case loads, and so we're using surveys that we can give out and be filled out asynchronously, so that way we can get the response back. The other side of that that I see here is the SPM, obviously sensory, the the the Barry very motor based, visual motor based, but then you've got the SFA, which a is freaking old, but b it's also more holistic, more occupation based, and it would be interesting, man. Again, right? Like I wish I had a little time machine here. Like even if we could just get your survey results from 20 years ago, and see what this looked like, and see how it's changed. Because, you know, what were people using 20 years ago compared to today, and what will they be using 10 years from now? Would be really interesting. And so, I'm not going to lie. I kind of wish you had published like an appendix with every single assessment tool listed out. And I'm not going to put you on the spot and ask you for that appendix, but like I would love something like that just to see because obviously we have your top three here, but for some reason there was a decision obviously to keep the article you know not too long to a degree, but yeah I would love to see the other tools because like the bot three isn't on here and which is a common one the Peabody so yeah that'd be interesting, but but again, yeah, always always great to to see everything. So, did anything? Hannah Smiles I think when you have so much data, like we ended up coming out with like we had so much data within our hands, and I think part of our like goal was to create something that was again digestible and a snapshot kind of vision, and that's kind of why we landed where we did. But no, I agree. I mean, there's we had a laundry list of all of the different options, and we kind of were finding the most notable as well. And so. Jayson Davies When it came to the assessment tools, was this just like a choose your most used? Was it select all the different ones you used? Do you recall kind of how that was on the survey defined? Hannah Smiles I think it was like you check the ones that you do use. Was the the question? I think that's how I can't say the specifics of the wording, Jayson Davies but that but you gave people the the option to not just say they're most most used. It was use all or the the five that you use or select several the ones that you Hannah Smiles yeah yeah it was select more than one if if they used more than one and we also had options for an option for I do not do any occupation based, or I do not do any skill based assessment. I do not do any environment based assessment because I mean, 22% of respondents clicked that they do not perform occupation based assessments specifically, like formal occupation based assessments. Okay, so yeah, that was one of the answers as well. Jayson Davies I'm still blown away. Way that half of us are using a tool that was published in like 1990 and still asked about floppy disks. Like I, but I get it too, and and I love it. And and we've mentioned it already here on the podcast that the SFA is being renewed. They're working on an SFA too, and I can't wait for it to come out. That's going to be awesome. But it only shows like obviously we want to use it. School-based OTs are using it, despite it being older than old. So, in terms of assessments, of course. Now, you seemed a little bit surprised when you were talking about the school environment using a formal assessment versus an informal assessment. I'm interested. Go ahead. Hannah Smiles There was there was very little for us to like give as an option for formal. Jayson Davies Yeah that. Hannah Smiles So I mean I'm more surprised that it just doesn't like exist like as an entity, and I think that's where the surprise came. It wasn't surprising that nobody, like, performed it. It's more that like this area has kind of been in in comparison to skill based assessment so lost. When especially in schools, it's so important, and we feel ourselves doing so much intervention in relation to the environment, that the the assessment formal assessment not being there, it it feels like that's a miss. You know what I mean? Yeah. the The Jayson Davies only tool that I can think of, and it's a newer one, relatively newer one, is the CC or CSCEA. That's an environmental tool. I want to say like the SFA asks about the environment, but it's more about like the student's ability to access the environment. Same thing with like the SPM and the sensory profile. Same type of thing. It's not like asking about the environment specifically, but it's asking how the student responds in certain environmental situations. But yeah, like I can't think of something like where we would go into the classroom and almost evaluate the classroom, the accessibility of the classroom, or the accessibility of the playground or cafeteria. Which, I mean, as I say that, kind of like you, the shock is like, wait, why? How do we not have that? And then I also think, well, do teachers have that? Like, is there an assessment for an administrator to go into a classroom to evaluate a the way that a teacher has set up a classroom? Obviously, it wouldn't look the way that we would put together an evaluation. But yeah, that's interesting. I'm surprised too that that there isn't something. So, all right, another one, another PhD project, hands on it. Hannah Smiles I mean, I know Wash So there's a assessment out of WashU that's called the Check, which is an accessibility evaluation, and they have a playground version. So Jayson Davies Okay. Hannah Smiles that is that was one option that I do know of. But in terms of like classrooms themselves, that's not anything I've seen. Unless it's like within another assessment is kind of where we had to kind of pull from. Jayson Davies Yeah, yeah. All right. I think we've I think we've covered referrals and evaluation, and then that moves us on to interventions. Unless there was anything else that you wanted to talk about the evaluation piece, but otherwise, we can going to share with us a little bit about what was discovered in the intervention phase. Hannah Smiles Yeah, so we were looking for all the different parts of intervention, so where they our respondents were delivering their intervention services, and also what kinds of interventions were they providing, as well? So, I think again, we really wanted to focus on that service delivery type. So, we had they were ranking their most frequently to least frequently used intervention types. So, direct pull out, direct push in, consultation, groups, co-teaching, and then school-wide programming was also included as an intervention type. So we wanted to kind of see how frequently they were doing all of those different things. So we definitely found that they most commonly deliver interventions in the classroom and the therapy room. So those were very close in and how we received the data, and then the playground and lunchroom were also areas that OTs were providing providing services as well. And then for service delivery type, we saw most commonly direct pull out was the most common response for most frequently used, and then followed by direct push in. So those were kind of our one and two, and then only 11 respondents reported doing schoolwide programming as their most frequent. So, and then the. Majority used had school-wide programming as their last ranked, or didn't rank. So they also didn't have to rank it if they didn't use it at all. So that also was a the least amount ranked was that school-wide programming. Jayson Davies Absolutely, and and I recommend everybody go and look at the article to really take this chart in and to to take in these numbers because you know we're talking about it on audio and I totally understand. Like it's hard to keep track of numbers when we're when we're on audio, but it's at the bottom of page five on the the downloaded version of the article, and the chart really does tell a lot. Before I do dive into the chart, though, you said that you know you talked about different areas that that students are seeing with the classroom and the therapy room being the most. Those are at 88% and 84% which like I'm actually surprised it's not higher. But then you have the playground and the lunchroom at 20 and 15% So that's that's not you know, that's not nothing. Like that's actually a decent amount. So people are seeing students most commonly in the playground and lunchroom. Maybe that's because they don't have a room to work with students in. I don't know, but but yeah, yeah. And then yeah, the table's great, and I can tell right like that, people did not have to respond to the most frequently used model because direct pull out had a total of 292 responses, which was actually lower than the 296 for consultation and push-in. So more people are using push-in and consultations, but they're not using it as frequently as those who are using direct pull out as their top use. Hannah Smiles Exactly. Jayson Davies And then again, notably, is that 189. So more than half, more than half, but not you know two thirds about are using school wide programming to some degree, which I think is actually pretty pretty good. Like I mean, the the two thirds of us almost, we'll call it maybe like 60 or 55% or so, are to some degree doing school wide programming, which is higher than I would expect. I actually, so yeah, I think that's not bad. Hannah Smiles Yeah, and we didn't have specifics on what that looked like. Like we didn't have any, but I mean, I think school wide programming could be a lot of different things, and it could be SEL, it could be sensory, it could be hand writing, all those things. So I mean, yeah, that's the amount of people who responded to that was encouraging. Yeah, in my opinion. Jayson Davies Granted, granted, half of those, half of the 189 ranked it as number six, so the the last one that they used. So how much they're doing it? Not that much, but still, like that. That's encouraging. You got to do something once before you can do it multiple times. So that's a good way to get started. Okay, you do actually have some information here, like you talked about earlier, with the different types of programs as well as RTI, and so I want to make sure I give you a chance to kind of elaborate on that. Hannah Smiles Sure. Yeah. So we also had a question about that formal intervention published intervention program and how those were used in practice. And I mean, respondents reported handing handwriting without tears and zones of regulations were their two top published intervention programs that they used, and only a few people said that they don't use any published intervention programs at all. Yeah, which we thought was notable as well. So these are having an impact on our, on the way that we do OT and the types of interventions that we're doing, and so I think that was an important part of the snapshot of, of the OT process in schools. Jayson Davies Do you do we have information on whether or not they were doing it like as planned, following the books, or if they were using strategies, do we have that information from the qualitative or not? Hannah Smiles I don't think we have anything that's like where you train. Like, do you have the formal training, and are you implementing it as trained? It's more the use of the intervention. Jayson Davies in some capacity. Hannah Smiles I believe it was in some capacity. It's there. We didn't have them describe their level of training or anything with those. Jayson Davies Yeah. No. Fair enough. Fair enough. I think we all pull strategies from all the different trainings we go to, right? Yeah. And so many of us have taken the zones training, and so many of us have taken the handwriting without tears. Like we are naturally going to embed some of that into our into our practice, so that that makes sense. And okay, and then so after that, also RTI. Hannah Smiles Yeah, so we actually were we created a question on RTI based on a question from a full. Survey done about RTI, and so that was we were using that because of how well it was made. And Dr. Cahill created a specific AJ article on OTs' involvement in RTI, so we kind of wanted to reinforce what she created, and that's kind of how this came about, and so they were ranking whether always, often, somewhat rarely, or not at all in all the different RTI activities that OTs can be involved in. So, one-on-one intervention, data collection, progress monitoring, in-service, universal screenings-all of those are included in response intervention RTI activities, and so they were ranking how involved they were in all of those. If that if that is clear, and I believe that there is not anything super new that we have discovered, but a lot of one on one, a lot of data collection and progress monitoring, which is great. And then we have a lot of almost not almost half about a third of the OTs who responded have don't do any universal screenings, and that that was notable to us. And program development was also pretty low as well as as kind of the not involved, and then everyone else was somewhere in between. So there's, it's, I guess it shows progress. It shows movement. Jayson Davies Yeah. Hannah Smiles We're not where we want to be, but we got to see some some movement in these in some of these areas that we would like OTs to be more involved in. Jayson Davies Yeah, I mean, I'll look at the bright side. You know, 35% of us aren't doing universal screenings, but 65% that are am I doing my math wrong? Yeah, 65% I mean, are doing some sort of universal screenings. Then, like, I don't know. I could, I could go and list all the OTs that I've worked with in the last you know decade, and I think it would be lower than 60% of them are using universal screenings. So, I I think it's a step in the right direction. It's also hard to do universal screenings because the systems really aren't designed for us to do universal screenings, none of the assessment tools that we do are designed to be a universal screening for the most part. So it's one of those things where we kind of have to break this mold. Like, if you go and work for a district, and the district OTs there have never done universal screenings, you're not likely to do universal screenings, right? And so it does take time for something like that to to start to get put into to place. So, yeah. Hannah Smiles Exactly. Jayson Davies Yeah, awesome. All right. Well, at the bottom of page seven, for all of you following along at home, right? There is a beautiful chart. It reminds me of the PEO chart, which makes sense now because you kind of use the PEO model to a degree, PEOP model here, and that's kind of what you use to kind of put all the qualitative information together here. So I just want to let you talk a little bit about some of the significant findings and you know the surprises, the not surprises related to the qualitative findings. Hannah Smiles Yeah, so we asked questions of the OTs to respond on the impact they found themselves having in schools, their role as part of the education team, and we kind of wanted to create themes based on those questions, and then as well as our data that we received from the quantitative section, and we kind of discovered this synergistic relationship between barriers and school-based practice and things like that. So the major themes that we came up with were role confusion, OTP role confusion, inconsistent view of OT leadership and empowerment of OTs, and the incomplete transition to the workload approach. So these were kind of things that emerged as the three major themes, and we kind of discovered that they all interact with each other in both a cause and effect relationship, and they're all the other, a lot of the other quantitative findings that we found, like our service provision, like providing mostly one-on-one and our high caseloads and things like that, are all kind of creating these themes along with kind of our qualitative questions that kind of had these themes arise, so. Jayson Davies Yeah. Hannah Smiles That was kind of how we discovered these these themes all kind of coming together. Jayson Davies Yeah, very interesting the wording that you chose here: incomplete transition to workload approach. That. I've never heard it phrased that way. We always talk about caseload and workload. Sometimes I'll hear people say we use a combination of caseload workload, and I'm always like, "How does that work? So you using the term, or the team using the term, incomplete transition to workload approach. Why? Why that phrasing? Hannah Smiles Sure. So we did have a question related to the caseload versus workload model and how therapists were operating within their own practice, and we got a very mixed answer. We got a few people saying that they were only caseload, a few people saying they were only workload, and then again, like you said, some a lot of people were somewhere in the middle saying they use a blended approach. So they don't feel like their whole workloads represented, but they don't feel like they're managed just based on their their caseload. So we see that as progress. We saw that as things are moving towards the workload model, we have a lot of people in this blended in between, and so we feel that there's a possible transition, but it's not complete yet. We don't have we don't have a group of therapists who all feel like they are their workload is represented. So that's kind of where that comes from, we see that in transition. If that makes sense. Jayson Davies Yeah, yeah, no, it makes sense, and like, it makes sense to be in transition. To me, like when I think about caseload and workload, I see them as almost like very different. And so, whenever I hear blended, I'm always like, I don't quite understand that because when you're in a workload model, you're counting the number of students versus when you're in a caseload, or sorry, vice versa, a caseload model you're counting the number of students. Workload, you're counting the number of hours. But I guess you can kind of you know find a system that works where you're you're taking into account both. But yeah, no, it's interesting to to see how that has become like the number one answer I get to when I ask people case loader workload, they're blended, and so I'm like, okay, okay. Hannah Smiles Yeah, I think they see. I think there's cases where parts of the OT's job is being considered. Maybe they get time for IEP writing, or they get a certain amount of plan minutes a week, but then that that's only part of the workload, you know. Then the other things are still being left out. So there's a few things included. That's kind of how we phrased it on our okay on our survey. Jayson Davies Gotcha. All right. And as we start to wrap up here, kind of at the end of the day, you know, you got all this data, you had the lit review behind it. What were some of the overall findings that you know, kind of good or bad? What did what did how did you put this all together and tie it up in a nice little bow? Hannah Smiles Yeah, so I think that our major themes are all interacting with each other, right? The role of the OT is misunderstood by the the education team, but also by OTs themselves, and that is really important to understand as an OT. Is you have to know kind of your role, and then that role confusions then also interacting with OTs' ability to be in leadership and feel empowered to kind of take the step further into what the best practice is suggesting to kind of be more involved at that population systems level and educate the team on that. And then the incomplete transition to workload is affecting both of these and is being caused by both of these, so we can kind of see how these all interact with each other. We need more OTs in leadership in order to transition to workload, but also being stuck in the caseload model causes it to become difficult to be a leader in other ways. So we can kind of see how all of these are interacting at the same time, and that's what makes it complicated, but it also shows us where our intentions need to lie and where we can grow as a profession and as OT practitioners ourselves. We are, I think, having the question about what we feel like our impact was on the education system was really powerful, and we got to see the OTs talking about how they're the only profession that links the whole child to the whole community in the whole environment, and that was, I think, the most powerful things for us. And we got to see that although we're we painted a picture and a snapshot of where we are, which is not quite where we want to be the power of OT is still so eminent and so there, and it's it can revitalize the hope for what school based OTs are and what they can be. So. Jayson Davies Man, that could go viral. We need someone to develop a marketing program around like we we are the. Only people on campus looking at all the different aspects. I that could go viral in a in a post or something like. Yeah, no, I think that's absolutely true. Yeah, and you know, you you've also got in there a little bit. I remember that you got a little bit about leadership and expanding the OTs' role within leadership, which you know anyone who's listening to the podcast for a few episodes know that I'm big on, and that's important, right? Like that leadership is where we can begin to to do more marketing for for ourselves a little bit, and so it's important. Hannah Smiles Yeah, and leadership leadership doesn't have to mean formal leadership. Leadership can be getting in on a problem-solving team and advocating for yourself to be in the room and have a voice there, and like for example, after doing this, that was something I had to do in my practice. Was I had to ask to be invited to team meetings and to problem-solving meetings so that I could have a voice there, and it wasn't a part of what my job requirement was, but I went to the leaders of those teams and asked to be a part of it, and that's an example of being intentional about a small way you can become more of a leader in your school and start working towards kind of those larger changes. It's a snowball effect, really. Jayson Davies Yeah, yeah, absolutely. Well, Hannah, thank you so much. It's been a pleasure learning about this, and I really do hope that 10 years from now you come back on the show and like, hey, I haven't updated. Right, we've got doing the same study 10 years later. Hopefully, the SFA two will be there instead of the SFA and a few other things. But I do want to know and ask you. You know, you talked about there being a capstone student before you, those kind of doing some things. You obviously you and the team did this study. Any follow up, either already completed or in the works or anything like that, kind of based upon this. Hannah Smiles Um, not specifically from our our end. Actually, after we were in publish, AOTA actually released a survey of school-based practice specifically to inform their policy and advocacy, and it looked like pretty similar to yeah, it looked pretty similar to a lot of what we were asking. So it's another another survey to see the results of how OT. Jayson Davies I don't know if we got it yet. Hannah Smiles Yeah, I'm. Yeah, I don't know. I'm. I. I'm looking forward to it. I don't think it has. I've seen anything yet. So. Jayson Davies Yeah, I'm gonna follow up on that and see if we can find something because I don't know if the intentions was to put together a report and put it out or not. But yeah, it would be nice because, in theory, right? Hopefully, AOTA has a very large sample size, and it'd be really, really cool to see some of those results. So I do remember that. So hopefully. Hannah Smiles Yeah, it was. It felt like a nice follow up to what we were doing as another another way to understand the perspectives of OT in schools. Jayson Davies Yeah, yeah, great. Well, Hannah, thank you so much for sharing. Really appreciate it, and we'll definitely link everybody to this article. Is there anywhere where people can go if they want to specifically connect with you? I'm thinking like LinkedIn or something like that. Hannah Smiles Yeah, I'm on LinkedIn, and I believe there should be a way to contact me through the if there's somewhere in the paper as well, but you can definitely find me on LinkedIn. It's just my name, Hannah Smiles. So Jayson Davies awesome! Hannah Smiles Find me there. Jayson Davies Perfect. Well, thank you, Hannah, and definitely look forward to 10 years from now when we get to do it again. Hannah Smiles Thank you! Jayson Davies One more time, thank you, Hannah, so much for joining me on the podcast today, and for sharing the findings from this really important research. I also have to give a big shout out to Charlie, Stephen, and Lauren for their part on this project as well. And of course, thank you also to the Open Journal of Occupational Therapy for making this research available to all. That is not common. There are a lot of journals out there that make it difficult to access the work that they publish. You do not. We really appreciate it. I also want to thank you for listening. Of course, whether you are at the gym on a flight home from a summer vacation, or maybe you are even driving between schools right now, I'm grateful that you've made a decision to spend that time with me here on the OT Schoolhouse podcast. I really appreciate it. Hopefully, I made your drive or your vacation trip home, whatever it was, a little bit easier. And yeah, just appreciate you being here. If today's episode got you thinking about your own practice, maybe your referral patterns or your leadership opportunities, or maybe even the gap between knowing best practice and actually living it out. I want you to know that you don't have to do this all by yourself. The OT Schoolhouse Collaborative is a community built specifically for school-based OT practitioners like you. You'll get resources, professional development, and direct mentorship from my. In a group setting, head on over to otschoolhouse.com to learn more about the collaborative and join us today. Until next time, take care. Amazing Narrator Thank you for listening to the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to OTSchoolHouse.com. Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

What if 20 minutes with a group of teachers could open the door to better collaboration all year long? Some of the most helpful occupational therapy work I have done in schools happened in a room with zero students. Instead, it happened while sitting with teachers, talking through a concern they were seeing every day, and helping them look at that challenge through an OT lens. In my experience, one focused teacher in-service can lead to more follow-up questions, classroom conversations, and opportunities to support students than a polished report that gets filed away and rarely revisited. And you do not need to prepare a 90-minute professional development session or build an elaborate slide deck. An actionable in-service can be 20 or 30 minutes long. It can focus on one concern teachers already want help with and end with one realistic next step. Here is how to plan a session teachers can use—and that makes it easier for them to collaborate with you afterward. How a teacher in-service can change collaboration Most teachers know that occupational therapy supports students, but they may not always know when to contact you, what to share with you when they do contact you, or how OT fits into their classroom system. This is not due to a lack of respect for OT. Teachers have full plates, and our role can look different from one campus or district to another. In episode 175 of the OT Schoolhouse Podcast, I discussed how teachers and administrators really think about school-based OT. Their perspectives are a helpful reminder that collaboration starts with understanding each other's roles and realities. Recent research out of Australia also highlights the value of clear communication, understanding each other's roles, and giving teachers and OTs opportunities to learn together. These studies do not prove that one short presentation will change student outcomes, but they support working together around the classroom activities that matter to students (Lavery, MacKinnon, & Clark, 2026; Jeremy, Hinitt, & Spandagou, 2025). An in-service gives you a reason to begin that conversation. The goal isn't to show teachers everything you can do. Instead, the goal is to make one school problem easier to address together. Of course, a presentation will not fix a large caseload, limited planning time, or staffing shortages. But it can give everyone a shared way to talk about the concern and make it easier for a teacher to approach you later with a question. Start by asking teachers what they need The easiest mistake is choosing your topic before talking to the people who will attend. It may be tempting to automatically present on handwriting, sensory processing, or fine motor skills. Those can all be useful topics—but only if they match a current need. Instead, start with one question: What is one concern you wish you had more support with this year? You can ask it in a one-question email, a short staff survey, a grade-level meeting, or a conversation with a teacher leader. You do not need a lengthy survey. You just need enough input to notice a pattern. If several teachers mention students shutting down during writing, your topic might be reducing barriers to written output. If transitions come up repeatedly, you might focus on routines and environmental supports. If teachers are unsure when to request an OT consultation, you might explain what early collaboration looks like. This is the same teacher-first mindset discussed in Episode 194 on coaching and creating lasting impact. When we begin with the teacher's priorities, the session is more likely to feel relevant than when we arrive with a predetermined list of strategies. Choose one outcome, not the entire OT scope Once you have a few possible topics, decide on one main goal for the session. Ask yourself: Is this a problem teachers are already trying to solve? Can I offer a participation-focused perspective? Can teachers use at least one idea within the next week? Can I cover the topic responsibly in 20–30 minutes? For example, “understanding occupational therapy” is too broad. “When a classroom observation may help before a formal referral” is more focused. “Sensory processing” is broad. “Ways to make classroom transitions more predictable” gives everyone a clear topic they can use. Your session is not a test of how much content you can fit into 20 minutes. It is an opportunity to help teachers leave with one useful shift in thinking and one action they can try. Seven in-service ideas for school-based OT If you are not sure where to begin, these topics can help you turn common school concerns into focused, useful sessions. But be sure to find out if these resonate with your teachers before starting to plan it all out.
1. How OT supports participation beyond handwriting Help teachers connect OT to access, routines, self-care, regulation, organization, play, and participation throughout the school day. Use a few brief examples from common school occupations instead of reviewing every area in the OT scope of practice. Practical takeaway: Give teachers a one-page “When might I collaborate with OT?” guide.
2. When to collaborate with OT before a formal referral Explain how a brief conversation, classroom observation, or Tier 1 support may help clarify a concern before anyone assumes that an evaluation is the next step. The article on Tier 1 OT interventions to reduce unnecessary referrals offers more ideas for this approach. Practical takeaway: Share two or three examples of concerns that could begin with collaborative problem-solving.
3. Classroom supports for regulation and attention Focus on routines, task demands, environmental factors, and student participation—not a menu of disconnected “sensory tools.” Help teachers observe when and where a student has difficulty and match supports to the activity. Practical takeaway: Walk through one classroom routine and identify a support that can become part of that routine.
4. Supporting written output beyond “more handwriting practice” Show how written work can be affected by motor demands, language, idea generation, executive functioning, visual demands, endurance, and the classroom environment. This helps the team move beyond a single explanation for every writing concern. Practical takeaway: Give teachers a quick checklist for identifying where the writing process may be breaking down.
5. OT collaboration within MTSS Clarify how OT practitioners may contribute to universal supports, targeted problem-solving, data collection, and team decision-making. For a deeper dive, see OTS 203 on MTSS interventions for sensory processing. Practical takeaway: Identify one existing school routine where OT can support a whole class or grade level.
6. Environmental changes that promote independence Use examples involving seating, materials, visual cues, room arrangement, and task setup. Emphasize that small environmental changes can sometimes reduce the need for repeated adult prompts. Practical takeaway: Invite teachers to look at one classroom area and ask, “What could we change here to help students do more on their own?”
7. What information makes an OT consultation more useful Teach staff to describe the activity, context, frequency, current supports, and effect on participation. “The student has poor fine motor skills” gives us less to work with than “During independent writing, the student stops after two sentences and needs repeated prompts to continue.” Practical takeaway: Provide a simple before-consultation prompt teachers can use to organize their observations. A simple 20–30 minute in-service agenda You can build a helpful session around this structure: 2–3 minutes: Name the teacher-identified problem. 5 minutes: Reframe the problem through participation, the activity, and the environment. 8–10 minutes: Teach two or three usable strategies. 5 minutes: Work through one realistic classroom example. 5 minutes: Invite questions and agree on one next step. I have used slide decks for in-services, but 15 slides are not a requirement. A one-page handout, short demonstration, whiteboard sketch, or guided discussion may work better for your staff. The format matters less than the focus. Teachers should be able to answer three questions when the session ends: What did I learn? What can I try? When should I follow up with OT? How to ask your administrator for time Once you have a topic, make the request specific. An administrator is more likely to understand a focused proposal than a general request to “talk about OT.” You can adapt this: I would like to offer a 20-minute in-service based on a concern teachers have identified: [topic]. My goal is to give staff two practical supports they can use immediately and clarify when collaboration with OT may help. Could we reserve 20 minutes during [meeting/date]? If possible, explain how the topic connects to a current school goal, a concern teachers mention often, or current MTSS work. Do not promise that one session will reduce referrals or improve scores. Keep the goal realistic: useful strategies, clearer collaboration, and one agreed-upon next step. Follow up so the in-service becomes collaboration The presentation is the beginning, not the finish line. Afterward, send the handout or slides and ask teachers to try one strategy—not all seven. Set a specific time to check in, even if it is just a quick email two weeks later. Invite a teacher to share what worked, what was difficult, and what they noticed about student participation. When appropriate, offer a classroom observation or a brief problem-solving conversation. These six strategies for impactful school-based OT consultations can help you plan what comes next. To see whether the in-service was helpful, pay attention to a few simple things: Did teachers try the strategy? What follow-up questions did they ask? Did anyone request an observation or consultation? What should you explain differently or revisit next time? Research on school-based consultation suggests that collaboration is most useful when it stays connected to school activities and student participation—not when it ends after we share information (Villeneuve, 2009). An older, small study of therapist-teacher teams also found encouraging results when they worked together on practical classroom goals, although the study was limited in size (Dunn, 1996). In other words, the real value is not the presentation itself. It is what the team does next. Start small and make it useful You do not need a perfect slide deck, a full professional development day, or even a "Perfect" explanation of OT. Ask teachers what they need. Choose one focused outcome. Share two or three practical ideas. Then make it easy to continue the conversation. That small, useful starting point can help teachers understand how you think, help you understand the realities of their classrooms, and create a stronger foundation for supporting students together. Want help planning your first—or next—teacher in-service? Get the free School-based OT Teacher In-service Starter Kit using the form above. After you confirm your email, you'll be redirected to the resource. You will also receive practical school-based OT tips from the OT Schoolhouse, and you can unsubscribe anytime. And, if you want an editable sensory-focused presentation and more ongoing support, you can also explore The OT Schoolhouse Collaborative. Listen to these OT Schoolhouse podcast episodes for more on how to improve OT-Teacher Collaboration What Teachers and Admin Really Think About School-based OT (OTS 175) Supporting Teachers First and How Coaching Creates Lasting Impact for Students (OTS 194) What MTSS Interventions Produce the Best Results for Sensory Processing? (OTS 203)

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 206 of the OT Schoolhouse Podcast. What if we've been asking the wrong question all along? For years, school-based occupational therapy practitioners have debated whether challenging student behaviors are driven by sensory processing differences or behavior. But what if that distinction isn't the most important one? In this episode, Jayson is joined by Kristen Brokamp, OTR/L and Breanna Lynch, OTR/L, co-founders of Holding Space Collaborative, to explore how OTPs can move beyond labels and instead focus on participation, regulation, trauma-informed care, and systems-level change. Together, they discuss why behavior is often a signal—not the problem itself—and how occupational therapy practitioners are uniquely positioned to help schools build environments that promote wellness, collaboration, and meaningful participation for every student. Whether you're supporting students individually, consulting with teachers, or hoping to expand OT's impact throughout your school, this conversation will challenge your thinking and inspire new possibilities. Listen now to learn the following objectives: — Learners will identify why focusing solely on "sensory vs. behavior" may limit occupational therapy intervention. — Learners will recognize OT's role in supporting school-wide wellness and prevention efforts. — Learners will identify opportunities to implement systems-level strategies that promote student participation and regulation.
Guest(s) Bio
Breanna Lynch, MOT, OTR/L is a native New Yorker who now calls Cincinnati, Ohio, home after graduating with her undergraduate and Masters degrees from Xavier University. Breanna co-owns Holding Space Collaborative with longtime friend and therapist, Kristen Brokamp. She brings extensive knowledge in program and systems development for preventative mental health work in schools and community partnerships. She is passionate about promoting care using a trauma-responsive and equity-centered lens. Breanna’s other special interests include reflex integration, gut health, and interdisciplinary teamwork. Outside of work you can find her outside with her family, drinking coffee, and being a tourist in her own neighborhood. Kristen Brokamp, MOT, OTR/L is an occupational therapist and private practice owner born and raised in Cincinnati. She completed her undergraduate work at Ohio State University and Masters in Occupational Therapy at the University of Indianapolis. She expands on previous experience in school-based, adult inpatient and acute rehabilitation, pediatric outpatient, and home- and community-based settings. She strongly believes that strengthening caregiver mental health is a key component to overall child and family wellness. Her therapeutic passions include airway health, sensory processing and reflex integration, and easy-to-implement strategies to support child and family activity participation. Outside of all things OT, you can find Kristen out and about with her family, traveling, and listening to music.
Quotes “We like to refer to Ross Greene quotes…The essential function of challenging behavior is to communicate to adults that a kid doesn’t possess the skills to handle certain demands in certain situations.” — Kristen Brokamp “You might be the only one that’s wondering the big picture.” — Kristen Brokamp "We can only function as well as the system we're in." — Breanna Lynch "There's no one person who has the capacity to address the behavioral needs of all students in the school." — Breanna Lynch "We can only function as well as the system that we’re in” —Breanna Lynch "The place where OTs can really shine is when we can bring in the occupation and play." —Breanna Lynch "OTs do it better." — Jayson Davies Resources
👉Holding Space Collaborative
👉Holding Space Collaborative IG 👉Holding Space Collaborative Facebook 👉Ross Greene 👉Every Moment Counts 👉Comfortable Cafeteria 👉OT Practice article: Advocating for a Seat at the Table

Episode Transcript
Expand to view episode transcript Jayson Davies Is it sensory? Is it behavior? Is it something completely else? If you have worked in the schools for more than five minutes, you have heard that question before, and honestly, it's the wrong question. And it's time to change it up. I'm Jayson Davies, and welcome to the OT Schoolhouse Podcast. Today, I'm sitting down with Breanna Lynch and Kristen Brokamp, co-owners of the Holding Space Collab in Cincinnati, Ohio, who have spent nearly seven years helping to facilitate AOTS pediatric trauma community of practice, and who are also now doing some of the most innovative system level work I've heard of in school-based occupational therapy. We're talking about redesigning in-school suspension rooms into actual intervention spaces, building tiered wellness programs inside of public school districts, and most importantly, making the case that OT practitioners are not just equipped to support behavior when sensory is involved, but instead that we are equipped to support behavior all the time, not just when sensory is involved. Yep, I said it. We can support behavior beyond sensory, and Brianna and Kristen are here to share with you exactly how they're doing just that. Let's cue the intro and dive into it. Amazing Narrator Hello, and welcome to the OT Schoolhouse 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 Kristen and Breanna, welcome to the OT Schoolhouse Podcast. It's such a pleasure to have you here. I'm really excited because we are going to be talking about the quote-unquote elephant in the OT room, especially in the school setting, and that is sensory versus behavior a little bit. But before we get into that, I just want to jump right into it, and I want to give both of you an opportunity to kind of share what it means to you to support behavior but beyond sensory. Breanna, would you like to kind of kick us off? Breanna Lynch Yeah, sure. So I think maybe the bigger question that we tend to look at is how do we support a student as holistically as possible? When we get into the is it behavior? Is it sensory? Sometimes we just get stuck in a rut, and it stops us from really thinking of how to support the student as much as possible. So I think something that OTs do really well is being able to sometimes tease out those things, but I don't think it's really all that necessary. So supporting behavior looks like to us supporting regulation, and now I think definitely we see more in the post-COVID world as we understand mental health better as we understand regulation, nervous system regulation, all these kind of like fad words that you see popping up in social media that touch every every little piece. In education, OTs can really be that person to collaborate with the team and figure out what are all the different areas and how is the behavior or the regulation, dysregulation impacting the student, and then move on to how can we really support that? Jayson Davies Absolutely. And Kristen, what what came up to or what came to your mind as I talked about you know beyond sensory and supporting students? Kristen Brokamp Sure, I'll second everything Brianna said and consider that if we're asking the question, is it sensory or is it behavior? Then we are too narrowed in to that question, and like Brianna said, need to take a wider, holistic view of what's impacting function and participation for the student. And I we like to refer to Ross Green quotes specifically one that mentions the essential function of challenging behavior is to communicate to adults that a kid doesn't possess the skills to handle certain demands in certain situations, and we know that as OTs we're skilled and probably you know one of the only team members who are looking at the environmental considerations, the task considerations, and the individual personal skills that a kid has that help them to participate, or that then present as behavioral difficulties. Right. So consider. those aspects as the OT, whether or not they're sensory challenges or other challenges, is where I feel we belong. Jayson Davies Yeah, absolutely, and I love that you both brought up like the holistic nature of occupational therapy, right? Like you even said it, Breanna. I think like it doesn't matter. Like it, I mean, when it comes to the actual treatment side, right? Like we kind of have to know which way we're going to go treatment wise. But and and I'll kind of pose this as a question for you. Like, can we not provide occupational therapy support to a student that? Has behavioral difficulties that are not based on sensory. I know we had this question planned for later, but I think that's like the question of the moment. So, yeah, what do you think? Can can we address behavior that isn't sensory related? Breanna Lynch 100 times over, yes, yes, absolutely. No, like no questions asked. Yeah, I mean, I think, like I said before, like, does it matter? Does it matter what the origin is? We don't know everything about every student. I know I touched on on like the piece of trauma responsive care, right? It's kind of that same understanding of having a trauma informed lens. Like I don't know everything about every individual that I meet, but I can still meet them where they're at with care and compassion and wonder to help support them. Right. So the same thing. Right. Who? What's? Who cares? It's this is the problem or the challenge that's inhibiting participation. That's making it difficult for the student to access the curriculum, the the extracurricular activities, whatever it is, right? So let's just see that for what it is. Okay, that's a that's the fact that we're kind of using, and then let's build intervention around that, right? I mean, I feel like that is the that's the heart of occupational therapy is figuring out okay there's this occupational performance thing that's challenging for this student so let's help support them through that Jayson Davies yeah yeah yeah and now both of you have you know experience as occupational therapy practitioners you're not brand new out of you know OT school, but I would imagine that maybe once upon a time you both kind of struggled with this whole idea of sensory versus behavior. And so, Kristen, I want to come to you and kind of ask you, like, do you recall you know as a newer pediatric therapist, kind of having this internal struggle of sensory versus behavior, or maybe sensory versus trauma, or kind of just that internal struggle that I think we've all experienced. Did you have that, and was there something that helped you kind of break out of that a little bit? Kristen Brokamp Oh, absolutely. I feel even if if you're starting out in school school based practice, especially having a mentor to guide you through the bigger picture thinking is essential, but not a lot of students have that right off the bat. Caseloads are high, and overwhelm and right traveling between district schools for direct intervention students is really difficult. So it's it's it's hard, and I hear Brianna talking about intervention for behavioral supports. And ideally, yes, that's amazing. And in a picture of perfect world and system, we're able to do that for every single student. But what can that intervention look like on a school level or a team level, and maybe not a direct intervention with a student level. So, thinking on those terms of what intervention means and what supports are in place. Jayson Davies Yeah, yeah, absolutely. And in fact, you know, I'm going to jump down to this because I went and looked at the article, Brianna, that you and I think it was Nicole published in the OT practice, and I've got this here. It's right here. You presented nationally on this topic, or sorry, yeah. In the in the praxis article, you and Nicole and Abe noted that establishing a wellness promotion can only be. You noted establishing wellness promotion can only be accomplished with system level innovation resulting from advocacy, and that's kind of what I just heard from what Kristen said. Like we can't necessarily do this just one on one. We have to develop this system level approach in order to support all student behavior. Brianna, I'll let you kind of follow up on what Kristen was saying in that quote a little bit and what that means to you. Breanna Lynch Yeah, I think you know. Back to your initial question, I still think Kristen obviously comes at it with a lot of experience in school-based practice too. I don't know that many new grads are thinking about about how maybe I would break out of the individual student intervention model, and and so I think that's a piece to acknowledge is that initially I don't think I would have ever thought like that as a new practitioner. I feel like most of the time you're like this is my caseload and this is what I do and I just do it to the best of my ability because I don't even know what I'm doing. Jayson Davies True. Breanna Lynch right? So, so I think that's you know from back being a new practitioner, it was like you just do the best with what you have, and I think that continues to be true. I'm still doing the best with what I have. I just have things that are different now, right? So. That article is based on a lot of really great work that I did with Nicole and Abe from a from an implementation, a realistic school-based implementation side, and also in advocacy on the state and national level and research. So there's kind of like the both and there, but really we can only function as well as the system that we're in. So, Jayson Davies I love it. Breanna Lynch If the system doesn't have the capacity for the innovation for this this outside the box thinking, if we live in a system which we do on a larger standpoint that doesn't value all education for all students all the time. Then it's hard. It's hard to do what we're saying. So I also want to make sure, and Kristen did this already, to acknowledge that it's really hard to function in a system that's not built for this, right? And so, part of what we're really passionate about in our practice and our business is to continue to reimagine what it looks like, and to build capacity within the system we have. Right. So, what does it look like to have a system that maybe is not necessarily going to change, you know, drastically? How do we build capacity and reimagine something? Redesign small pieces of it. Look at the roles and responsibilities of different team members, right? To to remake a system that is a better fit for the team members, a better fit for students, better fit for families, right? So that we can start to implement some of these wellness and behavioral type interventions on a bigger a bigger level. There's no one person that has the capacity to address the behavioral needs of all students in the school. So, yeah. Jayson Davies that's a powerful that's a powerful line, and I I think it's I mean you had a few powerful lines already in the first 10 minutes of this episode, both of you, and it's true, right? Like I think we often try to make something that's very gray into black and white, and you know it. There's so many quotes out there that just like throw that out the window. Like it takes a village, right? Like to to support a student or to support a child, and I don't think any one OT can support anything, just like I don't think any one SLP or ABA therapist or teacher can support an entire child, and it really does take a team. But the flip side of that is like sometimes we don't feel like we're always as much a part of the team as we'd like to be, and you just brought up the idea of that being a systematic problem. That's not an OT problem. It's a systematic problem, and that's something I say a lot as well. So, so really appreciate that. We've already jumped around a little bit more than I anticipated in the first five minutes of the podcast, which is totally on me. But I do want to back up and let you both kind of share a little bit, kind of because you you've talked a little bit about your business now and what you're doing. But I want to give you both the opportunity to kind of share, Kristen. You you talked about school base, Brianna, a little bit more pediatric side, but I want to let you both kind of share how you got to what you're doing today. Brianna was just talking, so Kristen, I'll come to you first and kind of share how you got to where where you and Brianna are working now together. Kristen Brokamp Absolutely. So I'm about 10 years in to my occupational therapy practice. I'm graduated from the University of Indianapolis, which had a great program. I felt like in a holistic development of practitioners, as well as evidence-based, a big evidence-based push and team treatment push. So when I got my first job in Cincinnati, it was at an outpatient pediatric practice, but they also did school-based practice. So I was a little bit of school-based practice and a little bit of outpatient pediatric treatment that was in a multidisciplinary trauma clinic, so we'll touch on that I think in a little bit because that's how me and Brianna developed into this holding space business that we are so passionate about. But from the school side of things, I had an amazing mentor who had been practicing for over 20 years, building up my knowledge of school-based practice and really suggesting and wondering what it could look like or when it could look like that I was developing relationships with school personnel, teachers, support staff and win that OT really building my confidence as an OT to prove and provide what we could in the schools, but also showcasing from an RTI MTSS tiered stand. Point of how we could integrate our knowledge and our skills into regular conversations and relationships that are built in throughout the schools. So that was super super influential for my practice development. Then eventually went to more school based practice, and from there have developed the holding space private practice that Brean and I do together. So I will let her. Jayson Davies Awesome. Kristen Brokamp Share as well. Jayson Davies Congrats, Kristen! I love it. I I think a lot of OTs start in a similar type of world where they have both that pediatric and school-based, and to be honest, I I often sometimes advise therapists to go into the pediatric world a little bit before in the schools because I think there's so much that you learn in the pediatric outpatient that you can bring to the schools and and vice versa. To be honest, but but yeah, no, I love that you got both both sides of it. That's that's fantastic. And Brianna, what about you? How did you kind of get to where you are today? Breanna Lynch Yeah, so a little bit different than Kristen. We met because we were working together in that outpatient pediatric setting. But my entire caseload, my whole week, was in the outpatient clinic in a variety of different clinics, but in that outpatient setting. And I really didn't get into school-based practice until I started working on the prevention and wellness team at a school district. Of course, there was lots of overlap with the families I was working with and outpatient of what their needs were at school, and kind of collaborating with the school OT or other school professionals to support the the kids I was seeing outpatient. But moved into a role that has shaped a lot of kind of our systems level work. Where I just happened to be an OT in that role, but the team was a multidisciplinary team, and our entire aim was to enhance the prevention and wellness promotion of students and staff across the district, and hopefully already we've made the point that we feel like OTs are positioned to do that. But that really gave me this very interesting lens. I grew and and was stretched as a therapist in so many ways to learn so much about special education from the practice and from like the legal side and some social work things and all of this was amidst COVID, so it was just like a really, I got a really interesting, just really threw in thrown into the deep end there, and it really helped me to hone my appreciation for the ways that OTs can look at shared problem solving, look at team collaboration. I feel like obviously super biased, but I feel like we're the best of the best of of trying to bring the team together to to look at a student or a scenario or a classroom in a really broad and oftentimes positive light. Like what's going well in this scenario? What's going well for this student? Let's look at all the things that this family is is trying to do to support their student. Like those kinds of things, I feel like OTs do so well, and I was able to bring that lens to a much larger team. In that, I feel like Kristen and I, along the way, have been always collaborating on on different work endeavors, and then also outside projects. When when we were new grads, we were working in a multidisciplinary trauma clinic, and that was something that we had to. We had amazing mentorship and supervision and support. We also were like, "What are we doing? So, so we really were super self-directed in figuring out, like, okay, we need to read all the research we can get. Which honestly, at the time, was very little within the occupational therapy scope of practice. So we read all different discipline research. We went to conferences. We did all the things. We started a community of practice within AOTA, all in the spirit of our own professional growth and learning, so that we could, you know, feel confident that we were the best therapist we could possibly be when we showed up at this very specialty clinic, and so that from there we spent a lot of time together, and and we grew really awesome friendship and and built this like vision that we had notes of together of one day we were going to have this practice together and it was going to was going to wrap all these things and all these interests up in a bow, and so holding space collaborative came to be almost four years ago now, and it's we're we're building a dream. Jayson Davies So that's awesome, man! Such a such a variety of experience between the two two of you, and I love it. I love how you're bringing it all together with holding space and more. That in a second, but we're going to take our first break here. When we come back, we're going to talk a little bit about what you might consider the missing word in the whole sensory versus sensory and behavior discussion. So we'll be right back. All right, we are back, and that word that I was talking about here is trauma. Trauma is not found in the term sensory versus behavior. I don't think it's really even implied when we say behavior, although you should absolutely assume that it should be implied. I think, but even as you were talking earlier, you know about your experiences in the past. It sounds like this, the work that you two had together kind of started within a trauma-informed approach, and I would love to get both of your takes on how trauma fits into sensory versus behavior. So, with that, I'll let the two of you speak on it. Breanna Lynch Sure. Yeah, I mean, our practice has always included a trauma informed and trauma responsive lens. So I can say we don't really know any differently. Not that I would say either of us came out of grad school like knowing anything really in that vein, But I think we've talked about this before, the two of us, and we talk about it with our employees and and like the fieldwork students we have is kind of like what came first was it was it the trauma and then we see like sensory processing changes or behavioral changes, or were there always these sensory processing things, and then there was also trauma? And again, like we always just come back to like, does it matter? You can stay on that hamster wheel forever, but like, does it really matter? And is it going to change the treatment? And like, 10 out of 10 times, it's not going to change how you approach the treatment. You're just seeing a student, a child, an adult, anybody. Here's how they show up. All right, let's go from here. But and I should say not but and we do know from mounting research that trauma impacts sensory processing. So I think without a doubt, those two are inextricably connected, and I don't think you can support and know that you're supporting a wide variety of individuals with trauma, which the majority of us have experienced adversity that's considered an adverse childhood experience without understanding how sensory processing is impacted, so I I do think that it's really hard to separate those two, and I also think that's why occupational therapy practitioners are in the just right spot. There, we have the the tools and the knowledge of sensory processing to help to kind of problem solve that with the team. Jayson Davies Yeah. And and I mean trauma is so unique. You talked about that, like what came first, the trauma or sensory. And you know, when you think about trauma, I think a lot of people try and try and like, okay, well, there's a change to the brain in the moment that that trauma was experienced. But I don't know that that's you know actually true. Like it almost trauma impacts from to from the day of the trauma, you know out out from there, and it's the experiences combined with the trauma, the the post traumatic experiences combined with that trauma experience that really start to I don't know. Like I'm not a trauma expert here, but like it's not just a one-time event. It happens over a period of time, and the same thing, like kind of with sensory. We don't know what came first: the sensory experiences first, or the sensory in combination with the trauma experiences and all that. So, yeah, I don't think, like you said, I don't think we can separate out behavior versus sensory versus trauma. Like this, all kind of comes together into this holistic. And I don't know, maybe the title of this podcast will be sensory versus behavior. Doesn't matter, like because that's kind of what it comes down to. Kristen Brokamp Yeah, I mean, and I'll add on that. Yeah, what, and especially as a new grad when you're coming in, and does it matter if you know what the trauma is? The trauma, or a trauma, is a subjective experience of something that has happened throughout someone's lifespan, and we know that if it happens in the early years, it impacts right the brain development and sensory processing and all skills moving forward. But what if, as a new grad, and you don't have all that information yet, you can still come to the table asking, you know, what has led you to this point? Right, not maybe not outwardly, because they might not be able to answer that. But what experiences have you had? What skills have you developed that has have led you to this point? I don't need to know all the answers right now, but I'm here, right, with you to help make sense of what skills we're working on and what would be helpful moving forward. So even calling it a trauma kind of defines that you need to know exactly point in time or what happened, and not necessarily the case. I think we can, especially as new grads are. If you're listening to this, you can consider every student or every family you're working with as just a a person who's experienced many things, and some of those things may have impacted the way they develop, and definitely has. And you don't need to have all those concrete answers to to help them recognize their strengths and be the best participation have the best participation in any environment. Jayson Davies Yeah, yeah, no, I. It's amazing because so we did an episode not too long ago about the occupational profile and how we should be conducting this occupational profiling, getting background on a student, and all of that. And but at the same time, if our answer is it doesn't matter, like what is the important pieces of this occupational profile that do matter? You know, is it did the student have an A score of whatever, or is it that the student has a diagnosis of autism, or is it that like what actually matters on our occupational profile then, and and even going further, what actually matters in our evaluation? And I don't know if either of you have thoughts on that particular thinking that's just going on in my brain right now. Kristen Brokamp Well, that's one thing we've added as a private practice to our intake questionnaire is a brief statement just about how the subjective experiences a person has in their life impacts their skills and development, and put an adapted ACE questionnaire into our intake form, so it gives us some very brief information about things that may or may not have have occurred, such as you know family separations or living with an individual who has a mental illness, or you know obviously any physical or emotional or other otherwise defined trauma. But that brings to light a little bit about what has brought them to this intake as we develop that occupational profile. Jayson Davies Okay, so then a follow up on that: How do you actually use that information? Do you feel like that is important within your evaluation, or do you feel like it's more beneficial to have that information when you're actually treating the student one on one or in a group, like when do you find yourself actually referring to that information? Breanna Lynch Yeah, I think it depends on on the person and how relevant it ends up being to their story when we do the evaluation. Even if we give it a mention in the the write up of the evaluation versus kind of just a nugget of information that we tuck into our pocket, and sometimes it depends on which of the child life events that they check. That we may tap into that more just based on our own knowledge of how some of the occupational performance skills may be impacted based on the type of trauma, but I think that's come with a lot of practice and it's a lot of nuance because I also feel we've gone back and forth about this a lot. If it's not, if it doesn't really matter, which and I think in our heart of hearts we don't think that it does. It doesn't. Not that it doesn't matter. Let me rephrase that. It matters a lot. It doesn't matter to how we are gonna like meet this person where they're at. You know, we're gonna do the intervention based on the individual that sits in front of us. And because the that adversity is so subjective, you know, when you've met one person that has experienced homelessness, you've met one person that's experienced homelessness. The same way people say that of when you've met one autistic individual, you've met one autistic individual, right? That that line works. Jayson Davies Can we just keep it as if you met one person, you met one person? Like, can we just exactly right Breanna Lynch Exactly? So I think if we get too stuck in the aces, two things in my mind. One, we get too stuck on it being black and white, and like, oh well, if this ace happened at this age, then this, and like, you'll drive yourself mad over that because every person is going to present differently, right? The second part is it also the ACE questionnaire again is only as good as the system it was developed in, and so we know so much more about adversity and how it impacts the brain and and our skill development now. The ACE questionnaire completely leaves out the systems that oppress and cause adversity to individuals, right? So if we leave out all of those things, we're really missing the mark too. When we're using a super holistic systems level lens to assess how to support a client or how to support a student or a family, so many of those are so much more pervasive in the everyday person that we work with, and so you know, it's the it's the both and it's it's great information to have as background, and we also want to take into account all the bigger things that impact a person. I think what's important to remember is that trauma impacts the way that the person sees themselves and the way that they see others and the world, right? So that's really what we're looking for. Like, how does this person view themselves, their own personal safety? How do they view trust and safety with me as this new therapist entering their world? How does it impact how they see the world, right? And when we talk about kids with dysregulation and behavior, everything is is unjust. It's not fair. It's it's me against the world. It's all you know those kinds of oppositional, defiant, all those words that you know like that. That's what we're thinking about. Like, what experiences have you had that led you to a place where you feel like it's me against the world? It feels like everybody's against me. Everything's unjust. Like I'm a bad kid, right? Like that's that's the using that trauma informed lens of just being like, wow. Like I wonder what brought you to this spot, but like we might not know. We're just at this spot with you, and then we go. Yeah. Kristen Brokamp and just as a school-based OT, you're sitting in those IEP meetings. You're you're writing those progress reports, right? You're sitting in those. You might be asked to consult on those functional behavior assessments or behavior intervention plans, and you just might be the only one that's wondering the big picture and not getting stuck in the this behavior is occurring talk. So just bringing to light that that you're you might be the person that is bringing the whole picture in as part of the team. Jayson Davies Yeah, yeah, and and man, so much so many directions we can go with this. We have so many questions that that we're not going to get to today, and that's totally fine. Brianna, like, just want to mention, right? Like you, you talked about during your background about this job that you had, where you were an OT but not an OT, like on this team, or at least not a job that was specifically made for OT. Breanna Lynch Yeah. Jayson Davies and I don't think we're going to have time to jump into that too much today, but we are going to have Nicole, your your supervisor, on the podcast in a few weeks to talk more about that that job. So we won't go into too much of that today, but I do know that that really shaped what you are doing now at Holding Space. By the way, Holding Space, great name for an OT company. I love it, especially a holistic OT company like the two of you are creating here. But I do want to jump into like what you are actually doing now, and you know, are you doing the traditional pediatric clinic where you're seeing students one on one, or is it completely you know different? And so, just briefly, can one of you mind sharing kind of what what the goal is for holding space? Breanna Lynch I can take it. Sure, we have our hand in a lot of pots, so I'll be brief. But so we're really actually excited that we are have just opened a small clinic here in Cincinnati. So we do have the ability to see clients, one on kids and adults. We see people of all ages in our clinic space. We're offering summer groups, so we're doing like a half-day therapy group for kids this summer, and so that's kind of like that's a small group setting versus one-on-one clients. We also do have some clients that are doing intensives with us, so we see them multiple times a week, do like a high-intensity burst of intervention. But originally, when holding space originated, we felt like we needed to fill a gap in the home and the community space. So we, for the past three years, have seen clients solely in their homes or in different community spaces, and that was out of need that we found from our student. Families, outpatient clients that really were having a hard time figuring out how to generalize the strategies that they were getting from their school-based practitioner, from their outpatient person, from their mental health therapist, from right, like it looks really good in the in the gym, and then like I don't know what it looks like at my house, or I can I can use this strategy here, but then when we go to the playground, like and these other factors are at play, like it's not really it's it's breaking down. So being able to really walk alongside clients in the places where they're finding the most challenge is where we have been for the majority of our practice at holding space. We also have a few different contracts, and so some of those are school-based contracts, and we are providing tiered wellness support is what I think is the best name for it. It's a lot of social-emotional learning support across all tiers. The majority of our work is systems level. So, what does it look like to provide wellness promotion within the entire curriculum? What does it look like to make a school building the environment, the playground, the way in which the schedule functions, the way in which the administrators address discipline? What does that look like to make sure that we're putting positive mental health and social emotional learning at the forefront of that, and then we also do some within that doing some small groups and one on one with with students there. So that's been a really cool way to kind of bridge like how we view our client practice, our one on one client practice, and some of Kristen and I's school-based experience, and bring it into schools that are looking for innovative ways to support students with the all different funds that they have. Jayson Davies Yeah, yeah, and obviously both of you have. I mean, Kristen, you have significant school-based experience, and Brianna, you were have a unique school-based experience, I should say. With with what was the name of that, by the way? What was the name of the team, or like what was it? Breanna Lynch Yeah, we were the prevention and wellness team. Jayson Davies Okay, so you worked on this prevention and wellness team with not just another OT, but you know the entire gamut of people who work in school-based OT. And it sounds like, to a degree, you're kind of taking what you learn from there, pairing it with what you both know about the traditional quote-unquote school-based OT role, and kind of flipping that upside down a little bit to support schools. Tell me a little bit more about what these wellness programs kind of look like. It looks like it sounds like you're supporting students at all three tiers. You talked about groups and even individuals within the schools, but I'd love to hear more about that. Kristen Brokamp So, on a broad level, it's environmental design, it's teacher coaching, it's staff educational opportunities, it's systems design. In that, instead of in-school suspensions, where students-and you can talk more on this, Brianna-but instead of students sitting down and completing a worksheet for an in-school suspension, there are other avenues of skills learning that the student needs to have to be successful in class. So, if you're flipping a desk, if you're right, what is the skill deficit that is missing in in that regulation, that impulse control, that right, that interoception piece for understanding what your body needs when you're angry or disappointed, and then you're reacting. So, what are those skill-based opportunities for students to learn in a newer alternative learning or discipline system, and helping reframe teachers' understanding because they are overwhelmed, they have many students, they are doing the job day in and day out, and reframing their understanding of what behavior support looks like-that's not the traditional. This student is suspended, or this discipline note is being sent home, or things like that. I don't know if there's anything you want to add to that, Brianna. Breanna Lynch Yeah, I think the the piece that occupational therapy practitioners bring to the table in this sector, among many, is the focus on occupation, and especially in schools, is the focus on play. And for our the programming we design, the small groups that we're doing, the individual student check-ins or sessions that we're doing, to be really as true to occupation and play-based practice as possible, which is so hard to do in the every the day-to-day of school. I think we just really try to acknowledge that. Occupational therapists have the ability to bring in some of the cognitive behavioral skills that more traditional talk-based mental health therapy that can be provided in schools has. That the place where OTs can really shine is when we can bring in the occupation and the play, and we know that lots of students just really Need that that is so therapeutic for students in a place where school especially has become very sterile, where we see like recess time being cut or used as punishment, where we see just the push for educators to be so focused on content and curriculum, and it's exhausting for the educators too. It's exhausting, and so to be able to bring a perspective of we need to meet kids where they're at. What's what do kids need developmentally? Like they need play, they need meaningful participation. And so I feel like that's where we've also gained a lot of buy-in in the way that we're designing the programs or the systems. Is like okay, yes, everyone's going to go to the cafeteria to eat lunch. Like, how do we enhance this experience? How do we think about every single experience that a student's having in the day from a wellness lens? And the same for staff, right? Again, we can only do as good as the system we function in. So students can only do as good as the staff. You know that the staff can can do too, and so the same thing for staff, right? Like everything is an opportunity for wellness promotion or to enhance prevention, and to be able to use that lens in resetting or reframing a mindset is really powerful. I think that's where our work has really has really shown itself as unique and extremely like beneficial from a from a data standpoint. Jayson Davies Yeah, the the in school suspension thing really like is impactful. It's like something that's come coming to thought more because my wife's an assistant principal, and I don't know. A few weeks ago, we had this whole like, she gets frustrated because teachers are sending the students up to the office to do work, and then when they come up to the office, the students are happy because there's no one really there to make them do the work, and you know they're out of the classroom, so they're happy, and she's trying to keep them in the classroom, and it's just like this revolving door of everyone's trying to move the student somewhere else because no one knows what to do with the student, and at the same time, the student is no longer in their least restrictive environment. They're no longer included in everything that's going on. People are making decisions about whether or not they should be able to go on an academic field trip, or if it's academic, so you can't miss an academic field trip. And like, but no one is trying to figure out what's actually best for the student when they are having this concern, whatever it is. So, what does this actually look like in practice? Breanna Lynch Yeah, yeah. This is something I'm really passionate about because I think you know the question is also if the student is so happy to come up to the office, like why, right? What is what are the the differences in the task demands, in the social interactions, in the environment that make this so much more suitable for them, right? Is it that the work demands are less? Is it that it's quiet and they're by themselves in a little study room? It like what is it about that? That's the kind of wondering that helps a team to get to to the meat of it. And so, in the project that I'm working on right now, in one of our school partners, that's what we're doing. We're just really digging into it. And so, the the term in a lot of schools is alternative learning center community environment, right? But there's very little learning happening in the learning environment, and to me, it is exactly what you just said, Jayson. It's the shuffling. It's the like teachers are like, I don't know what to do anymore, just like leave the room. Jayson Davies Yeah. Breanna Lynch students are like, just get me out of the room, right? And then, and then administrators are like, oh my gosh, we have 10 kids up here, and so it is this kind of like everyone's just in in the mix, and it's hard when you're in it to like come up for air and figure out like cool how do I reinvent and reimagine the system, and so that's the the positive of having a consultant work with you, right? But I think even be like being in the system and trying to figure out what to do is that like what about this is supporting the teacher right when they send a kid to the office what is it about that that helps them what is it about this being in the office that helps the student right like some of that wondering and putting the pieces together but making sure that it's actually still learning when we have. Students that are more than more often than not having repetitive disciplinary action things happening, we are, in my opinion, restricting their access to their education, right? And so, and I don't know that everyone really thinks about it like that, but when you have students that have repetitive behaviors or discipline, and they're up in the office or they're at a school or whatever it is. When you count up those hours, right? Like, and we're the adult educators, right? It is our responsibility to help students to stay in their least restrictive environment. So I'm not saying just everyone should stay in gen ed. That's not what I'm advocating for, but I am advocating for every student having access to an education, and so I think it's important to think about it that way too because that can sometimes like stop people in their tracks when we we're like we're not letting this child access their education, and so for the environment to hone in on skill building, right? What are the skills that this child needs to be more successful if they're coming to the office or the alternative learning center because of disobedience, disrespect, out of spot, you know all the different labels we can put on the disciplinary record. What are the skills that are are missing there that we can help to support? And then providing intervention. You know there are adults that are assigned to the disciplinary rooms or the different areas where students go, and so can those adults be supporting the learning and the skill building with the idea that we can decrease the repetition of these disciplinary actions while building skill, and that's something that doesn't take up time on caseload. Yeah, it can be something that occupational therapy practitioners can be pushing in and doing a larger group lesson or a small group lesson. Right, doesn't have to be one-on-one with a student. If there's 10 kids in the room, probably eight of them are there because of disobedience, whatever that means. So, like those are kind of the ways that we can get creative, and also have the opportunities for kids to explore what are my coping strategies, who are the safe adults here, how do I repair a situation? Right. So much growth comes in repair. So in this environment, the students have the opportunity to go through all of those things. They proactively use the calming corner with a variety of different sensory-based calming tools. They go through what their repair process for whatever the reason they were referred there is. They engage in intervention that's based in the school's existing social-emotional learning curriculum. They have body breaks, so they do different like walk outside when it's nice, and different motor breaks. They have all different types of activities, things they can do on the playground. So I think it's it's more honestly just us allowing ourselves to let it happen and not feel like oh well they are indisciplined, so they like can't smile, you know. Kids have to have to be regulated, and they have to play to learn. So. Jayson Davies Yeah, right. This isn't the Breakfast Club. Like, so you all put this. You you mentioned in there. I was going to ask you whether or not you use a curriculum or if you created a curriculum. It sounds like you said that the curriculum used is the school's already approved SEL program. Is that right? Kristen Brokamp Yes. Jayson Davies Okay. So then, I don't want to ask like YOT, but like YOT, like why was this something that they came to holding space, you know, collaborative to do as opposed to, you know, someone else, and then why was OT the two of you the right people to put this together? Breanna Lynch So I think the mind, I think the mindset is probably the answer to both of those questions. Jayson Davies Yeah, Breanna Lynch hopefully it's pretty evident if you've been listening the whole time that this kind of the way our brains work, and so I think that's part of it. It is like we are putting play and occupation and skill building at the forefront of everything that we do for students and schools from a systems level and from an individual student perspective. And so I do think that that sets us apart from the more traditional mental health practitioner agency or route, not to discredit our mental health partners at all, because because we still need them immensely. But just the the ability to have like this different holistic perspective, I think, is what brought this partnership to be in this specific instance, and what makes OT the right professional to help to enhance some of these systems that we're working to to build. Jayson Davies Yeah, bigger. Kristen Brokamp picture task breakdown, bigger picture environmental assessments, bigger picture. Education for for stuff and yeah. Jayson Davies Yeah and to push back though because I'm trying to obviously this is a podcast for school based OT practitioners right not former school based OT practitioners that have created a business and are trying to consult and so obviously always trying to put this back into the perspective of you know the I don't know. I don't. I would only want to say eight to five because some school-based OT practitioners are only contracted for 34 hours a week or whatever it might be. But we often hear like from OTs and going back, right? It's a system problem. But I don't have time to do something like this. It would be great, but how do I go about starting this? Do you feel that this could be? Do you feel like if you had been a full time OT at this district, this could be something that you could have pitched and put into place? I guess that even a possibility for a real school based OT. Breanna Lynch I think the feasibility is has to be bigger than just one person. Jayson Davies Okay. Breanna Lynch Right. So me as one individual OT being like, let's do this thing. Like I probably don't stand a chance by myself, right? I do think that, and I know you mentioned the the article that Nicole and Abe and I authored. Like I do think it takes advocacy, and there needs to be several team members at least on board, even if it's just within your building and it's not the district, you know your school-based team to get on board. I also think part of it is is the the rearranging and the building capacity. So like, let's everybody lay out on the table what's the caseload, what's the breakdown, what's the percentage of kids we do direct intervention with versus small group versus consultation, right? And maybe do doing some some jigsawing of that and figure out like, okay, who's the one person out of our three OTs in this school in these three schools that could take 10% of their time and do this type of work, or if we all rearrange this much, can we all take this little sliver? Yeah. And so I think that is more of like the realistic on a day to day school based OT way to go about it, and to also like in collaborating with your other interdisciplinary professionals, right? Like let's all sit down as a team and go through, like, okay, what is the school counselor doing? What's the school psych doing? And that's really different at every school. What are we all doing? And then, like, how can we? Right. So part of that is again having the team be interested in that change too, of just like, what's this small little thing? I think sometimes we underestimate just one tiny little change that we can make. Like you don't need to do the whole school. Start with with one classroom. If I try doing this push in lesson to co teach with a teacher about interoception, about whatever it is, like whatever top it doesn't even have to be you know mental health related, whatever topic of interest. Like, let me just try with this one classroom, right? That's my little pilot, and so I think, and that's the in. Like, do you have just one teacher that's like really interested in all the work that you do? Like, sure, they're gonna do a pilot with you if you go to them, right? They're like extra support. Okay, that's what I was Kristen Brokamp gonna say too. If I'm a school-based practitioner with a full caseload, and I walk in and I have 30 minutes in the morning and 30 minutes in the afternoon, and I I might eat my lunch with a teacher and try to develop that relationship and get that initial classroom push and buy-in, and a lot of that comes with developing the relationships, and or I might be saying hi to the principal as I walk in in the morning, right? And and being like, I have this buddy on my caseload today, and our goal we're doing this so he doesn't come down here, right? And then starting that conversation. Jayson Davies That's perfect because we don't talk to people, and that's a problem. Like we don't, we don't like. Hey, mrs. Principal, mr. Principal, like even if it's kind of in a joking manner, say you know they ask how you're doing, and you just kind of jokingly say, "Well, you know, I'm working with Johnny today. You know, we're working on this skill or whatever. Like, just make yourself a little bit more visible. I mean, that's key, and and you're opening up that communication because I was going to ask you, and obviously you're coming from the business consultant side working with this, but you had to either a find a school district that was interested in this service, or b pitch yourself to the school district to do this service, and the same thing a school based OT if they're going to do something like this, they've got to pitch it somehow. Kristen Brokamp Yep. Jayson Davies You mentioned doing a little pilot study with one teacher, but did you have to sell this to the school? Was the school already looking for something? How did that formulate? Breanna Lynch Yeah. So I would say our school partnerships that we have had over several years with holding. Space have were looking for wellness promotion, and they were like, "Do we do we hire this person? Do we hire this person? You know, they were just they cast a wide net, and we were connected to them, and and we sold ourselves well enough, right, to be positioned for what they needed. The school that I'm working at now, the specific project. They're part of a larger grant-funded project here in Cincinnati, and so they already knew that they had funding that was for wellness promotion, and then they were able to pick from a wide variety of agencies, practices, consultants of who they wanted to have for the job, so we did. You know, we Chris and I did have a pitch for them, but they were already interested in the work and had funding set aside for the work. Jayson Davies Yeah, no, but that again, it shows the importance of kind of being in tune with your school site, like beyond just the 60 kids on your caseload, and being in tune a little bit with you know what the board is talking about, what are they prioritizing? What is your principal talking about? You know, is there a does your principal have a dream for every kid on campus to complete A, B, and C by the time they leave their school campus? And if so, how can OT support A, B, and C? And knowing those larger initiatives that the school team, the district team have in place, and opens up doors for the OT to say, "Hey, I can fulfill A. I can't do anything about B and C, but I can fulfill A. I can help out there and develop a plan and an idea and pitch it. Because. Breanna Lynch Yeah, there is the importance of of knowing where all the stakeholders are at, and then figuring out, like, okay, I know where the stakeholder holders are at. What's the language I need to use, right? Like, OT language and education language are not always like in line. So, can I or board language or when we talk business, that Chris and I are figuring out how to talk business, right? Like. Jayson Davies Yeah. Breanna Lynch What's the what's the language, and then how do you get in there? You're like, oh, you want to decrease your in school suspension or out of school suspensions? Jayson Davies You figure out a plan for that. Breanna Lynch Let me let me say, oh, I think I could get in this way. Or you want to enhance your attendance? Okay, right. So all those you have to know what the stakeholders are interested in, yeah, and then show them your your value. You have to sell yourself on what what OT can do for them. Kristen Brokamp And if you're not there yet, and you're planning your fall case loads, right? And you have three students who are working on their self regulation skills. There are amazing OT driven recess and lunch programs that you can see your students in shouting out every moment counts. Look it up that you can provide your direct services in. Put it into your schedule and then make it a you know make it known to the teachers and staff and school personnel. Right, and look at it differently. Jayson Davies Yeah, and shout out to every moment counts, like you just did. My my wife, assistant principal, tried to implement the comfortable cafeteria program. She failed because she's assistant principal, not an OT, not a teacher on assignment. Like she has too many other hats to wear, and so it didn't work out. But she would have been happy if she could figure out a way to support the OT and the SLP working together to implement the program, rather than her having to do it as an assistant principal. Like that's not what an assistant principal should probably be doing, but it is something that an OT and SLP could be doing to prevent future referrals. It's a win-win-win situation. Breanna Lynch Yeah. Jayson Davies Man, I love it. Kristen Brokamp So much good stuff. Her head's in the right place, right? Jayson Davies Okay, we've been talking about the ALC, the the Alternative Learning Center, for a bit, and I think that's just like a perfect case example, and that's why I wanted to really dive into that one. But are there any other really cool, you know, wellness programs that either you're doing or working on or dreaming of? Breanna Lynch Oh, dreaming of-that's a big question. Our brain is like constantly-we're always pulling it back down. Yeah, pie-we're pie in the sky kind of people. That what-that's what keeps us going. Other things that we're doing-we're-we're definitely using every moment counts with our partners. I think the other thing that we've been pretty strong in, and again, is why why answers the question why OT is assessing the environment. I think that's a piece that other professionals sometimes miss. So really looking at how is the environment leading by example. So some of like what does the office look like when people walk in? What do the hallways look like? What do all those kinds of spaces? That's been something we've been working really hard on to make the the environments match what we're asking of students and staff. If we're asking students and staff to be regulated and to be ready to learn, then the space has to also be. Regulated and ready to ready to help learn, so I think that's a big that's a big piece that we've really been working on. That is definitely a part of wellness promotion, but maybe not always thought of in the same way that OT can bring can bring to that conversation. Jayson Davies Yeah, well, well, Kristen, Brianna, it has been a pleasure. I think we're out of time here. We have had such great conversations. Typically, I ask for one final like tidbit, right, to help out. But I think we've we've touched a lot. We provided a lot of tidbits between the two of you about things that school-based OT practitioners can do. And you know, listen, right, like even if you're not a consultant for a school like Brianna and Kristen are, you can do a lot of this internally, and these are things that real OTs are doing. And I can't wait to to talk with Nicole and and talk about how Brianna, you and Nicole and the rest of the team kind of did this more internally as opposed from an outside consultant type of type of business, but it's going to be amazing. I'm excited to see what you do dream up of and and do implement in the schools next because OTs have so much to offer. I'm going to kind of bring in something from my other world, which is OTpreneur, where we were in a conference talking about business and OT, and we were asking our audience members, like, why should OTs be starting these businesses? And one of the audience members like raised his hand and he said, because OTs do it better. And like, that's what you all are doing right here when it comes to these learning centers, when it comes to supporting mental well-being, when it comes to supporting handwriting skills and like all these things, OTs can do it better. We just have to find a foot in the door. Whether we're working as a consultant or working directly in the schools, we have a lot of knowledge, and we just need to kind of figure out a way to convince people to let us share it and show it, and and make progress. So I want to say thank you so much for your time and your energy and and your knowledge. And I also want to ask you, Kristen, where's the best place for everyone to learn more about holding space and the things that you guys are doing? Kristen Brokamp Sure, you can visit our website at www.holdingspacecollab c o l l a b.com, and then that is a good way to reach us as well. There's a form on there that you can fill out that goes directly to our email, so it's probably the best spot. We're also on Instagram and Facebook, although not our strength keeping up on that one. But we do do we do try to to do some social media, Jayson Davies yeah, yeah, and we will be sure to link to all that in the show notes for the episode. So be sure to check out the show notes, and yeah, one more time, Kristen, Brianna, thank you so much for being here. Really appreciate it, and we'll definitely keep in touch to find out all those things that you're dreaming of and that you put into place a year, three years, five years from now. It'll be fun. So thank you again. Appreciate it. Breanna Lynch Thanks for having us. Thanks, Jayson. We appreciate it. Jayson Davies All right, that is a wrap on episode 206 of the OT Schoolhouse Podcast. A huge thank you to Brianna Lynch and Kristen Brocam from Holding Space Collaborative for joining me today for such a rich, honest conversation about how we as OT practitioners can and should be supporting student behavior beyond the sensory lens, the work that they are doing is exactly the kind of thing that our field needs more of. Not thinking about sensory and sensory integration so much as thinking about participation and how maybe we use a sensory integration lens in order to support participation, whether that is related to behavior or otherwise, and of course, thank you to you for listening today. Whether you are a full-time school-based OT practitioner, maybe a part-time kind of within the schools and somewhere else, or maybe you're a stay-at-home parent right now just thinking about getting back into the schools, I really appreciate you being here, and I hope that today's episode gave you something to think about as you start the 2026 27 school year, or if you're listening to this later, whatever school year you are in right now. Now, if you enjoyed this episode and you want to keep going deeper on topics like this one and others, I'd love to have you join us inside the OT Schoolhouses School-Based OT Collaborative. That's our online community built specifically for school-based OT practitioners with resources, professional development, and direct mentorship from myself and the OT Schoolhouse team. And for this episode specifically, members can also get access to a slide deck that we build based on today's conversation. This is something that that will actually be able to help you kind of almost pitch to your administrators how you can support behavior within your school site. You can get all of that as a member over at otschoolhouse.com/collab. Until next time, keep showing up for your students. And keep being yourself, the amazing OT practitioner that you are. Take care. Amazing Narrator Thank you for listening to the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 205 of the OT Schoolhouse Podcast. Handwriting referrals fill school-based OT caseloads, but many practitioners feel underprepared to address dysgraphia and written expression challenges. In this episode Jayson sits down with Kelli Fetter, founder of Handwriting Solutions, to explore the complex world of dysgraphia—from diagnosis and assessment to evidence-based intervention. Kelli shares her personal journey as both an OT and parent of a child with dysgraphia, and explains why she believes school-based OTPs are the most well-positioned experts to lead on handwriting support. You'll learn practical strategies for implementing MTSS handwriting programs, understanding the difference between top-down and bottom-up approaches, assessing handwriting across different cognitive load levels, and creating intensive intervention models like handwriting camps and clubs. They also discuss the emerging "science of writing" movement and why now is a critical moment for OTPs to step into a leadership role in this space. Whether you're new to school-based practice or looking to sharpen your handwriting intervention skills, this episode is packed with actionable strategies you can bring directly to your students. Listen now to learn how to confidently support students with dysgraphia and written expression challenges — and why it's never too late to make a difference. Listen now to learn the following objectives: — Learners will identify the OTPs role in supporting students with dysgraphia within a tiered MTSS framework, including how to collaborate with teachers, SLPs, and special educators to address written expression as a shared team goal.
— Learners will explain assessment strategies across varying cognitive load levels — from tracing and near-point copying to dictation and self-generated writing — to identify automaticity gaps and guide intervention planning.
—Learners will explain the diagnostic criteria and team-based approach for identifying dysgraphia in school-aged students — Learners will differentiate between top-down and bottom-up handwriting intervention approaches and determine when each is appropriate based on individual student needs

Guest(s) Bio
Kelli Fetter is a Certified Handwriting Specialist and the founder of Handwriting Solutions, LLC, where she leads a team providing world-class virtual handwriting, reading, and spelling support to students worldwide. She’s also a respected educator for teachers and therapists, known for her evidence-based approach to handwriting, dysgraphia, and dyslexia. With a background in pediatric occupational therapy across clinics, schools, and early intervention, and inspired by her own daughter’s dyslexia and dysgraphia journey, Kelli is dedicated to empowering families and professionals to unlock every child’s potential.
Quotes “Handwriting is complex. It is nuanced.” — Kelli Fetter
“Teachers are thirsty for this. They want to be able to support their students.” — Kelli Fetter
“True automaticity only comes from being able to self-generate thoughts.” — Kelli Fetter
“Professional athletes aren't learning to be professional athletes one time a week.” — Jayson Davies Resources
👉Handwriting Solutions
👉Handwriting Solutions on Instagram
👉Handwriting Solutions on LinkedIn 👉Handwriting Solutions on Facebook 👉Handwriting Solutions Course for OTPs 👉Dyslexia, Dysgraphia, and Dyscalculia in Pediatric Occupational Therapy:A Practice Resource 👉Handwriting Breakthroughs Guidebook ( Freebie)
👉 Sold a Story Podcast
👉The Writing Rope
👉Size Matters Handwriting Program
👉Handwriting Without Tears / Learning Without Tears 👉VMAT (VMI App Tool) 👉ETCH (Evaluation Tool of Children's Handwriting) 👉THSR (Test of Handwriting Skills–Revised) 👉The McMaster Handwriting Assessment Protocol 👉DeCoste Writing Protocol 👉 Dr. Virginia Berninger Research 👉 Dr. Maryanne Wolf Research 👉Aspire OT

Episode Transcript
Expand to view episode transcript Jayson Davies Hey there, and welcome back to the OT Schoolhouse podcast. This is episode number 205 and today we are diving into one of the most requested, as well as one of the most debated topics in school-based occupational therapy. You already saw the title. You know what it is: handwriting, specifically dysgraphia, is what we're discussing. Now, I know some of you just groaned, some of you just leaned in a little bit closer, and honestly, either way, this episode is for you. My guest today is Kelli Fetter. She is an occupational therapist and founder of Handwriting Solutions, where she runs a virtual tutoring practice. Yes, I said tutoring, not an OT practice. However, her practice is staffed by OT practitioners, OTs as well as OTAs supporting students with dysgraphia. Now, while valuing the full scope of OT within the schools, beyond just handwriting, even Kelli wants to support OT practitioners in their role as handwriting experts because she knows that we are handwriting experts at the end of the day, and she is not afraid to say the things that need to be said. So, in our conversation today, Kelli and I, we are going to talk about what dysgraphia actually is and who, in theory, should be diagnosing it. Why copying in the therapy room does not mean a student has automaticity in the classroom, how cognitive load is quietly sabotaging your students when they are in the classroom, and what a real handwriting intervention model looks like from MTSS Tier One all the way to more intensive services like camps and clubs. Now, if you have ever felt unsure about your role in handwriting, which I know every single occupational therapy practitioner has, this episode is for you. You are really going to appreciate what Kelli has to say today. So let's get into it. Here is Kelli Fetter. Amazing Narrator Hello, and welcome to the OT Schoolhouse 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 Kelli, welcome to the OT School Hub podcast. It is great to have you here. How are you doing today? Kelli Fetter I am doing great. You know, I don't know. It depends on when this is released, but if we, if you are hearing this and you are at the end of the school year, chaos. I am with you. Hopefully, by now though, we're in summer break and we're kicking back and we're taking a little moment to to relax. Jayson Davies Yes, yeah, absolutely. I think we're looking at early July here when this actually is released. So yes, absolutely. Hope everyone is having a great Fourth of July celebration. You know, weekend long week as a school-based OT, we get some time off. Hopefully, much better. Yeah, hope everyone's enjoying that. Yes, absolutely, absolutely. Well, Kelli, I want to dive into a. I think this is a a fun hot topic question. We're going to kick it off with that, and that is, you know, as school-based occupational therapy practitioners, there is this like constant pressure and this constant like struggle that we kind of consume over, and that is whether we should, you know, dive into this role that we are often find ourselves in as the handwriting specialist or the handwriting teacher, or go the opposite direction and kind of escape from it a little bit, and maybe try and not do as much handwriting. Obviously, the gamut is wide. Those are that's an oversimplification of this. But within your business, you have obviously kind of just gone all in with handwriting, so I want to hear why you decided to go all in with handwriting-not just in your business, but also to you know, like within your OT career. Kelli Fetter My daughter has driven everything that we do at Handwriting Solutions, and for very good reason. I know a lot of us come into our careers and our passions, guided by some sort of personal reason, and she is absolutely my reason. Because when she was diagnosed with dyslexia and dysgraphia, the number of supports out there for dyslexia-I mean, you-it was such a low lift, right? There's so much, so much research and resources, and like it was there were no questions like here's what you do you have a dyslexia diagnosis here's what you do meanwhile now this was over seven years ago dysgraphia people looked at me like I had two heads they were like first of all what is that and is handwriting and even any important anymore and who does this? And let's point fingers. And the psychologist didn't even really still doesn't have a gold standard for diagnosing or assessing dysgraphia. So that is why I'm here, and that is why I am so passionate about handwriting in general, dysgraphia, and. Specifically, OTs role in this because we are the most well-positioned experts in serving these students, and it is a collaborative. And we'll touch on all of this throughout the podcast, but the collaboration is key, and we literally we have the skill set, so I get very I hate the word to use the word triggered, but it's true. I am on a bunch of Facebook pages and groups and conversate, and I love to have these open conversations. But nothing gets under my skin more than when OTs reject their role in handwriting and say I see it so like time and time again. You know what? They can't improve anyway past third grade. You know what? We've got tech, and that's our role is to access education. But let me be honest, as a parent, I refuse to accept that for my child. And I have seen firsthand that we can improve, we can remediate and accommodate at the same time, and so really we're just doing a disservice. It's kind of like what I like to think about because again, most people are more comfortable with the dyslexia world, and so that would be like a school saying, "Okay, the kid has dyslexia. Here's an audio book. Good luck. That's absurd, right? Like nobody would ever like. No, we're going to build their skills up as a team, and OT can be on that team too, and should be. Yeah, supporting that child so that they can learn to read and improve and progress. So I definitely get on my soapbox on this topic. Jayson Davies Yeah, I mean, five minute podcast. We're done. Let's call it a day. No, just kidding. Let's dive further into this because you obviously before you started your business, you were practicing as an OT like so many of us, right? Remind me again. You have you have school based experience. Were you also in the clinic as well? Kelli Fetter I did all the things: early intervention, outpatient, private schools, public schools. I did it all as soon as I got out of graduate school. Jayson Davies Okay, so before you started your business, was that something that conflicted you? You know, like whether you should lean into handwriting, not lean into handwriting, and what? I mean, obviously now you have, but do you recall having that internal conflict with yourself? Kelli Fetter Yeah, I think the biggest thing that I realized was a I had never heard of dysgraphia before, which is pretty mind blowing, right? As an OT working in pediatrics, that I had never that word just never in graduate school that we talk about learning disabilities. Never did we really go into dysgraphia much, and handwriting was very looked at from a well, okay. Let's build the foundational skills, which is part of it, right? And I know there's a big debate. I know that we've had you've had speakers come into yeah yeah schoolhouse, and what the research is showing now is that it really should be both, you know, the top down and the bottom up approach, and so I definitely back then was looking at it a lot from that that bottom up approach, and just completely clueless about learning disabilities. To be honest with you, and really, truly, it was not until my daughter was diagnosed that I was like, "Oh, okay, let me figure this out. Yeah, let's figure this out. And and I hear that from OTs all of the time. At least once a day, I get a DM or an email from an OT saying, "How can I support my students? I have a caseload full of students now that are struggling with handwriting, or who are have suspected dysgraphia or a diagnosis, and I have no idea how to help them. Wow. Yeah. Yeah. Jayson Davies Two questions, kind of about dysgraphia, the diagnosis per se. A, who is diagnosing students with dysgraphia? Is it an official diagnosis, or is this kind of a you know they've got difficult writing dysgraphia? Kelli Fetter It is. Yeah. So, psychologist. It could be educational psych, neuro psych. Ideally, a team. I in in the perfect world, I would love a team diagnostic where you have the psychologist, you have an OT, you have a speech, and you have education, and that would just be incredible, right? But let's be real. Like most of the time, it's just the psychologist, but it's it's tricky to diagnose, and I think that's why it is so confusing for everyone, for parents, for OTs, for teachers, is there is not a gold standard tool measurement tool for dysgraphia or diagnostic tool. So it is a lot of piecing together educational history, medical history, teacher report, parent report, OT evaluate, like looking at kind of all the pieces and solving that puzzle. And I think with that that ideal team, right? If we can all be on this team, supporting this diet. That is that is going to get a more accurate diagnosis, and that is going to get better support for that student. The other issue is a lot of psychologists are not well versed in dysgraphia, and I'll give you an example. One of our families, unfortunately, had not reached out to us at that point, went for a diagnosis, and they tested and got diagnosed with ADHD and with dyslexia. And the parent was like, "Oh, I thought they would get a dysgraphia diagnosis. And I kid you not, the psychologist said, "Oh, we didn't test for that. And I mean, this parent had spent 1000s of dollars out of pocket for for these you know this comprehensive diagnostic report and very frustrating. So there's even a misunderstanding at that highest level. Part of it is because of like you said, what exactly does dysgraphia like? What where does that fall? It is a specific learning disability. So we, if we, we won't actually see the word dysgraphia in the DSM because it falls under that specific learning disability. And then you've got the SLD in reading, SLD in writing, SLD in math. So I think just the nomenclature in and of itself can be really so SLD Jayson Davies writing is kind of where this would fall into. Kelli Fetter Exactly. Yep. Yep. But confusing, right? Because then you don't see the word, and then so sometimes in school systems they won't even say the word dysgraphia; they'll just say SLD in writing. There's also the whole. Jayson Davies Do you think we should? Kelli Fetter What? Jayson Davies Where do you fall on that? Should we call it SLD writing, or should we call it dysgraphia, or does it matter? Kelli Fetter Doesn't matter. I mean, like I think. I think for clarity purposes, it would be nice if we could pick one and go with it. But like, does it does it really matter? As long as people are knowledgeable and and aware and educated on it, I really don't like the nomenclature shouldn't stop us from diagnostics or intervention. intervention-that's just. I think sometimes we get lost in the weeds of like, what should we call it? But in the end, as especially as OT practitioners, we're not looking at a student by their diagnosis. We're looking at their function. So yeah. Jayson Davies Yeah, absolutely. You mentioned the evaluation process and talked a little bit about the school or various psychologists being involved. You also talked about you know when you had to go online and look for dysgraphia because of the nature of everything going on in your family with your daughter. I'm curious what you found you know several years ago who was treating dysgraphia at that time? Anyone or like I guess when you're looking at the research, where is the research under what journal is it under, or what websites were you finding that were claiming to quote unquote help students with dysgraphia? Kelli Fetter No, I mean nobody was really doing. Nobody was explicitly addressing dysgraphia then. The research I had to go into psychology. I had to go into education. There was there's research in on handwriting in the OT field, but not so much dysgraphia then. Again, this was seven years ago. Neurology, you know, I definitely had to seek out, and still do have to seek out from other fields the the research. It was highly under researched at that time as well, and really, you know, at that point in time, she was in a private school, and so we didn't have you know the gift of even like doing the whole IEP 504 and we kind of just like piece together, you know, some kind of school plan because they were supportive, but like it was truly just me piecing it together. And I will tell you, I get like I do empathize with OTs who have come from this like medical model and this foundational skill because I could not, Jayson, I could not wrap my head around my daughter's struggles. I was like her fine motor skill. Like I am the I am the Pinterest. I was the Pinterest queen of OT. Like I was like her gross motor skills are fine. Her fine motor skills are fine. She was through the roof visual spatial skills. What is going on? Like why is she like why is she struggling to read basic CBC letters? Why is she writing reversals and all over? Like she can draw. She was artistic, so I can definitely empathize of like that confusion as as an OT practitioner, as a parent, as a teacher with dysgraphia because it is it is a little bit of a puzzle, and it is quite broad in that it could be all of the things. So it could be motor skills impacting handwriting. It could be visual skills. It could be language skills. It could be executive function. It could be attention. All of those impact that occupation of writing. Jayson Davies Yep, absolutely. Well, thank you. We just kind of dove in headfirst into the background of dysgraphia and assessments, kind of before we're talking about school-based OT. So we're going to take a quick break, and when we come back, we're going to really kind of you know pair this with the world of school-based occupational therapy. So stay tuned. All right, Kelly. We're back. We've kind of have talked a lot about kind of the the foundation of dysgraphia, but now I want to apply that to school-based occupational therapy, and I think I want to start with the idea. Like we all know that handwriting is the number one, you know, referral reason within school-based OT. Now, within that, though, do you feel like basically every student that we have that has handwriting concerns that we're going to take on and provide intervention, do they have dysgraphia, or do you feel like that there are various you know things going on? Sometimes it might be true dysgraphia under a specific learning disability, or it could be something else. Kelli Fetter Yeah, it it could be a variety of things, and I think this is where that tiered system, when it is working, it is magical because ideally we are just getting those kids who do have maybe dysgraphia or or other concerns, right? And so we're ruling out a lot in that tier two and tier three. If they are getting good quality handwriting instruction in the classroom and building up some foundational skills as well, that will rule out a lot of our referrals, and then that tier two support of addressing. more broadly, you know, supporting the teacher, providing in services and training, supporting students in a in a more global way, so that again, when we do get those referrals for handwriting, hopefully that percentage will go from 98% a little bit lower, so that we truly are supporting those students. You know, obviously, there's the whole push in versus pull out, and there's nuance to that as well. But ideally, those are the students that we are really getting to spend more time with the ones who who do deeply need that support, and then the others will be supported at those various other tiers and stages. Jayson Davies Yeah, yeah, and you know, you you bring up the tiers, obviously very important. I think most schools at this point, not every school, but a lot of schools have what they will call MTSS A for academics or MTSS B for behavior. Maybe they have it MTSS math and reading, but I've never heard of a school that has MTSS handwriting or MTSS sensory. If we're going to go down other routes, right? OTs are trying to start these programs, but it's really hard to kind of like the handwriting discussion we had earlier. Do we narrow it down to one thing, or do we keep it broad? Like it's just MTSS OT. What are you seeing? Because I know you you obviously live the world of handwriting right now. What are you seeing in terms of schools implementing or not implementing handwriting programs? Because like that is the tier one, right? Like a foundational handwriting program. What are you seeing? Kelli Fetter So it's actually quite promising. And if you would have asked me this two years ago, I would probably have a different answer. Jayson Davies Okay. Kelli Fetter Because then I was like, oh my goodness, we have a long way to go. I mean, minimal schools were implementing this quality instruction. I think part of you know just bouncing back from pandemic, part of I mean we've got generations of teachers who just they aren't taught how to instruct in handwriting. One of my dear friends, she jokes with me because she put her son in our handwriting camp, and then she was like, "I'm a teacher, and I remember vividly walking in my first day and thinking nobody ever taught me how to teach this kid how to hold a pencil, so there's that. But I I think now you you're obviously seeing the headlines of schools are bringing back cursive. Jayson Davies Cursive, yeah. Kelli Fetter So it's on the radar. We've got a long way to go, but it is on the radar, which is a lot better than we were a few years ago. I'm like cautiously optimistic in that, though, because I do think our schools need training, our teachers need training, the systems need training. It needs to be a more a more important part of the school day. And it can easily be a more. I think that's sometimes like the misconception is that oh, another thing we have on our plates as teachers, right? That it really doesn't have to be this huge big thing. It can be easily embedded in their literacy that they're already doing, kind of like the science of reading shift. If you as. OTs, you know the listeners here. If you followed anything with the science of reading, you're seeing that shift in the school system. Of they went from balanced literacy and three cuing system, and realize that's not evidence based, and our kids are suffering, and the reading scores were going lower. So now we've got this shift of science of reading pulling in the science, reteaching the teachers of how to teach reading, so I think I I am optimistic that we're going to have the science of writing movement to really shift. Okay, handwriting actually is really important, and the science is there to prove it. And how do we implement this to fidelity because it's one thing to just have it mandated and legislated. Oh, okay, yay! We brought back cursive, but if we spend two weeks on cursive and then forget it, well, that's not really going to do us a lot of good either. Jayson Davies Yeah, you know that's interesting. You bring up the science of reading. I actually learned about the science of reading. I don't know all the specifics of it, but I actually found out about it because Beverly Moskowitz over at Size Matters Handwriting Program is kind of taking on using the term science of writing. That is what she's really going in on, and so you know you brought up that too. And so that then forced me to learn about the science of reading because I I saw that. So I yeah I I love it. Obviously, you brought up the the elephant in the room though is that just because it's mandated doesn't mean it's going to be really emphasized. Two weeks of cursive is not going to do anything. Just like oftentimes we'll get into later, right? 15 minutes of handwriting practice once a week probably isn't going to do much either. So yeah, it's a struggle. Where do you see, or how do you see this as an opportunity for school-based OT practitioners? Kelli Fetter Yeah, I it is literally like that's why I think I I am so passionate about OT practitioners being the leading force in this. This is like our moment to shine, and if we can be the driving force because we understand neurology, because we understand motor skills and motor learning theory. So if we can be kind of that leader and the driving force behind this movement, I mean, it will not only boost the school and the students and the rapport and all of that, but as a profession, I can see it really giving us a lot more credibility for what that is. As an aside, for any listeners who do want to know more about the science of reading and that whole, you know, history of that, and you're into podcasts clearly because you're here. Sold a story podcast is a great starter for you if you want to know more about that, and then I urge you to really ponder and like do some critical thinking of how that mirrors the handwriting and the writing piece, because it I can just it's laying the groundwork to what I hope in 235, years that we will have this whole movement for the science of writing and bringing that back in the school system. So yeah, I think again, just making our role. This is why I think that that role in the school as the OT practitioner is so powerful because again we can we're you know just one on one consulting with teachers, but providing some parent education, some teacher training. We've actually at Handwriting Solutions we've built out entire teacher trainings because teachers are thirsty for this. They want to be able to support their students, so we were like, okay, we'll train you, and it's really cool to train teachers, kind of from an OT lens as well, and then they're directly implementing, which again will end up making our lives a little bit easier. Jayson Davies Yeah. Kelli Fetter A little bit more manageable caseloads, hopefully. Jayson Davies Yeah, yeah, absolutely. I in the past have you know implemented an MTSS OT program at a school that I worked at. You know, it really started with one classroom, and then it kind of grew from there. Is literally one classroom that had one of my students in the class, and the teacher was like, you know, I I see you doing handwriting with that one student. You know, can we team up and and just instead of working just with that one student, can you come into the class and you know let's let's put together a program, and that's how it started. And then I had you know more teachers reach out say, hey, you know you did this with Miss So and So. Can can you do this in my classroom? And and it really built from there. I'm curious what you think are kind of some of the precursors or pre things that we might need to put in place if we want to put an MTSS handwriting program together. Do you feel like it's better just to kind of do what I did and start with that one teacher? Do you feel like it's better to submit a proposal, write something up, and hand it to the administrator? Thoughts? Kelli Fetter Yeah. I think it just. I wish there was like a a really simple answer to that, but I can tell you that it is so dependent on every school, every district, every state. Even some schools are like so receptive, and they are eager to see the research and to implement the latest evidence, and some are just so resistant, and so it really likely just depends on the school system that you are in and what their capacity is, and and so with that said, it's okay if you just start in that one classroom because, like you said, it it can have a ripple effect, and and of course, if that then leads you to this big proposal, and you know, great. But it's okay if you need to just start there with just a small group or one classroom at a time, and and grow it from from there. PTA is another way to just get some nice traction as well. Getting the parents, I had a parent email me this week about like there's you know, and again this is so common. The school, their child's school, is pushing tech, and they're like, she's like, they won't even consider handwriting. They're just like tech, tech, tech, you know. And she's like, can you point me towards research to to really show them the impact and the importance of writing by hand, and to hopefully shift their their thinking and this big picture, right? Which I at first was like, "Wow, way to go! Like it's a big thing to take on as a parent, but yeah, yeah, like we need parents, we need individuals. We might be the only one in that whole school screaming it, but. Jayson Davies I love that. Kelli Fetter Yeah, it needs to happen. Jayson Davies I advocate for the same thing. Like parents can be, you know, sometimes we have tough times with parents, but parents can also be our greatest advocate, especially when it comes to to this topic. I think, and you know, if parents want the schools to focus on handwriting? The schools will focus on handwriting because parents will make us think about it. They will talk to the administrators. Like we don't have to even ask them to. They will talk to administrators. They will go to board meetings. They will, you know, they will come up with with solutions. Sometimes when there is a problem, of course, that they're they're very passionate about. So absolutely, yeah. Now I don't expect you to have all the titles and names and journals and authors off the top of your head but you you've mentioned research kind of on best practices and also maybe research that points away from some of the the age old traditions and thought processes when it comes to handwriting. What where do you tend to look for, and what is? What are you finding? What are they saying about handwriting? Kelli Fetter Yeah. So I am working on a book, which I know I've shared with you before. So hopefully, it will be very accessible for people, so that they don't have to scour the internet for hours and hours to find this research. But I have done a major deep dive, like I said, looking at all different areas and fields to to collate and collaborate and synthesize all of it. But essentially, a couple of the leaders, Dr. Berninger, Dr. Wolf, are big leaders in the science of writing. Dr. Chang and Patel Zwicker is another name that comes to the top of my head that have multiple articles. But here's a little tip, a little AI tip. You can also just drop in AI and ask it for, and then of course do your vetting. Like click through the article, read the article. Make sure it's like sound. But that's a good, easy, quick way if you're in the heat of the moment. And yeah, you're like, what's the research actually say about this? It's a good, quick, easy way to to to get that going. But again, hopefully, my also my goal is to build out somewhere on our website kind of a landing page of research because people have been asking. I get asked about that all the time from parents, from OT practitioners, from teachers. Like, what is the research actually saying? And I think you know, going back to this whole shift, my co-author and I talk a lot about this this top down versus bottom up approach, and she is more. She's a works with students with dyslexia, and so she is coming at it from mostly a bottom up because the reading tutors are handling that top down approach. So it's interesting in this nuance of okay, and I. I tend to come at it from a top-down approach with handwriting at handwriting solutions. But then, what I would recommend, say for a school-based or an outpatient OT practitioner, may look a little bit different in some ways because they might also need to be addressing some bottom-up foundational skills. It's just that leaving off the top down that is often missed in traditional OT. Jayson Davies Yeah. Okay. Well, let let's come back to that topic. I want to. That's exactly where I was going next. But real quick question: You listed off a bunch of names of authors within the science of of handwriting, science of writing, is that primarily in the psychologist world, neuropsych world? That is a good question. Kelli Fetter Probably all over. Yeah, all over. Yeah, I have seen more publications in AOTA lately, though that has been refreshing. But yeah, I would say all over. Jayson Davies Okay, perfect. Now let's talk about that bottom up, top down, because I hate so many of the conversations that we have in the world of occupational therapy, sensory versus behavior, and the other is definitely you know top down or bottom up. You have alluded to something I very much appreciated. You know, kind of you got to go both ways a little bit here. You got to kind of come at this from from two directions. Handwriting is complex. There's a lot of factors, right? And you know we we often talk whether or not pencil grip matters, whether or not fine motor skills matter, all that. And then you have the other side of the conversation, like it's just you got to practice it. You practice, practice, practice. Handwriting is complex. Can we just acknowledge the handwriting is complex? Kelli Fetter Yes, please. Yeah, it's complex, and therefore it takes a team. Like it takes a team. We're not going to be the end all, be all. Like wave our magic wand for dysgraphia and handwriting. It has to be a team. That's why we, in my business, we pulled in my daughter's dyslexia tutor because I was like, okay, great, we got handwriting to a really functional skill or level, and then the plateau happened because of spelling. So now we need to pull in a specialist for spelling. So it's so convoluted and nuanced, and we can't just be the only one, but we should be. Okay, one of the big ones, yeah. Jayson Davies So let's role play this, right? Like if we're on an IEP team, we got a teacher, you got the OT, we got a speech therapist all involved, right? General ed and special education teacher. Now we're going to write a goal, you know, for the student to legibly write. We'll just say it's a sentence or two sentences. Kelli Fetter Yep. Jayson Davies How is that beyond an OT goal, and give me some examples about how you work as a team. Kelli Fetter Yeah, so obviously the OT role easy. Like we're looking at the actual functional skill of handwriting, as well as those foundational skills, those underlying performance skills. Gen Ed, special ed, obviously, if they are getting any sort of pullout services for spelling, for grammar, for syntax, for SLP can kind of overlap with that too. I think it's funny in the SLP world they kind of have a similar conversation of whose role is it? Is it the SLP role for dyslexia, or is it the special ed role for dyslexia? Interesting. Yeah, because they can address phonological skills and phonemic proficiency and. Jayson Davies Makes sense. Kelli Fetter Yeah, fluency and you know on and on and on. So. Jayson Davies Yeah. Kelli Fetter but I I'm of the like we don't need to necessarily like divide. Like here's what you get to do and here's what you like. I think if we're all coming together and addressing the big goal, which I I love that goal. Right, that's a very functional goal that every team member can contribute to, then that's really how the student is going to thrive. And like you said, if we're only working with a student 15 minutes once a week, that's really hard to make progress. But if I'm working on it, and the speech therapist is working on it, and the special education team is working. Jayson Davies Yeah. Kelli Fetter those minutes add up, and it's it's compounding and addressing parts, but also addressing the whole, to hopefully lead to faster progress. Jayson Davies Yeah. Now thinking about the OT role and going back to that discussion about top down, bottom up. Do I guess how do we make a session? Right, we got 30 minutes with a student. How do we make a session? How do we build this session that incorporates both a little bit of each of that top down and bottom up? Kelli Fetter Okay, great question. I love this. Okay, so let's pretend that we're going to the gym, and we want to get stronger, and but we we can only go to the gym 30 minutes once per week. Yeah, exactly. That's gonna it's gonna take off a bit to really get measurable strength, or if strength is your goal, that's currently my goal. But it's gonna. Take a moment. So, what if we use those 30 minutes to work on maybe some performance? You know, some some top down, like some reps, get some reps in, some observations, some educating the teacher who is with that student. Those rest of the minutes, that's where it becomes way more powerful, and I would argue if we can have more touch points with that student in the week, which I know is a huge dynamic system shift. So it's going to take us a while to get there. Yeah, but if we can maybe have two touch points a week with that student versus one, I think we're going to see faster and better outcomes. Just like if you're going to the gym twice a week versus once a week. Jayson Davies Yeah. Kelli Fetter it's kind of how I think about it. Jayson Davies Yeah, and and we talked a moment ago about collaborative goals, right? Yes, and I think that lends itself a little bit to maybe that second touch point isn't us, but if that second touch point is the RSP teacher focusing a little bit on handwriting or the general education teacher, that that's still a touch point that has been influenced by you being on the IEP team. Kelli Fetter Yeah, and same thing, you know, if the goal is is the foundational skill building, again, we're not going to strengthen hands in 15 minutes once a week. Like that's just impossible. So yeah, how can we make sure that that's happening outside of our therapy session, but also parent leveraging the parent too, and and really getting. I know that's trickier in a school based setting than say an outpatient setting, but for us in like how we do things at handring solutions is it is so evident when parents are active and engaged and carrying over versus when they're not. Jayson Davies Yeah. Kelli Fetter So I think that could be underutilized superpower of ours. Jayson Davies Oh, absolutely! Parents are are amazing. Now, for a long time, it was kind of thought if you work on fine motor skills, you will improve handwriting. I think we've kind of put that to rest, and we are almost at a point. And and of course, not everybody, but we're seeing this switch to that more top top down approach, where it's like if you want to improve handwriting, you just have to improve handwriting or work on handwriting. You mentioned earlier that we're starting to see research that's kind of pointing a little bit to to not one or the other, but a and you know the the underlining skills and the actual act of handwriting. Can you elaborate a little bit more on what that what you're finding in that research? Kelli Fetter Yeah. So I think so. For example, the grasp, our you know debate, right? Of like does grasp matter? And so oftentimes a pencil grasp is not functional because of weak hand muscles, and so in that case, we have to have that bottom-up approach to to improve the grasp, which will then improve their pencil control, and that top-down approach as well. So I think that's where the the nuances and the research is. I just I I don't tend to be like an extremist of okay, we've shifted completely from bottom up to completely top down. I just think that is more nuanced than than that, and we have to really individualize. I mean, that's what we do best, right? Is individualize to each student. Some students, that's that's you know you shift your framework based on the student too. Jayson Davies Yeah, I think I mean that's why the occupational profile, which we had an episode about a few weeks ago, is is so important. Understanding the goals and understanding where the student is. One of the things that I, you know, research is so important, but research is still limiting you to the information that you have on the six pages of that article, and I think that there's a lot of missing information there that if we had would kind of flip the script on some of our articles because in the articles we are told baselines on assessments, right? We are told where the student started on the handwriting without tier screener, or where they started on the edge and where they ended up at the end. But it doesn't tell us where the student fell on the edge baseline and post. Who was the one student in the 20 or 30 kids identified that had a non-functional grasp, and that student is naturally lumped in with everybody, and we don't know the results of that one student. That you know, the one student out of 20 who had a non-functional grasp. Maybe that student didn't benefit from the Learning Without Tears program or from an. The other programs that are being tested, so that that's a piece that we miss in the research. And you know, unless you do get a study of one individual student with a pencil graph that's non-functional. Kelli Fetter Yeah. Jayson Davies like those studies, I don't know that exist. Kelli Fetter Right. Well, and yeah, that's it because yeah, research in and of itself has to be so narrow to measure these outcomes, and so it's rare to measure the outcome of multiple factors. There is one research, and I'm blanking on the researcher. I want to say, yeah, I'll dig it up, and we'll put it in the show notes. Jayson Davies We'll put it in the notes. Kelli Fetter and it looked at. It was one of the few that actually did look at a like bottom up approach only a sensory motor approach combined with handwriting instruction, and then I think just the handwriting instruction. I forget I could be misquoting that, but I know that the the outcome. Jayson Davies I think I know the article you're talking about. Yeah. Kelli Fetter The outcome was the sensory motor approach coupled with the handwriting instruction led to the best outcome? That's pretty powerful for us, I think. Yeah, to kind of again come at it from from both angles, depending on the student. Jayson Davies Yeah, man, the nuances. One of the terms I've been hearing more, and and I really actually like this term because you know handwriting is getting a kind of you know it's it's that UG term. Whenever someone in school-based OT hears handwriting, they just kind of give a shrug. But we're starting to to use the term written expression, and I like this term because it written expression is used by teachers in multiple ways. Versus handwriting is very strict handwriting. What are your thoughts on that term, written expression, and the role we have as occupational therapy practitioners, both maybe handwriting and beyond? Kelli Fetter So I like there's a new image again, kind of played off of the science of reading. There's the reading rope in the reading world, and so I believe it was a researcher came up with the writing rope, and it's a really great visual for us as OT practitioners and for the schools in general to look at because it does kind of break apart those written expression pieces and parts and that transcription, which is basically the handwriting and the spelling part, and I love that as the written expression term because a that's what the diagnosis is typically called specific learning disability in written expression. B it is more all encompassing, so it does feel like we it lends itself more to okay. Well, we can have a role, and SLP can have a role in written expression, and again, that that collaborative approach. But look up, definitely look up that that writing rope because I think it is just a really solid visual. So we can say, oh, okay, there's our role. Like, pinpoint that. Jayson Davies Yeah, yeah, yeah. All right. Well, we're going to take our final break, and when we come back, I've got a question about auto mass, automaticity, automaticity, and you know, making sure that our students can actually write fluently because I know that comes up a lot. So we'll be right back. All right, Kelly. We've all had the student that when we work in the OT room, they've got it down. They can copy the quick brown fox jumps over the lazy dog, no problem. But we get back into the classroom, and the work samples from the classroom are just they they don't they don't measure up to what's needed, right? And they can't keep up in the classroom. Thoughts on that? Kelli Fetter Oh yes, I've got thoughts on that. So I have this conversation a lot, and we actually developed a whole like framework to conceptualize this, looking at the cognitive load. So I've seen sometimes OTs in Facebook groups again. They'll say, you know, what do you think about this student? And it's just a copy model, and that cognitive load is not matching the cognitive load that they will need in the classroom. So when I am teaching professionals or parents about this, I frame it as you know that that basic easiest lowest level cognitive load is typically the tracing or the imitation, and then the next load is the copying from near point, and then copying from far point, and then writing from dictation where the teacher is telling them what to write, and they write it, and then that highest cognitive load is that self-generated thoughts. The problem is if we're only working on copy skills and OT sessions, but they're expected to write from self-generated thoughts. That's why it's that's why it's breaking down. So we kind of have to scaffold and go. You know, work backwards and build up those foundations first, and bring them to that next highest cognitive load level, and then of course accommodate and support them as they are working their way up. Yeah, because the cognitive load in the classroom, not to mention, like yes, the writing output cognitive load is heavier, but also yeah, there's the sensory aspect, and one of my favorite activities that I do when sometimes when we do workshops is have parents or professionals copy like different figures, and it could be reversed and upside down and a mixture of print and cursive, and they have to do it with their non-dominant hand, and then I read to them while they are doing it, and at the end I'm like, "Who can tell me what I told just talked about? And they're like, "No, I thought we were doing a writing test. And that's it. I'm like, "That's the easiest and best way to really get them to understand cognitive load and how in the classroom it's like they can only have the bandwidth for so that's when it all falls apart and usually handwriting is the first thing to fall apart because they're so they're thinking so hard about like what do I want to write what was that really good idea oh yeah that okay spelling falls off handwriting falls off is like the top, the top two. So if we can automate handwriting in a safer space, and then bridge it up, you know, up the level of cognitive load, and then if they can get that spelling support, where that is more automated as well, that is how we reach automaticity in the classroom. Jayson Davies Perfect. perfect. We're going to come right back to that in a moment. You mentioned the different ways that you're going to assess handwriting, different levels, right? Copying, and then move your way up to eventually writing from their own their own thought processes. Is there a particular tool that you like to use for doing that, or do you just kind of, you know, I write down a few letters, let them copy it. I write down a few words, let them copy it, and then I give them a sentence to write. Kelli Fetter Yeah, we. I mean, there's a variety, of course, handwriting assessments out there. I just don't love. I'm not like married to any of them. Maybe one day I'll have to like come up with my own screener or whatever. But basically, that's what we've done. Is we've kind of when we have handwriting assessments. We have built out our own process for looking at all of those pieces and parts, and then we measure like to get some data. We measure, you know, letters per minute or words per minute. Jayson Davies Yeah. Kelli Fetter And then measuring like found or like mechanical skills too of line placement and sizing and spacing and starting, and sequencing, and all of that. But yeah, it's like there's just there's really not a gold standard handwriting assessment. There are a lot of options, and I will say something is better than nothing. So yeah, we absolutely should be assessing handwriting in whatever modality and means that you have. Jayson Davies Yeah, I mean, I've used. I think we've all used the THSR. We've used the etch. I I like the etch. It's short and it does have most of those components that you're talking about. So that's one that I've used. The McMaster standardized. I believe it's the THSR. What's that? Kelli Fetter The McMaster is another one. The cost. Decos. Yeah, yeah. I'm like decost. Jayson Davies Yep. Kelli Fetter Yep. Yep. Jayson Davies Yeah. So there's some out there. Kelli Fetter Yeah. Exactly. Exactly. So usually it's like whatever is handy in your school is fine, and then you just fill in the gaps, you know. Yeah. Based on those levels. And to be honest, if you don't have you know access to one of those, it really isn't that much different than like what Kelly just said. You know, just have them copy a sentence, have them write out a sentence from dictation, have them write a sentence from their own thoughts. And once you have that, you can easily compare the difference between copying and writing from their own thoughts. If there's a big difference, what does that mean, Kelly? From yeah, we see we see that a lot. That and that is one of the most powerful visuals that we share with parents because I'm like, look, no cognitive load. They can write their alphabet fine. Look at what happens when we add cognitive load. You can't read it, and so that indicates a few things. That indicates, you know, then you go back to that written expression piece of where where are the gaps? So is it a handwriting automaticity thing? Often it is. Is it a working memory? Is it a processing speed? Again, going back to the spelling, it's like they get so hung up on that and the grammar. It could be a variety of factors, for sure. Jayson Davies Okay. So to what degree can OT going back to that, right? A student is able to copy no problem, cognitive load increases their their handwriting decreases. How can OT support that automaticity to decrease the cognitive load? Is that our role? Kelli Fetter Yeah, I think. Definitely, is our role in parts. So, looking at the executive function is a big area that you can see that kind of fall apart. Ensuring that they are actually automatic because copying is easier because you've got the visual. But is it a true automaticity? Are they? Do they have that visual memory of the letters? Because if you take that visual off, you know, away from them, can they still have the visualization of what that letter is supposed to look like? Sometimes, and this is in like extreme cases or with younger kids, when you remove that visual, they draw the letter. You bring the visual back, they're writing the letter okay. The you know so it's interesting to see kind of how that how that plays out in their in their their brain and their neurology. But I will say that you never even if a child is strong in copy that does not indicate automaticity, and true automaticity only comes from being able to self-generate thoughts without the visual. Jayson Davies So I hope my faces over here did not like make you get confused because I'm over here thinking about everything you're saying, and hopefully we get this on YouTube eventually. But so everyone can see. But how do we not have a standardized version of how long it takes a kid at every grade level to write the Quick Brown Fox jumps over the lazy dog? Like Kelli Fetter I know. Jayson Davies Wouldn't it be the simplest thing, like assessment tool ever, to just have first graders all around the country, second graders all around the country, just write from their own rote memory, the quick brown fox jumps over the lazy dog. I mean, or something, right? Write, write one sentence. How long does it take to write out, you know, 20 characters or something like? Yeah, we should have that. Kelli Fetter Yeah, I mean, there's definitely data that is more broad in that, and that's what we pull from is like x number of words per minute based on grade level, but it doesn't break down the cognitive load, and that's where it's frustrating. So we'll see that a kid is faster with copy, but way slower with with dictation, or way slower with with the self generated thoughts. And so it'd be really interesting if somebody will do a study on breaking that down and like what should the expected pacing be for those various cognitive loads because it's hard to compare, right? Like copy pacing versus I mean even as adults, you know. Jayson Davies Yeah, yeah, it'd be interesting. And that's what leads to the difficulty with the research that's out there because we don't know the cognitive load of the research presented, and we also don't know any other factors about the individual students and and all that. You know, we're getting a general. Okay, you talked about like the the spelling issue, and obviously this is the cognitive load issue. If you are kind of seeing that where a student, they're obviously getting slowed down because it's just hard for them to remember how to spell words, and it's the grammar. That's what's really slowing them down. Do you try to? I mean, you mentioned executive functioning, but do you attempt to address this, or is that something that we try and work more closely with the teacher, let them know what we're seeing and and maybe what they can do? Any any thoughts? Kelli Fetter I think all all of the above. I think consulting and collaborating with the teacher absolutely making sure they are getting explicit and systematic instruction in spelling because often they may not be. It seems like that's fallen off of the curricula in a lot of schools too. They teach reading, and then they're like, "Okay, we're good. And really, reading instruction needs to extend third, fourth, fifth grade to to get that encoding, which is spelling. Spelling falls into the encoding as OT practitioners, what we can do is scaffold, and so you know, scaffold for their executive functions, scaffold for their spelling, as well as maybe pull in some memory tools, some graphic organizers, some other external strategies that might support them in the moment while they're building those spelling skills outside of our sessions, and I think that our role could definitely be powerful in that. Jayson Davies Yeah, man, so many. We only got to like a third of the questions that we actually planned for today, but I'm glad because all the all the discussions we've had today I think are going to be so helpful for everyone listening. We got to start to wrap up here, and one thing that I find really cool that you've done is you started to develop summer camps, and you're even helping other people to develop summer camps in handwriting. Now. For the everyday school-based occupational therapy practitioner, they may not be interested in a summer camp. However, I do want to pick your brain on how they can use this idea, this concept of a handwriting camp within their school-based OT practice. So I'd love to get just your thoughts on that because you have that experience. Kelli Fetter Yeah, I think there's actually been an article come out. I'll have to dig for this as well about a club model, like a handwriting club in a school system, and I think that could be so powerful and something the OTs could really capitalize on. And you know, as far as what that looks like logistically, it would you know depend on your situation. But even if it was once twice a week, that would be powerful. Our camp model is actually four days a week back to back. You hit that motor learning really hard. Of course, it's not like then we we don't say okay, you're done, you're good to go, bye bye. Like then we have like you know a follow up plan with the family, extended practice opportunities, and then sometimes they filter into our one on one tutoring model. But why I love the camp and the club that intensive model is it kind of goes back to if if OT practitioners are listening, that more episodic approach to therapy, which is really really powerful when it comes to motor learning theory. If we can hit the skills really intensive for a short time, and then kind of take a step back and let them, you know, apply those skills, and then maybe check in, do some touch points later on. To me, that can be a more powerful and effective model than stretching, you know, this intervention out. Jayson Davies 30 times a year. Kelli Fetter That's right. Jayson Davies Yeah. Kelli Fetter I would rather do 30. If we're doing 30 times a year, I would rather let's like go really intensive and then let's space out those last few. Again. Jayson Davies So when you say intensive, you mentioned four days a week. How many hours, or is it one hour or 30? It's an hour. Kelli Fetter Yep, an hour a day. Very like I mean, when you look at our structure, they're not writing. They're they're not pencil to paper for that whole hour. So yeah, yeah. You know, we we do very intentional brain body warm ups, hand warm ups to get their their bodies and their brain ready to write. We do multi sensory sensory motor warm ups and handwriting lessons, and then really about maybe 20 minutes of that is pencil to paper, depending on the student's age. More longer if they're older, less maybe if they are younger. But they're still writing. You know, there might be writing on a chalkboard or a dry erase board or in sand or whatever. Yeah. But it really is some of these before and afters. Like the pictures speak 1000 words, and it it's amazing what those. It's less time for them to forget if they just did it yesterday and then they're doing it again today. There, you don't have that regression, that skill loss. yeah. Jayson Davies There's a reason that kids go to school every day for five days a week for five hours or for 180 consecutive days for the same exact reason. Did Did you say how long are they a week long, two week long, four weeks long? Kelli Fetter Right now we're doing four, just one week, four days. But typically we'll recommend four days. Okay, yeah. So it's a short burst. It is instructional level only. So I say that you know if they need more of a remedial level, they're gonna need more than four days. But and and again, it's not like we wave our magic wand and they're good to go. They still have to do that outside work to achieve the automaticity. But what it does is give them the foundation, four days of foundational handwriting instruction, which so many kids don't have so. Jayson Davies Yeah, and I, I think this would be a perfect tier two MTSS program, right? Like we just kind of work with our administrator and say, you know what, maybe if four weeks after the school year starts, I'm going to host this little two week program and kindergarten teachers can basically recommend any student to be a part of that program. They are the ones referring kids to the program, not the OT going to evaluate them. And you have this little program that might prevent four assessments throughout the rest of the school year, which, to be honest, is going to be less time than the camp itself. So you're kind of replacing four four hour assessments later in the school year with you know 10 hours of of camp. Kelli Fetter Right. Yeah. Yeah. Yeah. For sure. I love that. I love that model. I'm here for it. I mean it is. Jayson Davies All right. Kelli Fetter It is so powerful. I just can't say. Jayson Davies Yeah. Kelli Fetter And that's why. So this will be interesting too. Initially, when I very first started Henry Solutions, we did a once a week model, and I quickly learned no, it's twice a week, a minimum twice a week that we are working with students, and that's one on one, of course. Jayson Davies Yeah. Kelli Fetter and. It's amazing to see how much faster their gains are. Yeah. Jayson Davies I mean, it totally makes sense. We know that you know professional athletes aren't learning to be professional athletes one time a week. Kelli Fetter That's right. Jayson Davies Kids are going to school to do learn to do reading, math, everything a lot more than one time a week, and so I don't know why we think that we should be so magical to to help a student with handwriting in one time a week? Kelli Fetter That's right. I mean, I wish. Jayson Davies There's no research out there that points. Kelli Fetter to it. No, no. Well, I always use yeah for parents. Sometimes I explain it as exactly like you said. Like if I wanted to learn how to golf. Okay, well I could grab my golf clubs and go to the golf course and hit once a week, and it would take me a really long time. But if I hired a golf professional and they gave me some lessons, and then I practice a few times on the off days, yeah, I still probably won't be great. But I'll be, I'll be doing better. I'll be doing better than I was. Right, right. Yeah. Jayson Davies Yeah. We're gonna see Kelli out there on Thursdays, Fridays through Sundays on on TV soon. Now, all right, Kelli, it has been a pleasure. Thank you so much. Really appreciate it. This has been a great conversation. I know it's going to help a lot of practitioners. Where can everyone go to learn more about you and everything you got going on? Kelli Fetter Yeah, we've got a lot going on. So it's handwriting solutions.org is our website? You will see tabs for parents, tabs for professionals or educators, OTs. As I mentioned, I am working very diligently on getting this book out. So TBD on when it will actually be out. But we are building a course for OT practitioners that will hopefully launch this fall. So I will make sure that we include a link in the show notes so that you can kind of sign up on a wait list or get in on our email list. We send weekly emails, very educational, zero fluff. As with Jayson's emails, they're just I love Jayson's emails every week. It's yep. You're welcome. Jayson Davies I love yours too. Kelli Fetter Thanks. Jayson Davies They're one of the few that I actually stay subscribed to, so no, I can attest to them as well. Kelli Fetter Yeah, yeah, very powerful. And then yeah, we're always doing workshops and trainings, and just it is a passion of mine. If you can't tell, so and I think comes from a genuine place of you know living the struggle, and so I want to empower as many OT practitioners as possible. So yeah. Also, we're on Instagram, we're on Facebook, we're on LinkedIn. I can probably drop a freebie as well. So make sure you check the show notes for a little little special freebie for the OT school house listeners. Jayson Davies Perfect. Yes, check it out. Head on over to the show notes. The link is right down here, or just head on over to OTSchoolHouse comm podcast, and you'll see Kelli's episode and click there, and you'll have all the links that we talked about. We're going to do our best to dig up as much of that research that we discussed today, put them into the show notes to make it nice and easy for you all, Kelli. Thank you so much for being here. Really, really appreciate it. I know we're gonna have to do this again sometime. Maybe when that book comes out, we can we can do another one. It's Penny, right? You're working with Penny. Kelli Fetter Yes. On that. Yep. Jayson Davies Awesome. Yes. So we'll have to get both of you on here and do a nice little dyslexia dysgraphia session together. Kelli Fetter Love that. Jayson Davies It has been a pleasure. Thank you so much, and we'll definitely keep in touch. Take care. Kelli Fetter Yep, thank you. Jayson Davies Okay, that is a wrap on episode number 205 of the OT Schoolhouse Podcast. Thank you so much for being here, and a huge thank you goes out to Kelly from Handwriting Solutions for joining us today and sharing her expertise around dysgraphia and handwriting support in schools. I cannot wait until that book comes out that she teases about both dysgraphia and dyslexia. That's going to be amazing. Make sure to check out the show notes at otschoolhouse.com/episode 205205 for all the links to Kelly's website, her Instagram, and all the resources that we mentioned today. Especially for this episode, that is going to be super important for you. And of course, thank you for listening. Like seriously, you show up for your students every single day, and even in the heat of summer, like many of us are right now, you're here listening to a podcast, thinking about your students and how you can better yourself for your students. Episodes like this one only exists because of your drive to keep learning and growing as a practitioner, and I cannot thank you enough for showing up here today and listening to the podcast. Now, if you want to keep that momentum going, I would love to have you join our school-based OT collaborative. It is the community that we have built specifically for school-based OT practitioners, just like you, it is packed with resources, professional development, CEUs, mentorship, all that great stuff. And you can learn all about it over at otschoolhouse.com/collab. That's otschoolhouse.com/colab to learn more and join us today. Until next time, take care. Enjoy your summer. Amazing Narrator Thank you for listening to the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! 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Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 204 of the OT Schoolhouse Podcast. If you're a school-based occupational therapy practitioner feeling burnt out, dysregulated, or overwhelmed by your caseload, this episode is for you. Robyn Chu, MOT, OTR/L, author of Sensory Wellness: The Art and Science of Thriving, joins us to flip the traditional sensory conversation on its head. Instead of focusing solely on how to support students' sensory needs, Robyn discusses how understanding your own sensory processing can be the foundation for everything else you do. Robyn discusses why "calm all the time" isn't the goal, how sensory input actively creates emotions (not just reactions to them), and why you have more control over your regulation than you think—even in challenging school environments. Drawing from neuroscience research and years of clinical experience, she offers practical insights on energy management, nervous system regulation, and why addressing your own sensory wellness isn't just another item on your to-do list—it's what makes everything else work. Whether you're driving between five schools in a week or sitting down to write reports in a fluorescent-lit room, this episode offers practical wisdom on energy management, nervous system regulation, and why "calm all the time" isn't the goal. Listen now to learn how sensory wellness can help you be your best self for your students—and for yourself. Listen now to learn the following objectives: Learners will identify how your own sensory processing patterns impact your daily regulation and work performance
Learners will recognize the difference between interoceptive and exteroceptive sensory input and why it matters for adults
Learners will apply practical sensory adjustments to your work environment that you can control, even in challenging school settings

Guest(s) Bio
Robyn Chu, MOT, OTR/L, is an occupational therapist, author, and researcher specializing in sensory integration and its impact on emotional regulation, mental health, relationships, and performance. With over twenty years of clinical experience, she is the founder and Executive Director of Growing Healthy Seasons, a therapy practice with more than 75 therapists.
Her work is grounded in research and clinical application, including research conducted with UCLA and UCSF, where she has focused on how sensory processing shapes human behavior and well-being. Robyn is recognized for translating complex neuroscience into practical sensory frameworks that people can apply in daily life. She is the author of Sensory Wellness: The Art and Science of Thriving and the Sensory Wellness Reflection Journal, available at robynchu.com.
Quotes "Sensory wellness is not one more thing to add to your list. It is the foundation that makes everything else on your list actually work." — Robyn Chu
"Sensation is a key ingredient of how we actively make emotions and shift our experiences." — Robyn Chu
"The most energetically costly thing that can happen is your body getting stuck in a fight-or-flight response." — Robyn Chu
"We still often forget about all the interoception and all the different ways that sensory has an impact on us—and we're the trained ones.” — Jayson Davies,M.A.,OTR/L Resources 👉Sensory Wellness: The Art and Science of Thriving by Robyn Chu — Robyn's book on sensory wellness for adults, parents, and practitioners 👉Sensory Wellness on Audible — Audio version of the book, read by Robyn 👉Robyn Chu's website: Growing Healthy Seasons — Free downloads, activities, and links to neuroscience research 👉Future Horizons Publishing — Publisher of Sensory Wellness 👉Star Institute — Sensory processing training and research organization 👉Lisa Feldman Barrett's research on emotion — Neuroscience research on how emotions are actively made through sensation 👉UCSF Neuroscience Research Team — Robyn's research collaboration with Dr. Pratik Mukherjee (radiologist/neuroscientist) and Dr. Elysa Marco (neurologist) Episode Transcript
Expand to view episode transcript Jayson Davies Hey there, and welcome back for episode number 204 of the OT School House podcast. I'm your host, Jayson Davies, and today we're doing something a little different, something perfect for summer, whether you are listening to this right when it comes out before Fourth of July or maybe you're listening to it a little bit later as the school year's just about to get started. This is the perfect episode to start with before you kick off the school year. Today, we're spending some time thinking about our own sensory needs, as opposed to the sensory needs of all the students that we serve. So, I want you to kind of let go a little bit of all the students that you're thinking about right now, that you usually think about when we are listening to this podcast, and let's think about ourselves today. Our guest is Robyn Chu, a occupational therapist, author of Sensory Wellness: The Art and Science of Thriving, owner of three OT clinics in Northern California, and someone who has spent the last 20 years at the intersection of sensory integration, clinical practice, and neuroscience research this summer I wanted to take a step back from the day to day grind of school based occupational therapy and as I mentioned before focus a little bit more on us the practitioners and Robyn's book does exactly that she takes everything we know about sensory processing and flips it toward the adults doing the incredible demanding work like us in this conversation, we talk about why sensory wellness isn't just one more thing to add to your already overflowing plate, it's the biological foundation that makes everything else on that plate actually work. We get into what it means to bring the body back to work, why calm all the time is actually not the goal, and how understanding your own sensory system might be the key to preventing burnout and supporting your students. If you've ever driven between schools, skipped a bathroom break, or just sat in silence on the way home simply to decompress after a long, crazy day, this one is for you. Let's get into it with Robyn Chu. 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 Robyn, welcome to the to the OT School House podcast. And first of all, congratulations on your brand new book out, Sensory Wellness. So happy for you to get that out. We had the chance to officially meet in person at AOTA in Anaheim. It was wonderful. Thank you so much for the book. I really appreciate it. Robyn Chu Of course, and thank you. Yes, this is a huge milestone, and really excited, very, very excited about this. Jayson Davies Yeah, and you know, as I'm going through the book, a few things really came to my mind, and the first thing was that I wasn't reading a book about how to provide sensory interventions to a child, which is, you know, what most books are about, right? Robyn Chu Yeah. Jayson Davies and so I just really appreciate how you flipped the script from sensory integration, for you know, kind of that general term, and turned it into sensory wellness and sensory health, presumably for the adult that is reading it, right, and I really want to just kind of let you share a little bit like where that decision came from, because you are a sensory trained occupational therapist, you know sensory very well, you own multiple clinics, and you support children, you know all day, every day, but you flip this to adults, and so I want to just kind of hear your why. Robyn Chu Well, my why began in a parent meeting a long time ago, about 10 years ago now. I was talking with some parents about the sensory needs of their child, specifically vestibular needs, one of my favorite systems. And the dad was at this parent meeting, and his eyes got wide, and he said, Oh my goodness, wait, this is all sounding so familiar. And he and his wife went home, and they talked about their own sensory needs, and he dug up this psychologist report from, you know, 40 years before, and found words like super active, really energetic, won't stop talking, bouncing around the room, and they emailed me that night, and they said, Well, okay, so you're going to help our kid, you're going to help our family, but How do we get help? What do we do? And then you layer on that years of mentoring occupational therapists from around the world, starting out with my partnership with the Star Institute in Colorado, and therapists saying I technically know what to do now, and I'm so grateful, but my own regulation is getting in the way, I can't keep thoughts straight. I'm, you know, I'm flipping out, I'm dysregulated in the session, I'm worried, and now I'm getting burnt out, because this is such hard work. So those two things added together, and I thought this book needs to support the helpers. Yeah, it needs to help the helping professionals. Jayson Davies Yeah, and I think you're right, and this is something that's not just for the parents of the students that we support, either, right? Like, as I, again, as I was reflecting a little bit, I started to wonder, I was like, do we almost kind of have this like branding problem with sensory, and you know, as OT practitioners, we really understand sensory. We understand how a little bit of vestibular or proprioceptive input, you know, around 2o'clock in the afternoon can really keep us going for the rest of the day. But outside of OT, the terms that you might hear that might, you know, make a light bulb go off in the OTs mine might be like stress anxiety, and those are the terms that are being used outside of ot, and I almost feel like somehow we have to merge this, and you know, sensory wellness, the title of your book, I feel like that's kind of meshing those together, and I just wanted to hear your thoughts, kind of as you, you heard me say that. Robyn Chu Hopefully I love that. Hopefully it's a bridge. Hopefully it generates questions. Hopefully it helps people to say, well, I was thinking I was overwhelmed, maybe I'm overstimulated and under aware, and start asking their own questions, getting to know their own sensory preferences. Yeah, I hope it generates curiosity for people. Jayson Davies Yeah, and trying to piggyback off of that, you know, in today's world, for those who don't understand sensory wellness and sensory processing and integration, how do you feel, or if at all, how do you feel that people actually practice sensory wellness at all right now, you know. Before reading your book, and we weren't really understanding sensory. Robyn Chu I think that the news and social media point to a lack of awareness, a lack of conscious choice within sensory, so we've got people who are in front of screens more than ever, who are skipping meals, who are working so, so hard, are shoving down even the urge to need to go to the bathroom. I talk to OTs all the time who are like, I don't even know when I need to go to the bathroom anymore, because I just don't go all day long, and then I get home, and I realize, oh my, so right, these bait, right, totally these basic sensory messages that our bodies are trying to send us. I think we might be at an all-time high as a society of ignoring those messages, which, um, I try to look at things glass half full a lot optimistic side that means there's a lot of ways that this can help right like because the needs are so great because people are out of survival ignoring incoming sensory clues we can really help this could be a game changer for people. Jayson Davies Yeah, yeah, that's really unique. Because I mean, even back in OT school, right, we learn how some of our senses are designed to actually kind of turn off a little bit when we need to focus on something else, but to what extent are we doing this in a way that might, you know, be a little hazardous, as opposed to what our body is really designed for. Robyn Chu Right. You mentioned that the OT programs, and that has been my favorite part of the book launch, actually is talking with the OT students and feeling the resonance because they're saying I want to get in a helping profession, right? I want to be the helper, and I'm already burnt out, like I'm already at my max capacity. So, what do I do now? And seeing those dots connect for OT students, I did a guest lecture recently, and one of them came up to me and said, this actually, this lecture, this one class changed the trajectory in my life. Jayson Davies Wow. Robyn Chu so that was really powerful. Jayson Davies Yeah, yeah, and that speaks to how things change over time, because I mean, it sounds like you correct me if I'm wrong, but when you wrote this book, were you writing it kind of for that parent that you mentioned, that you know they have a, they have their own student that they're trying to support, and they themselves are overwhelmed, but now you're finding out that this applies to so many more. Robyn Chu Yeah, absolutely right. So the parents were the first vision. In my mind of why I wanted to write this book, and then it really expanded from there. OT students, OT practitioners, even 2030 years in the field, are saying, "Oh, I can bring my body to work, I can tune into my own sensory needs, and that'll actually help me be a more effective practitioner. Jayson Davies Yeah, you use that term. I can bring my body to work. What do you mean by that? Robyn Chu Well, I work with a lot of therapists who go to work with treatment plans that are well thought out that they've spent hours on right, and there's a list of activities that they're going to do, either they're going to have the kid do, or maybe they're going to do them with the kid, but I rarely, when I first start working with a therapist, do I hear that therapist say, well, in the first couple minutes of the session, we both tune into our bodies and figure out what we need from a sensory perspective in order to be ready to play, ready to learn, ready to grow, and include their own body, their own interoceptive and exteroceptive sensory needs in their plan for their day. Jayson Davies Wow, yeah, you know, these are things that we, I mean, even us as OT practitioners, who, whether we're SIP trained or gone through Star Institute, or, you know, one year out of OT school, we understand sensory, I don't know, what, 90% more than the general population, you know, and we still don't think about, we still often forget about all the interoception and all the different ways that sensory has an impact on us, and we're the trained ones. Robyn Chu Right? Yeah. Well, I often hear we're like, shoulds, you know, the concept of a should, right? Like, I know I should meditate, or I should eat a little nutritious food during the day, but those shoulds are creating kind of like a cognitive dissonance, a push and pull, almost like a fight within their body of well, I know what I should be doing, and I got to just use my brain to think harder and do more, as opposed to starting with what is my body needing and modeling that for and with the clients that we're working with, like as simple as an OT saying, "Wow, I'm just noticing this room is really loud right now, and it's hard for me to hear the words that you're saying, Sam, Johnny, Kate, right? So, ah, what do you think we should do? Right, like I'm modeling that my sensory systems are talking to me in this minute, and they're giving me information about how I can be my best therapist self, and I'm narrating it out loud. I think those can be incredibly powerful words. And then at the end of the day, you don't want to sit in silence. I so many OTs are like, I just drive home and I sit in silence in my car. How about if we don't get to that point where we need that every single day? That would be cool. Jayson Davies Yeah, yeah, the overwhelm is just so, so real in our profession, and so many other professions. Robyn Chu Yeah. Jayson Davies you got me thinking a little bit, because we talked about, you know, how OT practitioners, we understand sensory to a degree, most of us, right? And we still forget some of these things, and others don't understand the idea of sensory integration at all, can't even tell you the vestibular and proprioceptive are sensory systems, right? Robyn Chu So true. Jayson Davies The outside world, and when I say outside world, outside of OT, right, I think really views sensory as a reaction, but we know that we can plan and we can use sensory and we can, I mean, look at, look at sensory integration itself, and just using it as an example, we know that the environment plays a very important role within our treatment, and we know that being child-led makes an impact, and a lot of that is adapting the environment, making the adapting the environment to set it up for the child to succeed, but outside world they don't understand that. So, is that something that you really wanted to try and convey within your book? Is like letting people know, like you can have an impact on your environment. Robyn Chu Yes, and so one of the things I really was excited about in this book, another bridge, actually, is taking this momentum that our society has created with all of our sensory founders, Jean Ayres, there's so many of them, our world likes the word sensor. Three, now, so. Jayson Davies True. Robyn Chu When I started out as an OT, too much, that's says every school-based OT ever, right? So, when I started out as a school-based OT, my boss, a principal, used to be a principal, administrator, special ed director, said, do not put the word sensory in your report, it is a bad word. We don't, so this was 20 plus years ago. We don't use that word. It is a bad word. It is illegal, out of bounds. As a sensory school-based therapist, you may not use it. So now the pendulum has shifted so far that movie theaters have sensory-friendly movie show times. Right, my daughter and I were going to go to the Nutcracker Ballet in San Francisco, sensory friendly offering a matinee. Jayson Davies Yeah. Robyn Chu Our world is wanting to and using the word sensory a whole bunch, and they don't necessarily know what it means, so then as school-based OTs, we get referral after referral after hot potato thrown right at us. Ah, they said the word sensory, so could you take this now, and can we sign an assessment plan immediately? And so our poor school-based OTs are like, what do I even do? How do I survive this huge wave that started out as exciting momentum? Right, we want to acknowledge that sensory plays a role, a huge role in behavior, in success, in learning, and yet it doesn't mean that every single kid that we work with needs one on one direct services and assessment plan signed. So, anyways. Jayson Davies Robyn, don't you do this to us. I love this. I love, I mean, like, there's so many rabbit holes that I could go down with just in the last two sentences that you said, because absolutely right, we are getting overloaded with these evaluations, and the concern is sensory. It's not that the student is overwhelmed because of an environmental factor in the classroom, it is simply the referral reason is sensory, and you know, right, there's at least eight different sensory systems that can be in play, and it can be very difficult to tease out which sensory system is, and you also alluded, right, sensory and behavior are very connected, and we understand that, but others don't necessarily understand that. Gosh, I like.. I'm talking right now, like I don't even know where I'm going with the question, right? Absolutely, but it's hard, and I think that it leads to the, like, you mentioned, right, the overwhelmed of the school-based OT practitioner themselves, right. So to kind of get us back on track here, I want to kind of bring the focus back to the overwhelmed, you know, school-based OT practitioner, and you know, again, we have a general idea of sensory integration, but in your book you still really dive into the eight different systems, but as I mentioned earlier, this is not a textbook where we're talking about supporting school-based or not, where we're talking about our clients, we're talking about adults themselves. So, right, when you're talking about the sensories and you're taught the sensory systems in reference to adults rather than the children that we serve, is it all still the same information, or does it feel like, you know, us as adults need slightly different information about sensory processing than when we're working with our students? Robyn Chu Oh, that's a really good question. Is it all the same information? Yes, and I would say most occupational therapists are not fully up to date on what the research is saying about sensory integration and processing, so is it the same as you know for your students? Yes, and that information is ready to evolve with the help of neuroscience, with the help of fMRIs, of DTI analysis, of understanding more this division between interoceptive sensory input, including proprioceptive and vestibular input, information that represents what's going on in your body, and extra receptive, and by starting to understand that as the initial division, we can understand more how to take care of our bodies and. No matter what environment we're in, right? So a school-based practitioner says all these external factors, some of them sensory, some of them not, are impacting my regulation. Yeah, yes, that is true. Absolutely. Can I change how many assessment plans you have on your desk right now. No, I cannot. Can you change the amount of fluorescent lights in the classroom that you have been assigned? Amazing Narrator No, Robyn Chu but you can turn them off. You can use natural light, so you can adjust some of the extra receptive sensory input, and you can, no matter what environment you're in, adjust your interoceptive sensory inputs, so we, as adults, can understand sensory at a more complex level, even dividing interoception into visceral organs, giving us input and the other interoceptive components, and I know this is a huge hot topic. We could talk about this for a whole hour, but this is important for the adult trying to understand their own sensory needs. Jayson Davies So, what I'm hearing is we understand that a sensory integration type of framework can work when we're supporting our children, you know, given that we have the training and everything, but that will look different if we are trying to support ourselves, partially because, you know, we are adults, our brains are different, we have a general more control over our own selves and our actions, you know, it doesn't matter who you're supporting, you have more action over yourself than you do anyone else, right? And so we hope so. Yeah, we hope so, right? Robyn Chu We, we really hope so. Yes. Jayson Davies yeah. Robyn Chu No. Well, I'm making a joke only because I think this is something important to emphasize here. We have more of an internal locus of control, we hope, than the kids that we're working with. Right, we hope that we've gotten to a point in our own development, and yet I think in this post-COVID world, a lot of people are feeling like the world is just happening to them, it's hitting them like wave after wave of hard and so finding our way back to that internal locus of control can be done through sensation, so that's why I feel like I made the joke, because it's so real right now. Jayson Davies Yeah, yeah, absolutely. And a term that I've heard, you know, within sensory wellness is that this is not just, how do I want to say this? I feel like we are framing sensory wellness as a biological foundation, per se, and not just a strategy. And so, how is it that if we have this foundation within sensory, that it can improve our entire life, per se, and what does that foundation really hold true to be? That's a very limited question. Robyn Chu So, that's such a great.. so, okay, here's the first place I want to go with it, and then you can back me up from here. So, Lisa Feldman Barrett has done a lot of research on emotion, right, and, and some people might jump to when they hear the word regulation, they jump to emotion, right. I'm frustrated. I just, I just talked to some moms that were talking about rage cleaning, right, like they people feel like, okay, emotions are driving my actions. Jayson Davies Okay. Robyn Chu Sensory is such a biological foundation that it actually is helping you actively make emotions. So, Lisa Feldman Barrett's work turned the whole mental health world on its head, because she came out and said, look, the research is saying emotions don't just happen to you, they are made. How are they made? They're made through sensation and past experiences coming together in your brain, and your brain then predicting what might happen next. Sensation is a key ingredient, so the biological foundation is not just it is fight or flight versus rest and digest. Obviously, it is autonomic nervous system that we learn in school. Yes, and it is the key ingredient of how we actively make emotions and shift our experiences. Jayson Davies Wow, wow. Thank you for the, for the knowledge on that research. I appreciate it. Robyn Chu We can go backwards and talk about more of, more other things of about the. Components, the biological foundation of sensation, but that is just where my heart wanted to jump to for the listeners. Jayson Davies I think it's interesting, because when you've looked at the development over time, all sorts of programs have leaned heavily on emotions, right, and I know there is kind of this this movement right now about sensory versus emotions, you know, the type of language that we use really matters, and that kind of, you know, is very much ingrained in what you just said, but I hadn't heard about the research that really kind of where that comes from, to a degree, and so I guess, how do we use that with ourselves, you know, if we're having a bad day, right? Right, how do we.. how do we use sensory approaches, if we want to call them that, to, you know, make our day better, as opposed to, you know, thinking to myself, think happy thoughts, think happy thoughts, think happy thoughts. How do we go about using this? Robyn Chu Just look for the bright side, really, really hard. Where's the silver lining? Oh, it's not working. Yeah, absolutely. So I'm thinking about our sensory world, and I'm thinking about environmental adaptations, adjustments that we can make to incoming actively seeking input, right. So, so you're having a bad day, you don't quite know why you're having a bad day, but the sky is no longer blue, there's no rainbows or unicorns, and you know, and you let's say that you are a. I just have a thought, you know, how we have emotional intelligence, like your EQ. What if we have your SQ? So, what if you are a highly intelligent sensory? You're, you have a high sensory quotient, your SQ is off the charts, all right, and, and you know that the temperature outside, the sweat that comes on your eyelids and your upper lip, it just drives you insane. It's so frustrating. You might also know that you can adjust other systems in order to be able to tolerate that external input that you really, really don't like, that is maybe having being a key driver in your bad day. So, the higher your, we're going to do this now, the higher your SQ, your sensory sensory quotient gets, the more tools you have, the more you're able to adapt your environment, but also adapt the active drivers that you're adding to your day, without feeling like it's just another thing on my to-do list, or man, if I was just more capable of thinking happy thoughts, I would be a better person, because that's not real. Your brain is doing its very best job of predicting with the incoming information from your sensory systems, but you can now change that incoming information both in what you're doing and where you're doing it. Jayson Davies Yeah, yeah, I think the same thing kind of holds true, like we can't in the moment change our processing ability of the sensory stimuli, but we can absolutely turn up the AC, or you know, change our current environment, and yeah, we can't, you know, if you're at Disneyland, you can't just leave 100 degree day in Anaheim, but like to an extent we can absolutely have control over the environment and make changes based upon that. One of the chapters in your book, as we get into more of the, you know, actionable ideas, you talk about energy, and this is something that I know autism level up, they have really talked about energy rather than emotions, so I just want to pick your brain on, you know, how does sensory, all the things in our life, and how we process it, to what degree, or how does that impact energy? Robyn Chu Oh, okay, so you get a whole bunch of sensory input that is triggering to you, whether it is triggering because of the way you are wired genetically or past trauma experiences, you now go into a fight or flight response. The most energetically costly thing that can happen is your body getting stuck in a fight or flight response, then your energy level goes way, way down. Adrenaline has been going for too long, cortisol levels have been high for too long. Now your immune system is compromised, and now your energy level drops even more because your body's fighting whatever every single kid in the class. Classroom had that day as they're sniffling and wiping their nose, right. So, so there is the energy, there's the micro level of wow. If I have more colors on my walls, I feel more alert. If I put a little drop of peppermint in my water, I feel more energetic, sensory arousal level, right. There's also the cumulative effect of a lack of sensory wellness. If you get stuck in fight or flight, if you don't have the fluctuations that define health, the heart rate variability level, like my, my aura ring, or you know, your, your watch could tell you right, if your heart rate variability is low, and you don't have these fluctuations between the sympathetic and parasympathetic nervous system, your energy level is going to drop substantially, and I think this is something those beginning programs that teach about energy understandably simplify, right. We want to teach kids about what it feels like to have lots of energy and be super tired, and how to adjust that. I think that's a noble effort, that's a really good start. And to your point, as OT practitioners, for ourselves, we can add to that, we can work a layer above that too. Jayson Davies Okay, so you were talking about the heart rate activity and the parasympathetic and sympathetic, and to me, what I heard was, I feel like you're saying actually going between the two can make you, am I oversimplifying this, making you more alert by going between the two? Is that accurate? Robyn Chu Yes, absolutely. So, there is a huge.. Jayson Davies Go ahead. Robyn Chu there's a huge misunderstanding that I feel like occupational therapists are doing a noble, wonderful job of trying to fix, and that is that calm all the time is best. We don't want calm all the time. Calm all the time is a serial killer, that is not what we are going for, right? So when we're thinking about energy demands, if I find, let's say I'm amazing, and I find my energy level up, and I do them all the time, and I am just at that brink of alert, but not dysregulated, I'm just going, going, and I get 10 reports done with those awesome sensory inputs that have kept my energy level up right at that calm alert state. I also need tools to come back down from that, because at some point I want to be able to go to sleep at night, so the most advanced energy adjuster is someone who fluctuates between different energy states that match what they need to do that day. Jayson Davies That makes sense, right? Like, who? Yeah, it's if you're at a pool party, being calm, you know, sometimes is good, and some, if you want to lay out by the pool, com is great. If you want to, you know, do a cannonball, column is not great. So, and it's okay, obviously, to be at different alertness levels, have different energy levels. Sometimes it feels like we don't have control over that, right? Like, if it is a mundane day at, you know, school is out, and we just have two and a half hours, or an hour and a half, even, just to write reports, it can sometimes be difficult to muster up that energy and bring up our arousal level a little bit to kind of get through the work day, you know. Some of us turn to caffeine. Cheers, right, and but there's, but there's other ways, and I feel like we're really good at kind of sharing those other ways with our teachers and the kids that we support, but we're not always great at doing that ourselves, hence the caffeine, so I guess I kind of bring this full circle. Is that kind of your goal with this entire book, is to help you know the adults in our lives, and us included, to help us better understand our own sensory systems and how we can impact that? Robyn Chu Yes. yes, with a so what? So I absolutely got a different it wasn't, and Jayson Davies that time it was so what this time. Okay, let's go Robyn Chu So, well, who cares if you understand your sensory needs if you're not getting to do what you love to do and want to do. In life, so this is this is why I get so excited, because I feel I hope that sensory wellness is actually touching on the heart of what occupational therapists do, and that is we connect foundational body functions with meaningful life participation in the things we care about most, being our best selves for our clients, and I want us to do that for ourselves too. Jayson Davies Yeah. Robyn Chu So I'm hoping that people understand their sensory needs and preferences, and then that helps them to do what they want to do the most and connect with others. Jayson Davies Yeah, I mean, at the end of the day, the reason that we care about our well-being is so that we can do the things we love. Robyn Chu So, yeah, exactly. Jayson Davies Do you feel like your book reads differently from an OT perspective versus a non-OT perspective. Robyn Chu Well, my editor would say maybe so, and I hope that putting all those definitions in there helped, so that helped so that people could understand and benefit from it, either. Jayson Davies Yeah. Robyn Chu as occupational therapists or non-OTS. Jayson Davies Yeah. Robyn Chu That was it. Was a, it was a battle that I was facing while writing it. Right, is I want this to help occupational therapists, even if they've done every sensory training ever. Jayson Davies Yeah. Robyn Chu And I don't want to lose the parents and the non-OTS in the process of helping them. Jayson Davies And that's the hard part, right, because I mean, even if you go on to school-based OT communities, we see sensory become, you know, complex and difficult to understand, and that's from people who have to some degree sensory training, and kind of goes back to the big getting, you know, one of the first questions I asked you about, like sensory branding, like sensory is not easy to understand, and so I love the idea of your book, because for that exact reason, because it kind of is bringing a understanding of sensory and the so what piece to it to you know the non-OT practitioners out there, and that's important, along with two OT practitioners. Robyn Chu Yeah. Jayson Davies You know that, like, this is the type of book that you could, you know, hand to your friend that isn't an OT and is feeling a little overwhelmed, and so I think that's, that's a, that makes it great. Robyn Chu Thank you. Yeah, I recently talked with a group of athletes at a college, a local college, and heard from them how much they feel this is going to be helpful in their competition, in their training schedule, in their competitions, because you think about it, each and every one of us have things, hopefully, that we love doing, and for the athlete, the college athlete, it can be really tricky. They're balancing a lot, it's different things that they're balancing, but they're also trying to come down from the high of competition to be able to fall asleep at some point, and then gather the energy to do the next day of double day training, so that's been kind of a fun eye opener of hopefully this is for everyone, hopefully we can all reconnect with our senses and be our best self. Jayson Davies Yeah, exactly. Earlier I didn't dive into it, but you talked about, you know, how there's studies going on the fMRIs and whatnot, and like those are things that OT research doesn't have necessarily the resources or even potentially just the the knowledge of even how to make it happen, but we are seeing that in other research realms outside of occupational therapy to a degree, we're seeing it in OT, but not nearly as much as I think we really need to, because I think those are the types of studies that really connect with the world outside of OT, and you know, those are the types of things, oh, that you could see on news, like, honestly, like, how often do you see on the news, like this new FR, FMRI study, right? Like, I don't know, I would love to see more of that. It is difficult, but I think that that is the kind of shift that needs to happen for the general public to use sensory in a way that is, you know, not every single aisle is filled with sensory toys at Target. We need to, we need to develop this, this understanding of sensory, and so that's what's great about your book. It really can help with that. It is not an OT textbook. It is a book that you know someone can pick up and really start to understand the different systems and how to, how they interact, but also how to.. what's the word I'm looking for.. actually have an impact on their own sensory system. So, really appreciate that. Robyn Chu Love it. Yeah, that's what I'm hoping. And yes, if anyone listening is excited about doing neuroscience research, we have a couple of great teams across a couple universities, and there is room for you. This is an important field. We need to start looking at what is happening neurologically and physiologically before, during, and after occupational therapy interventions, so these are expensive studies, but they're very, very fun studies, and they have to be inclusive of multi-discipline collaboration, so it's, it's been really fun, but there's more to come. Jayson Davies When you say multidisciplinary, are you saying multidisciplinary in the sense of like multiple people, different disciplines that are treating the student, or multidisciplinary in the sense of like the OT working with neuroscience, who is doing kind of the data piece, Robyn Chu the second one, so on our team at UCSF right now we have Prateek Mukherjee, who is an incredible radiologist and neuroscientist. We've got Elisa Marco, who is a neurologist. She's working with these families in a clinic as a neurologist, practicing medicine, but also doing the research, looking at the brains, and then we've got incredible neuroscience students, PhD students who are crunching numbers, and oh my goodness, knee deep, waist deep in computer code, analyzing the data with incredible computer power, so it does take everyone. I'm not going to be the one that is running a whole bunch of code and saying, okay, I got this number for you guys, but I am going to help as the occupational therapist to say that's really interesting that we're seeing an increase in connections in the brain within in brain connections and decrease in out of brain connections. What does that mean for resilience building within our intervention? So this is, I think, this is where the field is going. This is the exciting stuff, but that's just me. Jayson Davies It kind of has to, everything, yeah, I mean, everything's being data driven, and we have, I mean. Robyn Chu yeah. Jayson Davies With the, with neuroscience advancements in the last, what, 50 years, if not even 20-25, years. Robyn Chu Even five years, right? Jayson Davies Yeah, yeah, I mean, and then you, you bring AI in as a data analysis tool, I mean, we are going to start, yeah, we're going to see, so it's going to be possible, not just easier, it's going to be possible to see connections that couldn't be seen a decade ago, and yeah, we have to, let's be honest, like we know that data is important, we as OTs are not always great at data, you know, our goals are very functional. Yes, and they are very, they're hard to track sometimes. I'll just say that they are hard, they're difficult, but we need to, and if we can get the neuroscience to help back us up, it only makes it even better. So that's awesome. See, another, another topic for another day, we should dive into the research behind OT and fMRI, that'd be great, but. Robyn Chu Absolutely. Jayson Davies Robyn. Before, before I let you go earlier, I kind of asked you a little bit about how most adults practice sensory wellness, and to a degree, it was kind of, you know, a little not non-existent, but you know, it varies, really. It does. What is your goal? For you know, after someone reads your book, you know, what is your hope that their few weeks after that start to look like? Robyn Chu I hope that after someone reads my book, they will daily be thinking about how they might not be able to change the whole world immediately, but they can change their world that's right around them. I hope that someone will recognize that there are adjustments, and even if they feel slight, they will know that they are important, and that that occupational therapist is worth the two extra minutes that it takes to adjust the sensory input, because of what they will be able to do and who they will be able to help in the middle of that day. Jayson Davies Yeah, yeah, I'm gonna ask you one more follow-up, pie in the sky type of question. Robyn Chu Love it. Jayson Davies Where should occupational therapists be in the medical world in order to support others in doing the same thing, not just through a book, but actually through like a service as occupational therapy? Does that make sense? Robyn Chu Where should we be? Jayson Davies Yeah, traditionally occupational therapy lives in certain worlds, right? There's school-based occupational therapy, there's acute health. Where do you feel that occupational therapy needs to be if we truly want to make an impact on the general public well-being? I mean, this could be, you know, yeah, in our, in our, you know, in Kaiser, in our, whatever, medical offices, this could be in the government somewhere. Where do you feel like we need to be? Robyn Chu Okay, so I think occupational therapists need to be a part of wellness programs, so we can start within our own profession, we can make sure that we're prioritizing wellness amongst our immediate team, right? So we have IEP meetings, we can also have meetings with our current team to support their wellness, but what I hope is from there you said pie in the sky, Google will call me up and say, man, our wellness program as an organization is missing the boat. We are teaching time management and executive functioning, and we're buying pizza for everyone on Fridays, and yet it's all falling flat. Help us bridge the gap. Help us make our wellness program effective. This is a whole industry that we, as occupational therapists, have a unique ability to help in. So, I see us going there. Jayson Davies I, that's fantastic. I love the, I love big ideas. I love big ideas, and I love even more when I see on LinkedIn, like that has been achieved, right? Like, I love seeing on LinkedIn, like, someone's like, "Oh, I got a new job working at this tech firm. I'm like, "You're an OT, what are you doing at a tech firm? And, like, yeah, they're in the wellness department, or they're helping with improving accessibility for users of a product. Like, I love that. Go ahead. Robyn Chu Can I tell it? Well, there's something that's already happening right now, but it's just really small. I met an OT at AOTA that works at a college, and she's supporting the college students from a regulation standpoint. Can we do more of that? Right, like, why can't we do more of that? Because we know college students are asking for accommodations more than ever before, and the rates of anxiety and depression amongst college students is skyrocketed in the last 10 years, five years. So, where are we? There's, there's like a health department within a college. Why are we not there? So, I would say that's a place that we already are a tiny bit, but could we expand that? Could we do more? Can we help more? Jayson Davies Yeah. Robyn Chu And the answer is yes, obviously. Jayson Davies Absolutely. Yeah, and you notice it's not uncommon for various departments in a university to kind of like create student clinics and whatnot, so it's very doable, especially with every college that has an OT program, right? It could turn it into a field work experience, and all that good stuff. Yeah, no, I agree. I've heard of a few people doing something to that degree, and I think it's just, just awesome. And then it leads to people, you know, once they leave the college, I'm talking about the outside general public, if they, you know, appreciate that program at college. Well, it's something that is in their mind when they go to work, when they become an administrator at Google, or when they become, you know, some person who can make an impact somewhere. Yeah, they recall, you know, occupational therapy had an impact on me, and this wellness program back in college. You know, let's, let's hire an OT, so great. Robyn Chu Let's hire an OT, right? Yes, absolutely. Yes, Robin, I think that's amazing. Jayson Davies Yes, thank you so much for being here. Really appreciate it. Where is the best place for people to learn more about you and your book? Robyn Chu All right, well, I would say for the school-based occupational therapists listening who drive between five to 10 schools in a week, Audible is the easiest way of accessing my book. And then, in the moments you have in between sessions, my website has links to all the neuroscience research that I've gotten to be a part of, and that website is robinchu.com It also has free downloads too, so there's activities that you can do even if you don't buy the journal or the book. So. Jayson Davies Awesome, we'll be sure to link to both of those. Great idea with Audible book, because yes, all the time, all the time I use Audible. Me too. Robyn Chu I'm right with you. Jayson Davies Yeah, all right, Robyn. Well, it has been a pleasure. Thank you so much. Really appreciate it. And I can't wait to continue diving into your book and also see how it's going to make more impact in all the OTs, as well as the general public that we talked about today. So, thank you. Really appreciate it. Robyn Chu Yeah, thanks so much for having me. It's been a blast. Jayson Davies All right, and that wraps it. Up for today, Robyn. Thank you so much for joining me on the OT School House podcast. Your passion for sensory wellness through your book and through everything that you've done in your OT career is not just wonderful for the students that we serve, but also for us practitioners, and we really appreciate it. It's really something that we, as school-based OT practitioners, need to hear from time to time, so I'm glad we were able to do this episode. And if you haven't already picked up your copy of Sensory Wellness, the art and science of thriving, do yourself a favor and grab the audible version. It is perfect for listening between schools or on your commute home. If you enjoy the audible version, go grab the physical version. It's nice to have to actually reference from time to time when you just need to read a page or two to get back in this mindset of we can do amazing things. Thank you so much for spending a part of your day with us, Robin, and I really appreciate it. You pour so much into your students, and I hope this conversation reminded you that your own sensory needs matter as well, if you're looking for more support, more professional development, and maybe even a community of school-based OT practitioners who genuinely get what you do every single day. I would love to have you join us inside the OT School Houses School-Based OT Collaborative. It's where we share resources, host live and recorded professional development sessions, and connect with practitioners just like you. You can learn more about the OT schoolhouse over at OT schoolhouse.com/collab And remember, if you join the impact here, you also get access to the back to school conference. Until next time, take care of yourselves just as much as you take care of your students. You deserve it. I'll see you next time. Take care. Amazing Narrator Thank you for listening to the OT School House podcast. For more ways to help you and your students succeed, right now head on over to OT schoolhouse.com Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! 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Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 203 of the OT Schoolhouse Podcast. Struggling to figure out how occupational therapy fits within your school's MTSS framework? In this episode, Dr. Courtney Boitano shares findings from two groundbreaking studies on sensory processing interventions for kindergarten and fifth-grade students. As a faculty member at San Jose State University and a school-based OT with over 15 years of experience, Courtney provides practical insights into implementing tiered sensory supports that actually work. You'll learn how to use free screening tools like the Strengths and Difficulties Questionnaire (SDQ) to identify students who need additional support, why teacher consultation may be more impactful than you think, and how to implement Zones of Regulation strategies across different tiers. Whether you're new to MTSS or looking to refine your approach, this episode offers evidence-based strategies you can start using tomorrow to support students and empower teachers with sensory processing challenges in your schools. Listen now to learn the following objectives: Learners will identify the research findings from tier 1 and tier 2 sensory interventions with kindergarten and fifth-grade students
Learners will implement evidence based teacher consult strategies as a high- impact MTSS intervention.
Learners will identify the Strength and Difficulties Questionnaire as a screening tool to identify students who may benefit from sensory processing interventions and determine appropriate tier- level supports.

Guest(s) Bio
Courtney Boitano OTD, OTR/L, BCBA-D Courtney Boitano is a faculty member at San Jose State University teaching in the occupational therapy masters and doctorate (OTD) program. Courtney also teaches the Pediatric Clinic course at SJSU. Recent research has focused on the role of school-based occupational therapy practitioners in MTSS to affect students’ sensory processing. As an occupational therapist, she has over 15 years experience working in a variety of pediatric settings and school-based practice. Her clinical practice, OT OuTside focuses on children with developmental disorders and parent support.
Quotes "The consultation piece was huge. It was like a different person filling out the post-test of the SPM because they didn't just see the tip of the iceberg—they understood what was beneath it." — Courtney Boitano OTD, OTR/L, BCBA-D “MTSS can work beautifully when there's alignment at the administrator level.” — Courtney Boitano OTD, OTR/L, BCBA-D “MTSS isn't just the OT doing MTSS. It's not just the reading specialist doing RTI. It's not just the behaviorist doing PBIS, but it's all of us like really working together to see how can we support the student in across these domains and how can we like bridge it together.” — Courtney Boitano OTD, OTR/L, BCBA-D Try to get your foundation under you with everything else, I think, before really diving into MTSS.” — Jayson Davies,M.A.,OTR/L Resources 👉Strengths and Difficulties Questionnaire (SDQ) 👉Sensory Processing Measure (SPM) 👉Zones of Regulation 👉San Jose State University OT Program 👉OT Outside (Courtney's Practice) 👉California Foundation for Occupational Therapy 👉Courtney's Research Article Episode Transcript Expand to view episode transcript Jayson Davies Jayson, hello, and welcome to the OT School House podcast. If you are a school-based OT practitioner, or maybe you're thinking about becoming one in the future, I want you to know that you are in the right place. I'm your host, Jayson Davies, an OT practitioner just like yourself. Today, I'm thrilled to welcome Dr. Courtney Boitano to the OT School House podcast. Courtney is a faculty member at San Jose State University with over 15 years of school-based OT experience, and today she's here to share with you research on sensory processing interventions within the MTSS multi-tiered system of support framework. If you've been wondering how to actually implement MTSS in your school, beyond just talking about how tier one is for 80% tier two is for 15, and tier three is for the final 5% of your students. This is the episode for you. We're diving into Courtney's research with kindergarten, as well as with fifth-grade students, to uncover what really works when it comes to sensory supports, primarily at tiers one and two, by the end of this episode, you're going to learn how to implement free screening tools to identify students who may need sensory supports, understand the practical difference between tier one, two, and three interventions, and also discover why teacher consultation might be your most powerful MTSS strategy, even though it may be the hardest to prioritize. Stay tuned to learn how Dr. Boitano implemented this 10 week MTSS program, and how you can too. Stay tuned. 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 Courtney, welcome to the OT School House podcast. It is such a pleasure having you here today. How are you doing? Courtney Boitano Good, thanks for having me. I'm so excited to be here. Jayson Davies Absolutely. Well, I have to start with something here. I was just on the California Foundation for Occupational Therapy, and looking at the awardees, and I happened to type part of your name in, and it just came up like nine different times. You apparently have figured out how to get some support with your research, and what it looks like some of your students' research through the CFOT. That's awesome. Courtney Boitano Yes, yeah, I'm so grateful for the work they're doing to support research and getting our work out there. Jayson Davies Yeah, and for those of you who are not in California, the California Federation Foundation, sorry for occupational therapy. It's kind of this: they are not associated with our state association, but they are closely aligned in their goals and furthering the aspect of occupational therapy. And they do have several different grants that they offer every single year. And Courtney has apparently used it for herself as well as really enabled her students to use it, which is just fantastic. What has that process been like? You know, helping your students understand that they can get support that way. Courtney Boitano Yeah, it's been so helpful to, for not only their learning, but also that kind of sense of empowerment, of like we're, you know, doing great work, and there is support out there for it, and to get even that, you know, practice of writing a grant proposal, and the some of the research I've done that we're going to talk about today was funded through a CFOT grant, and it just also makes, you know, getting those different protocols, you know, it's costly, or having a little incentive to give to participants just helps all of that research come together as well. Jayson Davies Yeah, yeah, absolutely. Well, really quickly, thank you, CFOT, for, you know, making that possible for many of the OT professionals out there that want to find some research, because in some cases, like today, that eventually leads to several published articles and information for us to talk about on the OT School House podcast. So, thank you, CFOT, not sponsored, just a nice little shout out. All right, Courtney, you have a lot of experience within the world of occupational therapy. You are on staff at San Jose State University, you have been a school-based occupational therapist. You also have some of your own clinical experience with OT outside in that platform. How have these experiences really led you into these articles that you ultimately published about with MTSS? Courtney Boitano Yeah, and I've gosh, when I graduated from USC with my master's, I knew I wanted to be a school-based OT. They had an opportunity, it was a training grant that we could, a small cohort of us could complete our level two field work in. In schools, and you know, concurrently, while we were doing our coursework, and I loved the experience so much. I was at Long Beach Unified, and just had an amazing mentor, and it was great to, you know, have that clinical practicum experience, and be able to talk about it in our coursework with, you know, our instructor, and I then did the OTD at USC, and was working at LA Unified, and just went straight into schools. So, now, for like, gosh, almost 20 years, I've been working in schools, and, you know, still do a little consulting here and there, supporting students and schools, teachers, administrators. I just love that aspect of Jayson Davies it. Yeah, yeah. Wow. Fun note, I also had access to that school-based OT special program at USC. That correct me if I'm wrong, but when you came out, you also got like a little, not a stipend, but they helped with your student loans, right? Courtney Boitano Exactly. Yeah, it was amazing. It was an amazing training grant. Jayson Davies Yeah, yeah, I did not do that. I did not think I'd end up in the schools, and that's kind of funny now, right? So, yeah, kind of wish I would have done that program, you know, given where I am today. But that's awesome. I'm glad, you know, that's really cool, because it's not many people get to come out of school with the foundational understanding of school-based OT. USC had that program in place for, for so many years, I don't think they have it now, because it was a grant, right? So it's really awesome that that you're able to get that. You said you landed at LAUSD after that, right? Courtney Boitano Yeah, yeah, so I was at LA USD, and then I worked for the Southwest Selpa down there in Southern California. Ended up working with a smaller school district down in Southern California, but just have always been so drawn to that energy that schools provide, and that that collaborative piece. Jayson Davies Yeah, How long would you say it took you to a learn about MTSS, or did you already know about it from the USC program? And then, how long did it actually take you to, you know, what? Say, I can see students beyond the IEP, and let me actually figure this out. Courtney Boitano Yeah, you know, it's really funny. Recently, I was going through some of my, you know, old like school materials, like, yeah, it's you know, when it was just like paper, you know, printed with that plastic comb, and so I had this booklet on RTI in public schools, and I remember, I think LAUSD, you know, they would do different like in services for the rehab professionals, OT, PT, and so it was like an in-service on that, and it's really interesting to look back at that, and then to look at where we are now with RTI and MTSS, and to see that we've been doing it now, you know, for a very long time, but just that evolution of how it's become so encompassing in so many different realms and domains where students and teachers need that support, so it's been especially, I think, helpful for us as OTs, as we've had these conversations about case load versus workload, and these different models, and to to look at how we can make that happen, because we can reach so many more students when we are implementing RTI MTSS frameworks. Jayson Davies Yeah, at LA USD, were you at that time, were you able to get into MTSS at all, or did it take you a little bit further down in your career to actually figure out how to make it actually work a little bit? Courtney Boitano Yeah, I'm definitely kind of with that. That evolution of what it's been has been how I've also evolved in my own practice of how to do it, and it's so it is. It's hard when you're a new grad and working in the schools and managing the caseload and the different school sites and and just building those relationships and knowing how to do it, so I think there were little like glimmers of being able to do it. I remember my first, you know, first year collaborating with the adapted PE specialist, and there was a great team, you know, APE Speech and myself, and we worked really closely together, and would be at the same site on the same days, so we could do some like really cool groups and kind of bring in those tiered interventions, and I would say that's almost more unique, right, to have that kind of like magical team chemistry come together, where it's like we all were like, oh yeah, we could be doing this and have these different groups, and so it was, you know, long story to say, you know, it's been easier at, you know, some schools versus other schools and. And also, just as I mentioned, kind of having that relationship and rapport building, so it's become easier as I've been able to establish a rapport with the teachers, with the administrators, with the school site. Jayson Davies Absolutely, part of the reason I asked you that question is because I wanted to hear that answer. I kind of assumed that that was going to be the answer, because that's my answer too. Like, MTSS is not something that you can jump into most school sites and start doing on day one. Most schools don't have MTSS built within the confines of OT, or OTs built within the confines of MTSS, to probably say it more correctly. And so it is something that you, as OT, kind of has to, you have to take that on, and maybe you do find a really awesome SLP and an AP teacher or a PT that, that will do that with you, but I often, you know, get asked, and I'm sure you have too, from, you know, newer students, like, what to focus on in your first year as a school-based OT, and, like, MTSS was the last thing I'm telling people to focus on, not because it's not great, like it is great, but it's so difficult, and try to get your foundation under you with everything else, I think, before really diving into MTSS 10 years from now, that might be different, Courtney Boitano yeah, for sure, Jayson Davies but that's how I kind of view it right now, so awesome, I think that is helpful for everyone listening in their first year, maybe even first few years of school-based OT. Courtney Boitano Yeah, all Jayson Davies right. Well, let's go ahead and dive into kind of explaining MTSS from the from the way that you actually perceive MTSS. Everyone has a slightly different understanding of MTSS and RTI, but I would love to hear kind of how you explain MTSS, whether it be to a fellow OT, a teacher, or a parent, even. Courtney Boitano Yeah, and kind of building off of what we were just talking about, how it's evolved. It's been interesting to really see how the terminology has even changed with these frameworks, and how you know, and in kind of doing this work with students, and we've looked at the literature, you know, you go back and it's like it was called early intervening services initially, and then you started to see RTI creeping into the literature a little bit more, and now that more prevalent term that's being used both in the literature and then at school districts is that MTSS term, and so I really, you know, see it as being kind of MTSS as that broader umbrella, and then response to intervention that RTI is kind of that that part underneath the umbrella, those tiered interventions across domains, whether it's for reading, behavioral support, OT being in there, and you know, with MTSS, it's really governing those multiple processes that are supporting students, and so it's, you know, RTI is under that PBIS, the positive behavioral interventions and supports, also falls under that umbrella, and that biggest piece, kind of tying it all together, is that collaborative piece, right? That it's multiple professionals working together, it's not just OT doing MTSS, it's not just the reading specialist doing RTI, it's not just the behaviorist doing PBIS, but it's all of us like really working together to see how can we support the student in across these domains and how can we like bridge it together. So I love that that umbrella image to see how it all, it all falls under that, and it all has to be covered under that umbrella, Jayson Davies yeah, yeah, absolutely. I mean, it takes a village, right, to raise any human being and to support any human being on campus. Definitely takes a village. So, yeah, along the lines of that, I think most of us understand that there are three tiers of MTSS and RTI. There was three tiers too, as well. How do you overarchingly describe the three tiers of MTSS? Courtney Boitano Right, you know, I always go back to those percentages because it, it makes sense to me when, when we're looking at that, you know, tier one being that the 80% of students, tier two being that 15% of students who need just a little bit more support, and then that, you know, tier three being that 5% that smaller percentage of the students who need that more one on one focused intervention, and so I can really, you know, see how when the team approach comes together to meet the students and the teachers, I include the teachers in there of how, how are we doing those tiered interventions for the teacher, not just for the student, but you know, there are those those teachers, I think we can even kind of align some percentage. Is to teachers, there's some teachers, you know, where we can, we'll kind of get into this, you know, where it is like maybe we're doing an in-service, or maybe there's a teacher who needs more of that one on one consult with the OT, and so, how can we meet both the needs of the students and the teachers within those tiered levels? Jayson Davies Yeah, it's so interesting how MTSS can look very different, like two OTs can implement MTSS even at the same particular school, but it's going to look so different. I do feel that the teachers are one part of the dynamic, of course, we are part of the dynamic at play, all the other team members are part of that, and it all influences what your program can actually look like, right? Like, we have to, to a degree, play to our strengths, and some teachers we collaborate really well with, and other teachers maybe we don't have that same connection, but that doesn't mean we can't get creative in a different way to continue to support that teacher at various levels, and of course, their students. So, yeah, absolutely. How do you find that MTSS and special education work together or integrate together? Does that question make sense without additional context? Courtney Boitano I think so, and I mean the way that that I conceptualize that is, you know, MTSS can certainly be and is used for the general ed population, right, but where we bring in that that special ed piece is, you know, where we are seeing, and let me back up a little bit, of like I think the classroom dynamic has changed so much from 20 years ago, 10 years ago, to even five years ago, right? The classroom looks so different, so even in a, you know, quote unquote general education classroom, like we are seeing kids with significant needs whose needs aren't being met, and so I think, you know, just keeping that kind of binary separation of general ed and special ed, of course, you know, we have our, you know, frameworks and laws to really define that, but we're seeing it kind of intertwined so much now, and so MTSS really provides a great way to meet the needs of kids, whether they are in general ed or, you know, are in a special day class, you know, in special education, getting an IEP, or have a 504 plan, or have nothing, right? And so I think MTSS really helps to kind of bridge that gap, because you know, like I said, the classroom is looking so different, and teachers are needing so much support, and we really can provide that support to them, because that, that support they're needing is, you know, behavior management, you know, kids having decreased attention spans and a need for more movement, more differentiation, and how they're being taught, and so, and how their needs are being met, and so we can really help teachers understand that. I think we have a really unique perspective for that, so going back to your, you know, question of like MTSS, I think really is that perfect bridge between special ed and general ed, and then just what the classroom is looking like these days. Jayson Davies Yeah, yeah, one something that's come up a few times is about I think people forget that even if a student is in a classroom, a more contained classroom, a special education classroom, per se, that, and maybe they have direct OT one time a week for 30 minutes or less, consult, or whatever it might be, that they fall outside of this realm of MTSS, but I don't think that's true. I mean, we can absolutely still be supporting that teacher at tier one that's going to support that student. We can potentially have that student involved in a group inside the classroom at tier two, whether or not that is on the IEP or not on the IEP, because we just happen to have a tier two program in that classroom, and I think that sometimes goes forgotten a little bit. Courtney Boitano Absolutely, I agree 100% And yeah, I don't think they can be separated, of like, oh, MTSS is just for that general ed, and yeah, it has to be embedded across, you know, general ed, the, you know, essay sai classrooms for all levels of kids, like we, we really need that, Jayson Davies yeah, yeah, all right, I want to start diving into your research a little bit, you did two different, you have two different published research, one, the effects of sensory processing at tier. One and tier two among kindergarten students, and the other is tier one and tier two for sensory processing with fifth grade students. So, you've done this kind of twice with two different populations. My question here is, before we dive into that, this is a question that I go back and forth with all the time as an occupational therapy practitioner going down the MTSS route, are we providing occupational therapy as MTSS, or are we providing a specific support, such as handwriting, fine motor skills, sensory processing, social skills, emotional regulation, as part of that MTSS, and I ask this because I feel like sometimes if we just try and say OT is MTSS, it's just too broad, it doesn't allow us to go into one specific area. Obviously, you kind of have well defined this as sensory processing, and I'm wondering if that was, I mean, for research it has to be on purpose. But yeah, trying to collect your thoughts on that. Courtney Boitano Yeah, I think you raise a really good point, and I think it's one of the things that I often come to, just as an OT, of like what we're doing as occupational therapists is is going to look different based on the unique needs of the individual, or in this case of the classroom, and so this was defined, you know, as okay, we're doing, you know, the OT was specifically, you know, defined as sensory processing, because that was the unique need in both the classrooms, and you know what, I continue to emphasize is the unique need, really across classrooms. Now that's what I'm constantly hearing teachers really struggle with, is like really that, and when I say sensory processing, that you know self regulation, you know, kids being able to do that modulation to, you know, bring that arousal level, you know, we have to be able to match that arousal level to different activities, settings, environments, and that's a big challenge right now, and so this was, you know, sensory processing was chosen because that was the need, and how this all came about, so I can dive into a little like context. Let's Jayson Davies go in. Yeah, let's go for it. Courtney Boitano So, so at San Jose State, we have these really unique clinics on campus, and I lead our pediatric clinic, and so one day we're on campus, and then as a school-based OT, you know, when I started teaching our clinic course, I was like, well, you know, so many grads go into school-based OT, can we have one day be at a school? And so we got this contract with a local, it's a parochial school, so a local school nearby, and one day a week, the student, a small cohort of students, usually around like 10 to 12 students, we go to this school, and this was all, you know, we don't have the manpower, there's just, you know, a few of us, so it's not individual services, so we're doing RTI, this was, you know, okay, How can we expose students to those tiered interventions, so we're doing tier one whole class and tier two small group interventions, and so in response to the needs, you know, following the pandemic, the school administrators, you know, noticed that the fifth grade students, and so that was the first study that came about, also because at San Jose State, master's students do a group research project together that is led by a faculty mentor, and so I, you know, had this kind of need from the school with administrators, kind of saying, like, these fifth graders don't have tools for self-regulation, you know, following the pandemic, we're just seeing a, you know, huge shift in how they're showing up in the classroom, so I thought, okay, this could be a great research study, so it, you know, really was this great opportunity, not only for education of, you know, the clinic students, the research students, and then just to kind of satisfy my own curiosity, but to really meet this, this unique need that we're seeing across schools. So, so we did that first with the fifth graders, and then there were a few shifts I wanted to make, so then we did it with the kindergartners, so I could talk about a little, a little bit more about the fifth graders, but if you have a question, Joe, Jayson Davies I, that's exactly what I want to dive into, is that that first article that you have, you were looking at specifically tier one and tier two for sensory processing for fifth grade children, so I mean, let's. Just dive into, I think, a little bit of the methodology, like what did it actually look like. Courtney Boitano Yeah, so because you know that was kind of the problem that was brought to us, of like, here we have this fifth grade class and they need tools for self-regulation, so we did, we use the SPM, the sensory processing measure, as a screening tool, and what that really turned out, and it was at two different schools, so the one school where we have the clinic, and then we did another nearby parochial school, so same kind of makeup of students, so we can get some comparison, and the difference was that at one school they had us, this, you know, OT students coming in and doing, you know, the tier one and tier two interventions, and then at the other school, the fifth grade teacher got a workshop, like a in-service that I led one one day, you know, after school, and so what we found with using the SPM as a screening tool was that in reality, you know, there was just a small handful which aligned with what we know about RTI, right, that there's going to be about 15% of students who really, you know, are showing that they need that, you know, tier two intervention, and so this is, you know, wrapping everything into a nutshell, real briefly. But after looking at that, it was like, oh, you know, that using the SPM as a screener for the whole class is just not feasible. It's time consuming for the teacher. It's really cool. Jayson Davies So the teacher had to do it. Oh Courtney Boitano yeah, so the teacher filled out the SPM, and the, you know, it was costly too, because the, you know, cost of each SPM. So, what we found, you know, from doing that with the fifth graders was that there were some results with the in-service, you know, teachers were understanding the zones of regulation more, and we chose the zones of regulation because it was already kind of being used in the school, so there was some kind of base knowledge of what the zones of regulation is, and it aligned with their social emotional curriculum, and we also, in terms of what that intervention looked like it also brought in some like mindfulness-based strategies, so things like, you know, helping the kids with, like, okay, what are some coping strategies when you are, you know, getting into the yellow and red zone, you know, breathing techniques, taking a break, and it was great to see that the teacher's understanding of what these terms were was, you know, really changing, so because you know I saw that the SPM was not a great screening tool, and we were then hearing, like, you know, our kindergarteners are coming in, and I was like, that would be a great class to do it with, because they don't have the knowledge of the zones of regulation. So, what could this look like with a group of young kids who are coming in? Some have had preschool, some haven't had preschool, some have had, you know, a junior kindergarten program, TK program, some haven't, so we're really, you know, kind of getting a broad, broader mix of background coming in, and one of the things that we then changed with this, instead of using the SPM as a screener, is that we did the Strengths and Difficulties Questionnaire as a screening tool, and this was one the I don't know if you're familiar with the SDQ, but it's a free tool, and it really kind of can tease out some of that behavior, and the like kind of more sensory like components of, you know, like being fidgety, decreased attention, and I have a BCBA also, and I have a BCBA because when I was working at the SELPA, they had a small cohort of students, they offered, or not students, of people working in the Selpa. Yeah, they said, you know, if you're interested, we're going to have a cohort, and I was like, "Gosh, I'm constantly getting asked the question, is it sensory or is it behaviors? It's like, "Sure, I'll do it Jayson Davies if you're gonna let me go for it. Yeah, sure. Courtney Boitano So that's always been interesting to me to look at kind of that behavioral piece, and that's what teachers really identify, right? They identify the behaviors. Yes, I often use that, like iceberg, you know, analogy of like what you see above the iceberg, at the tip of the iceberg are the behaviors, right? The, you know, kids blurting out, the kids out of their seat, you know, they can't focus, but then we, you know, with our OT perspective, we understand what's underneath that I. Iceberg, so all that to say, I thought, okay, the SDQ really kind of helps to tease out, like, okay, what is that behavior, and what we can then look at, like, what are these sensory components underneath that iceberg? So we replicated it with the kindergartner students, but this time instead of just doing the RTI interventions, the tier one and tier two, and the in-service, we added a consultation piece, so we had three kindergarten classrooms, instead of just like before, we had 2/5-grade classrooms, we had these three different groups, and what we before I jump into what we found, the interventions that were being done for the RTI group, the same idea of following the zones of regulation, because the teacher used the zones in the classroom, but also including, you know, some real like hands-on kindergarten age, you know, different artwork. They are doing sensory activities to, you know, understand, kind of bring in that interoception piece about, like, when we're feeling this way, when our body is feeling this way. Like, what does that tell us, and what can we do with those kind of, you know, mindfulness-based strategies, of, you know, the breath work, asking for help, being able to, you know, advocate for yourself and take a break when you need to take a break, and then one teacher got, you know, consultation, and then another got just that in service, so what was interesting about this, and jump in if you have a question too. Well, I was gonna Jayson Davies ask, so just to clarify, so three different classrooms, one just got one in service up front, I'm assuming that was, or did all the teachers get that in service, or did you literally just sit down with one teacher. Courtney Boitano No, that's a good question. So the teachers that this was at another school, so two schools again. So two teachers at this one school got the in service. All the teachers, you know, grades K through eight got the in service, and then at the other school it wasn't the in-service, it was RTI intervention. So then the other school, the third teacher got both the in-service and the consultation piece. Jayson Davies Okay, so in service, and then what? How often was the consultation? Courtney Boitano That was about every two weeks, I want to say, Jayson Davies okay, over the course of how long? 1010, weeks, okay. And then course or classroom number three, then was the one who actually had the RTI intervention itself, and kind of just really briefly, what did that look like? I know you talked about zones of regulation a little bit and interception, but as far as like frequency and whatnot, what did that look like? Courtney Boitano Great question. So it was once a week, and it was broken into that tier one whole class, so going in and doing like a whole class, you know, activity on, say, you know, understanding our internal cues one week, and then next week about, you know scenarios and role playing different zones of regulation, and then there was also a tier two small group component, so then breaking into small groups with the different activities for zones regulation. Jayson Davies okay, so I'm assuming the classroom itself, the tier one was like a 30 minute collaboration lesson with the teacher, and then some students got an additional 15 to 30 minutes for the tier two part of it. Okay, gotcha. And again, over the course of 10 weeks, right? Courtney Boitano Yeah, Jayson Davies awesome. Okay, was the SDQ is that what was used to determine Tier One and Tier Two in that case, or how? How do did that determine who was Tier Two? Courtney Boitano Great question. So we use the SDQ as a screener for then who would we would have administered the who we would administer the SPM to, so then we use the SPM again, but instead of just using it for the whole class, we were then able to administer the SPM. The teacher filled out the SPM for the students who the SDQ total difficulty score was elevated. Jayson Davies Interesting, how big or so were these classrooms, just in general? I'm assuming 15-ish kids, Courtney Boitano right? Yes, we had 11 who consented to participate for the RTI group, and so not all 11 had, you know, had these elevated scores on the SDQ. So I want to say it was about Jayson Davies like five. Courtney Boitano Yep, I was just gonna say five. Who, then we administered the SPM four. Jayson Davies okay? And then were those five, if they got the SPM, did that basically mean that because they had the elevated score, or whatever score on the SDQ, those five were in tier two, and you use the SPM to help with the data for only the kids who were at tier two. Is that summarized correctly? Courtney Boitano Right. Yes. Yes. Jayson Davies Okay. Got it. Courtney Boitano Lot of things going on with the study, because we had the teachers completing the zones implementation surveys, you know, the zones of regulation came out with some data collection tools, which wasn't in existence when we did the fifth grade study, so it was really, it was interesting to bring that in, to use that as a survey to, to have to be able to measure then how the teachers were implementing and understanding the zone, so we used those measures as well for the teachers. They were completing different surveys, and and we were able to kind of look at that for both the students and the teachers. Jayson Davies Yeah, I really wanted to break that down a little bit, because school-based OT practitioners are always trying to figure out, like, well, how do I know when a kid needs tier two intervention, and so you know you're kind of providing that, and of course this was research, so you probably did more than you really might need to do in a clinical setting, maybe you don't need to do the SPM, you just use the SDQ, which is already free for anyone to access, and of course the SPM does get expensive. And then could you have used the, I mean, if you didn't have the SPM, would you have just used the SDQ again later, or maybe you already did that? Courtney Boitano You know, that's a.. that's an interesting question. I do like using the SPM for that follow-up piece, because I really think that is the great bridge between, okay, here are these behaviors that the teachers are seeing and are reporting, and then we can bring in the SPM to really back that up and give some concrete examples of, you know, well, here are these different areas where we're seeing, like, oh, you know, actually, you know, their auditory scores are really hearing on the SPM are really high here, or we can really kind of tease it out a bit more, so I think the SDQ serves as a great screener for that, and what was interesting, I mean, our results were not as, as great as I would have loved to see, like, oh, all the SPM scores, you know, really changed, but what we did find was a positive correlation between the results of the SDQ on the total difficulty score, so it gives you a total difficulty score on the SDQ with elevated scores on the SPM, so it did show, like, oh, this really can be a good screening tool if you didn't have the time, you know, didn't have the resources to, you know, I mean, it's mainly time, it's really time consuming for the teacher to do an SPM on, say, 20 kids, but the SDQ shorter, faster, so you could use it as that screening tool, and we did see this positive correlation. I mean, granted, it was a small sample size, so we want to be careful with general generalization, but, but then what we saw too is, so because the SDQ is more kind of behavior-oriented, and it gives you some pro social scores. We saw that there was a negative significant correlation between the pro social scores on the SDQ and the social participation subscale on the SPM. So, what that means, yeah. Jayson Davies Explain. Courtney Boitano as the pro social behavior scores went up on the SDQ, the social participation difficulties went down, and vice versa. So that's what we would want to see. So we would want to, you know, we don't want to have these elevated scores, and then seeing that, you know, if they're having more social participation difficulties, we would want to see that. Then you know their scores are kind of. Jayson Davies Yeah. Courtney Boitano opening out, leveling out. Jayson Davies It wouldn't make sense if both scores were elevated for good social and difficulty with social skills. So, okay, we're going to take a quick break, getting closer to the end of the episode, but I do want to follow up with you more about the results, and also ask you one more question about using that SPM. So, we'll be right back. All right, Courtney, I do want to move on more to the results, but first, going back to the SPM, this was in a parochial school, you know, not your typical school setting. Mean, or not, your typical public school setting, I should say. In the public school setting, you've worked in LAUSD, a few other school districts, you know the whole referral process and the assessment plan to use standardized tools and whatnot. Can you picture what that would look like when we're using it in this process, whether it's the SPM, the SDQ, or any other tool, when we're using it as this like screener versus an assessment tool on an IEP. Do you think that, and maybe you have more insights on this? Do you feel like we have to let parents know that we're using the SDQ or the SPM if we are giving it to the entire classroom or a group of kids as opposed to an individual student used for the purpose of an IEP. Courtney Boitano I think that's a conversation that is often had about, like, okay. Where is this kind of gray area of, is it? Are we able to do this, you know, just as kind of practitioners in a classroom, or.. and I think just the broader, because there are, you know, nuances and different have different rules for that, but I think just as a broader kind of lens to look at MTSS, I think when we can have these really intentional systems in place at the administrator level, so really looking at kind of that macro level of like having this in place of like we're doing a screening tool, using a screening tool, doing a screening for all, maybe it's at the start of the year, for every grade, you know, K through fifth, parents are, you know, asked to complete the STQ, or we're asking, you know, teachers to do it, and it doesn't need to then come from the OT per se, we can help advocate for this, but if there's a real intentional system put in place, and this is where I think MTSS can can work beautifully when it there's alignment at that administrator level of we're going to be using these screening tools, and then OT can come in and say, oh, you know, I'd really like to look at those SDQs that had elevated scores. I know that that might be indicative of sensory processing challenges, and I'm going to, you know, then when I'm in the classroom, I'm going to just do an observation, and we can certainly be doing an observation, and then say we notice, oh yeah, gosh, that here's three kids who I'm really seeing some red flags. Then we could go that step further, of maybe we need to, you know, start some data collection, get some, you know, consent in place to maybe, you know, whatever the school's policy is for that data collection period to then you know maybe have an SST and and go you know further down the line but I think when it really is done intentionally and across again that collaborative piece of it's part of the PBIS so the behavior support team is involved it's this, you know, hopefully, gosh, you know, the school counselor, if a school can have a counselor, you know, they're involved too, because it has metrics that can be really indicative of needing additional mental health support, we can really then create that wraparound support we, we strive for. Jayson Davies yeah, yeah, I like to often like kind of compare a really like if we were to put a screening process in place as occupational therapy practitioners, it needs to be a system like what you're talking about, and I often kind of just compare it to the way that a lot of schools do like vision screening every so many years, every student gets screened for vision, and you know it's every kid doing it, it's not being singled out who's getting it. I notice might go home a week or two before saying, "Hey, your kid's going to be screened, please let us know if you don't want this to happen. Like, that is something that can happen, but yeah, it has to happen at a systems level, and you could probably start with just the three kindergarten classes on campus first year, and maybe work up from there, but yeah, I do think it needs to be part of a system. I would not advise an OT just to go ahead and start this screening process without reaching out to the principal and saying, hey, I found this new SDQ that I've heard about on a podcast, and it'd be really great if we could just give it to every kindergartner, and you know, look at the data and see if there's something we can do. There you go. Yeah, a template to use. Courtney Boitano A little like anecdotal story of my own children's school, you know, public school. They, as I. Was, you know, doing this study, and kind of came across the SDQ. I was like, oh, I've done this before, and so my kids' school, they did that, they did that, they sent it out, kind of same thing, just like you said. We're, and it came from the counselor, we're going to send out the SDQ, totally optional to complete it, and they did it two times a year. Jayson Davies Oh, wow. Courtney Boitano And it was so great, and this school also has a really strong PBIS program and systems set up, and it is where I have seen I often go back to it, just, you know, mentally, of like this is where RTI was done so beautifully, because I was also providing some OT services there too, and so I was able to go in and, like, co-treat with the teacher, I would lead a center while she was doing her writing workshop, and while I only had, you know, two kids on my caseload in that classroom, I was able to touch all 20 by having them come through my center, and you know, just kind of give that OT lens of like, oh, you know, those little pencil grip adjustments, or like, oh, I'm kind of noticing that this one, you know, their writing is all over the place, let's try it, you know, slant board, or whatever, those little, those little weeks we can provide. Jayson Davies Yeah, I love the idea of MTSS, but I will admit it is hard to put into place, and that's why we're seeing a lot of professional development around it. Dr. Jan Hollenbeck, Jamie Spencer, and Mahler Bushel just presented about it at AOTA Inspire in Anaheim, and it was a full packed room, like everyone wants to do this, but it's not easy, and it's great, like we have the ideas now, we just got to put it into place, and we got to put the systems in place with support from other people, which is like where this entire conversation started by you talking about your amazing APE teacher and speech therapist that you got to work with, so all right. Before we do wrap up, though, I know that you kind of teased a little bit ago that the findings weren't exactly what you'd hoped for, but this is also a small study, and kind of a, you know, pilot per se. What were some of the results that kind of, you know, were not what you hope for, and also just, you know, how you feel that it can move forward. Courtney Boitano Yeah, for sure. Yeah, I mentioned, you know, of course, I wanted to see that we would really see big changes on the severe difficulties and moderate difficulties on the SPM, and that wasn't the case, but what we did find, you know, as we kind of sat with the results, and like, okay, what does this tell us? You know, one of the things we thought of, the students and myself, is like, I think, you know, it really shows how the teacher's understanding of sensory processing changed, and we, we know that, because we also had this qualitative component where we interviewed them, and we were able to, like, really hear what, what this was like for them to be a part of this, and they had a totally different lens on doing the, you know, pre and post of the sensory processing measure, they had a totally different lens after even just the in service, so we saw that, you know, the in service was really helpful, both for the fifth grade study and then the kindergarten study, that the teachers gained so much, but the consultation piece was huge, so in doing the post test of the SPM, it was a, it was like a different person filling it out, right, because they didn't just see the tip of the iceberg, right, they didn't just see the behaviors, they understood what was a little bit beneath it, which was just so cool to the testament of OT and what we can provide from these different modalities, right, whether we are working with the students or we are doing an in-service for K through eight teachers, or we are doing that consultation piece a couple times a month, and again, like really tailoring it, that's the nice thing about that consultation, really tailoring it to the unique needs of that teacher of that classroom of the students in her classroom. Jayson Davies so you had a total of three different tier one interventions, you had the upfront workshop, you had the consult with the teacher, would you call that still tier one? Courtney Boitano Well, no, I kind of think of it different. Jayson Davies tier two. Courtney Boitano Yeah, I would say, like, yeah, that's more.. I mean, maybe even tier three for the teacher, because it was that one on one time. Jayson Davies Interesting. Yeah, I like to think of the personally, I like to think of tier one as being like beyond the classroom, so multiple teachers. First, I like to think of tier two as being classroom specific, because I think that just kind of puts it in a nice shell, and then maybe small group, which then it confuses - it gets confusing because now you're saying wait as a classroom or small group, and then tier three being more the individual. Either way, the point of my question was to kind of go back, would be of the three different models you used, if you were talking, you know, to a school-based OT and said, 'Hey, I want to get involved with MTSS. Would you, would you advise one versus the other? Courtney Boitano I would highly advise that consultation piece, and I often talk to colleagues, you know, working in schools, and really, you know, as they share the, like, the consultation piece is the hardest, because it's what it's where we kind of can feel like, oh, we have wiggle room, right? Like, oh, I have an IEP, like I'm not going to make that consultation time, like I could push it off, right? Or, you know, just to the teacher isn't available when you're available, and. Jayson Davies Yeah, it's hard. Courtney Boitano It's very hard to really figure out how to do that, but kind of going back to where we started with, like, how does this work well? And I think it works well when we have that rapport built, where we, we build that community at our school sites, and I've, it's why I love school-based OT. It's, you know, I've some of my best friends are teachers that I've worked with, right. And it's just the hanging out for 15 minutes over lunch in their room, and that's the consultation piece, right? Or it's, you know, they're doing car line in the morning, and I'm out there with them, chatting, and you know, having it's also great to get to know that, you know, the family side, yeah. work with, but you know, finding these ways where we can build that community, so that that consultation starts to happen more seamlessly, where we, you know, can become kind of more top of mind for the teachers to be like I'm going to run that by Courtney, I'm going to run that by my OT, so it doesn't seem like such a big ask or a big kind of to-do item on our on our list of things to do, and so I think, like, that is one of my big takeaways. It's so impactful for the teacher to get that opportunity to problem solve, to troubleshoot. We can offer a few, you know, suggestions and strategies. They can try it and tell us whether or not that worked. They're with the student five days a week, where we might only be with them once a week, maybe twice a month, and so it can really help with that carry over and empower them, like the teacher at the school who got the consultation piece. She was a veteran teacher, you know, 20 plus years, and she said at one point she was like, I just feel like all of my tools in my toolbox are not working anymore, and you know such a sense of defeat, right? Of like, I know what I'm doing, I'm a good teacher, but nothing is working. But then there was a sense of empowerment, right, where we can offer those tools, and she's doing it, not the OT coming in and leading the group, it's not the OT coming in and making environmental adjustments, but she's doing it for what works for her and her class. And then she felt the sense of empowerment and could speak to the parents too, and actually bring up some of her concerns. That was a big piece too, of sometimes feeling like I don't know if it's my place to bring up some of these concerns, but where we can help with that explanation of what's going on, not just from a behavioral but from a nervous system perspective, and increase their knowledge of what to do, build that toolbox up again can be really empowering for for teachers who are feeling like this is a different classroom than I stepped into 30 years ago. Jayson Davies Yeah, one on one can be so impactful. I'm wondering if you think that if you had met with, assuming that there are other kindergarten classrooms at that school, do you think you could have had similar impact if you met with all two or three of the kindergarten teachers at the same time? Courtney Boitano Absolutely, because I think that also builds a sense of comradery. I mean, hopefully they already have that sense of camaraderie amongst themselves, but really gives that opportunity for them to to use each other to to build off each other strengths, you know, they know the school system, they know the administrators, so to really get some of those conversations going about, you know, how they could even advocate as the kindergarten team, right, or the first grade team, or whatever it might be, Jayson Davies yeah. Yeah, I just think that's a way that you can, it can be difficult to talk to three, four, or five different teachers, time consuming, but yeah, if you can meet with all the kindergarten teachers at once, maybe even K and one, if they're having similar concerns, or at least maybe TK and K, like that can save you some time and help more people all at the same time, so for sure, very cool. Courtney Boitano Yeah, I love trying to go to their team level meetings, like a number of, you know, will get out early one day a week for collaboration, and then they'll break into, like, they'll have maybe a faculty meeting, and then break into their team level meetings, and so I'll try to go to, like, whatever is kind of top of mind that I know they're needing some support, and even just listen, you know, maybe some weeks I'm not saying anything, and I can, you know, get some charting done, but, but just hearing what's going on, right, and it just also builds that that sense of community, and being being someone who's on their team too. Jayson Davies Yeah, yeah, that's important, having someone on your team. So, all right, Courtney, I think that is going to wrap us up. We talked a lot, and we did not get to dive into every single detail of your articles, but that's okay. They are available, they're out there on the JOT C to read, and you can access them there. So, thank you all. Thank you, Courtney, so much for your time. I really appreciate it. And thank you all for listening to this episode. Really quickly, Courtney, where is the best place for people to potentially find you if they just want to learn a little bit more about you, about the research you've done, your, you've done, and are doing? Courtney Boitano Yeah, I have a website for my small private practice, OT outside.com and then also, you know, at San Jose State on our website, and it can easily be reached there as well. Jayson Davies Fantastic. And if you are potentially a student listening, San Jose State, you could go there and learn with Courtney and the rest of the staff that they have up there, which are some amazing people. I always enjoy when we get to AOTA and get to see some of my San Jose State friends, it's always fun. So, Courtney, thank you so much. Really appreciate it. And we'll definitely have to stay in touch, especially when you have new research coming up, perhaps soon. All right. Well, thank you so much. We appreciate it. Courtney Boitano Thank you. Jayson Davies Well, Courtney, I want to say thank you one more time for joining us today and sharing your research on MTSS, as well as how you actually implement these sensory interventions in practice. Your work at San Jose State, as well as in the schools, is helping us to understand how to make MTSS more sustainable and impactful, especially through teacher consultation, which, as you shared, can sometimes be a little difficult to prioritize, as well as implementing, so thank you for that. Really helpful. Now, I don't think I've mentioned this quite yet. I usually do, but be sure to find all the links that we referred to in this episode in the show notes, like the SDQ and the zones of regulation at ots.com/episode 203203 203203 and if you want to dive even further into implementing MTSS within your schools, building consultation skills, and getting support from a community of school-based OT practitioners like us, who are doing this work right alongside you, I'd love to have you join us inside the OT School houses school-based OT collaborative. There you'll get access to courses, monthly mentorship calls with myself and a supportive community of practitioners navigating the same challenges that you are every single day. Head on over to OT School house.com/collab to learn more about all the resources, mentorship, and CEUs that we have available, and join us in the community. Thanks again, Courtney. Really appreciate you being here, and also thank you for listening. Until next time, keep making a difference in the lives of your students, and yeah, we'll catch you in episode 204 Amazing Narrator Thank you for listening to the OT School House podcast. For more ways to help you and your students succeed right now. Head on over to OT School house.com Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 202 of the OT Schoolhouse Podcast. Are you still relying on the Peabody or BOT as your go-to assessment? You're not alone, but you might be missing something critical. In this episode, we dive deep into occupation-based assessment with Dr. Alysha Skuthan and Dr. Erin Gaby, who recently published groundbreaking research on the occupational profile in school-based practice. This conversation is for every school-based OT who has ever wondered: What actually makes an assessment occupation-based? Why does the occupational profile matter? And how can I fit it into my already overwhelming workload? The research reveals surprising findings from their research showing that 35% of school-based OTs don't complete occupational profiles, despite it being a formal requirement in the Occupational Therapy Practice Framework. You'll hear practical strategies for collecting occupational profiles, honest talk about barriers like time constraints and parent communication, and compelling reasons why using occupational language in your reports matters for advocacy. Plus, they discuss occupation-based alternatives to common standardized tests and share their favorite tools like the School Function Assessment. Listen to learn how shifting to occupation-based practice can transform not just your assessments, but your entire intervention approach. Learning Objectives — Learners will identify the key characteristics that distinguish occupation-based assessments from skill-based assessments — Learners will recognize why the occupational profile is an important component of every SBOT evaluation — Learners will identify the importance of using occupational language in evaluation reports for professional advocacy Guest Bio Alysha Skuthan, PhD, OTR/L, CWHS is the capstone advisor and an adjunct assistant professor in the Post-Professional Occupational Therapy Program at Shenandoah University where she facilitates doctoral research and academic writing. As a pediatric occupational therapist of 11 years, she prioritizes occupational engagement through occupation-based practice and family centered care. She is well published with over 18 peer reviewed publications, more than 40 poster presentations, and an AJOT Authors & Issues Webinar: Session 39. She graduated from Nova Southeastern University and the University of Florida. Erin Gaby, ppOTD, OTR/L, BCP earned her entry-level Master of Science in Occupational Therapy from Milligan College in 2006. Since 2007, she has worked within the Greene County TN Public School System, where she has spent the past 19 years supporting students and school communities through occupational therapy services. In 2023, Erin obtained board certification in pediatrics through American Occupational Therapy Association. She further advanced her education by completing her post-professional Doctorate in Occupational Therapy from Shenandoah University in 2025. Quotes "We are occupational therapists. Occupation is what gives us our skill. That's our special sauce because nobody else is an occupational therapist but us." — Alysha Skuthan, PhD, OTR/L, CWHS
"If we aren't using occupational language, then no one else is. We as OTs are our own worst enemies because if we're not advocating for our profession, nobody else is going to know." — Erin Gaby, ppOTD, OTR/L, BCP
"If we want to have therapeutic benefit, we have to have that rapport. And it starts with finding out what do they like? What's important to them?" — Erin Gaby, ppOTD, OTR/L, BCP "The occupational profile allows me to facilitate participation with the kid, that active engagement, which is so essential in therapy." — Alysha Skuthan, PhD, OTR/L, CWHS "I've never regretted picking up the phone and calling a parent. I have regretted not picking up the phone and calling a parent." — Jayson Davies, M.A., OTR/L Resources 👉AOTA Occupational Therapy Practice Framework, 4th Edition
👉 School Function Assessment (SFA)
👉Pediatric Evaluation of Diability Inventory Computer Adaptive Test (PEDI)
👉OT Schoolhouse Occupational Profile Template
👉Integration of the occupational profile in school-based occupational therapy evaluations: A mixed methods survey
👉Dr. Wendy Stav
👉Bruininks-Oseretsky Test of Motor Proficiency(BOT)
👉Beery Visual Motor Integration (VMI)
👉Miller Function & Participation Scales (M-FUN)
👉Goal-Oriented Assessment of Lifeskills (GOAL)
👉Print Tool — Occupation-based handwriting assessment
👉Evaluation Tool of Children's Handwriting (ETCH) Episode Transcript Expand to view episode transcript Jayson Davies Are you skipping the occupational profile during your evaluations because maybe they take too long? If so, you are not alone. We're going to talk about that research in just a moment. However, you might be missing one of the key pieces to your evaluation that AOTA actually requires. Welcome to the OT School House podcast, where we dive deep into school-based occupational therapy practice. I'm your host, Jayson Davies, an OT practitioner with over a decade in school-based OT experience. Today, I'm joined by two incredible OT practitioners, Dr. Alysha Skuthan, a faculty member at Shenandoah University and a leading researcher in occupation-based assessments, as well as Erin Gaby, a school-based OT practitioner with 19 years of experience, who recently completed her post-professional doctorate, which, of course, we'll be discussing right now. Together, Erin and Alicia published research revealing that over a third of us school-based OTs aren't completing occupational profiles during our evaluations, and that is despite it being a formal requirement within the occupational therapy practice framework that document we call the OTPF. In this conversation, we are going to break down what actually makes an assessment occupation-based, why the occupational profile matters more than you might think, and practical strategies for fitting it into your already overwhelming workload. So, if you've ever wondered if conducting an occupational profile is really necessary, or how to conduct it in an efficient manner, or maybe even how to incorporate it in your real report that you have to write for that IEP. Today's episode is for you, and if you already know all that, well, stay tuned anyways, because we're going to talk about how this occupational profile can actually guide which assessment tools you use later in your evaluation. Let's dive in with Erin and Alysha. 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 Erin and Alysha, welcome to the OT School House podcast. I hope you are having a fantastic afternoon, and I want to start off with just a really fun question, and you know what, Alysha, we'll start with you. What was the first assessment tool you ever remember using in your school-based OT practice? Alysha Skuthan Oh my gosh, I was ill prepared. Jayson, no, I'm just gotcha. I think, right? I think, honestly, probably the first tool I ever remember in schools was the PD, or no, yeah, I think it was the PD. Jayson Davies the PD. Alysha Skuthan Yep. Jayson Davies all right. And you know, we're going to start talking about some occupation-based assessments here in a moment, and maybe that one will come back up. But I also want to throw it over to Erin really quickly. And for you, the same question, what was the first school-based OT assessment tool that you recall using? Erin Gaby I would say it was probably either the Peabody or the Berry Visual Motor Integration, that's probably what I was shown first when I first started. So. Jayson Davies that's very common, right? Especially the Peabody, that's a common one. So now I want to throw it to whoever wants to respond first to this one. Is that an occupation-based assessment tool? Erin Gaby No. Jayson Davies Perfect. That should be the answer. I think that's the answer for most of us. I think a lot of people would have responded with the Peabody as well. The PD might be out there, the bot, whether it's the two, the three, whatever iteration that was out there when they came in the SPM sensor profile, right, those are very common assessment tools that we get to know in our first few days as a school-based occupational therapist. But today we are here to talk about occupation-based assessments, and let's dive in. And I really want to start with you, Alicia. What does it even mean to be an occupation-based assessment, like we throw this term or word, we also say don't use jargon, and this is obviously a jargon-filled word. What does it mean? Alysha Skuthan Right? Great question. So, I think it's so it can be so muddled, but yet it should be so clear, because we are occupational therapists, right now. I try to explain to my husband, who's not an OT, and he goes, yeah, occupation, you use occupy, I go, yeah, can you elaborate, you got it after all these years, he goes, maybe, right, so it's just it's one of those terms that can be so nuanced, but when we think more about occupation based, I think the key is to prioritize occupation as the focal point in what we do, right, so that is what gives us our skill that's our special sauce, because nobody else is an occupational therapist, but us, right? So that's why it's intended to be infused in what we do. So, how can we incorporate occupation at the core through the lens when we do assessments, when we do our treatments, and when we do interventions? So, occupation-based practice is really at the forefront. Prioritizing occupations instead of more of the rote skill type practice, which might be, oh, stack these blocks, oh, write your name, oh, do this. It's looking more holistically that top-down approach for what are the occupational challenges that the child might be experiencing when we're in schools, and how can I best facilitate that type of progression versus only writing a name, only doing a button, only you know, looking more specific at the skills, occupations more holistic, looking top down at overall, what are they able to do, are they able to engage in their everyday routines in school, what does that look like, what are those overall occupation-based implications? Jayson Davies Gotcha, and okay, you kind of answered this already, but I'm gonna, I'm gonna go a little bit further. I'm gonna press if a school-based occupational therapist, your practitioner, right, is listening. Like, I just want to be able, in 10 seconds, to recognize if this assessment tool that I use 300 times a year is occupation-based, is there a quick question that they can ask themselves? Alysha Skuthan I think, yeah, I think it's what goals do you create, right? So, I think it's, and when we have something like Aaron mentioned, the Peabody, right, it can be very specific, like I'm making a goal for them to build VMI, I'm making a goal specifically to improve fine motor, whatever that might mean, right, versus I have an assessment like the SFA, where it's looking holistically at their performance within schools. My goals are going to be more related to their participation, they're going to be related to more of their academic performance, they're going to be related to larger scale contexts, which are the occupations that we want to dive into when we're doing these more specific assessments. I'm not saying there's not a place, but it's not occupation based in the same way I think that we're trying to do occupation based practice when we push in in the classroom, when we're in that academic setting, it lends itself to occupation, but yet sometimes those assessment tools that are so rote, we've done them so many times, fall into that skill based assessment, and we miss out on the overall occupation. Jayson Davies Man, I wish we could all talk about occupation the way that you do. That would be fantastic. Alysha Skuthan Thanks. I'm a little obsessed, so it's a problem, but I'm willing to admit I have a problem. Jayson Davies It all starts with understanding that part, right? Alysha Skuthan Right. Jayson Davies Okay. Now you have been completing this work for some time, and we're going to dive into Aaron's work, specifically about the occupational profile in just a moment, but this is to a degree a piece of your larger project where you are really trying to support OT practitioners to be occupation-based, not just in assessments, but in general, and I just want to hear from you, like, a where that started, and kind of be where it is now. Alysha Skuthan Yeah, great question. I appreciate that you're calling me old. I'll take it. It's okay, but I have to first give to it's fine. It's fine. Dr. Wendy Stav, she's phenomenal, fantastic. She was my mentor back when I was getting my PhD, and she opened up my eyes to I identified occupation was not happening with what I was seeing in pediatric practice, but she helped paint the picture of, oh my gosh, it's actually lack of occupation-based practice, and that was my light bulb moment of a, I am sick and tired of doing the Peabody, I am not going to do it again, these goals, if I see one more goal for stacking blocks from a level two field work student who comes in, or from an assessment I'm given when I collect a patient from somebody else. Right, we all share them. It was just.. I was done. I was tired of seeing it. I'm like, what? What makes me skilled, right? If there's.. if somebody else can come in, a developmental specialist, and say, okay, these are the results if I was doing EI of this limitation developmentally here. What makes me unique as an occupational therapist. So it just was a lot of reflection, and I go, "Oh, wow, you know, I think I missed out when I was first practicing on this concept of occupation, because I was so focused on getting that insurance check mark, getting my billing taken care of, that I didn't take a step back and reflect on, am I actually doing occupational therapy or am I doing skill-based supports that don't require this OT lens that we grow and we acquire during our time in clinic, clinical practice, and back in schools. So, it led me to my dissertation, and that came in several publications, and I've been grateful to continue working on that. But my one of my biggest studies came out in age ot 24 no, 24 I don't know what year it was, 2021 I think it was 2021 maybe, maybe 22 My son was born like it's a model, but it came out in a jot, and I really dove into, okay, what are OTs out there using, especially pediatric wise? Am I right? Is it really the Peabody? Is it really the bot, or am I? Is it something where there are other assessments I'm not familiar with, because I'm still growing. We're all learning every day as OTs, right? So I wanted to take a big scale approach and quantitatively explore what's out there. Do people know what occupation-based assessments are, and if so, why not? What does that look like? So then I did a qual study where I dove more specific. Into what that implicates for practice when they do pick occupation-based assessment tools, and then it's just spiral from there. So it's just a continuation of how else can I look at this occupation-based assessment component and highlight, okay, there is a problem, but what can we do to kind of fix that problem and help us as a profession use occupation intentionally, beginning at that assessment piece. Jayson Davies Okay, I've gotta, I've gotta ask this follow-up, because I can, I can hear people screaming at me. You mentioned, like, what are the outcomes of using an occupation-based assessment? I believe you would, where you would go forward from that is the actual intervention itself. Before you mentioned that, I was going to ask, like, what is the problem with non-occupation-based assessments, like, you know, the Peabody BD and the Bot Three, but let's go with the more, I think, positive kind of the direction you were going, and why is, how does it help us down the road? Alysha Skuthan I think it changes our perspective, right, so when we pick the skill-based assessments again, there's a time and place. If a kiddo comes in and they're having really specific visual motor integration, great, pop out the beery, fine tune, facilitate, but yet when we get those specific skills, what is our overall goal here? We want to make sure we have the translation and the application to the occupation, because that's our job, right? We can practice and say, okay, yes, this kiddo can now do a puzzle. Great. So, what, right? So, for me, and when I, you know, did some of these studies and things, when therapists intentionally use occupation-based assessments, it was very common that they said their perspective shifted, so occupation remained the focus, and depending on their setting, when it was school-based, it was that collaboration with the teacher and really intentionally integrating into the classroom and that child's routine, right? So that way the occupational focus could be embedded into the appropriate contextual facet, whatever that would be for that particular child. And when I talked to outpatient clinicians, I saw that the therapist who did and were intentional about it really focused on the caregivers, right, rather than them being the OT end all be all. You got to come see me, I'm going to give you the supports. It was a how can I shift my perspective through parent coaching and modeling through this occupation lens? Because that kiddo is with that parent way more than I'm with them. So how can I facilitate the occupational engagement when I'm not here? Right, it's just it's just that mindset shift. So interventions tend to look more occupation-based versus a here's a worksheet, right? Try this grip, try this whatever specific tool that would be more skill in nature, and instead can be okay. The occupation, the problem is that this child can't sustain attention in the classroom. It's not that they can't write right, they have that component, but how can I tie in handwriting within this overall occupation to promote the attention, to promote the participation in the classroom, which is the occupation that we're looking at there. Jayson Davies Absolutely, and part of being an occupation-based practitioner is using an occupational profile. Cue the segue over to Erin. This is perfect, because I, I use an occupational profile. One of the things that at the OT schoolhouse we did years ago is we actually kind of adapted a OTs version of an occupational profile kind of to fit the school needs, because it's a very different environment, and we needed something, you know, specific to our environment. That said, I never thought about it really as an assessment piece, like for me it was just kind of this knowledge background, right, like getting to understand. So, Aaron, I want to kind of jump over to you here and kind of say, or ask, what was your hypothesis, and why address the occupation profile when it is very well established in the OTPF? It's something that I think we all learn about in OT school, so why was it necessary to kind of dive into it further? Erin Gaby So I've been an occupational therapist in a school setting for 19 years, and so I've seen a lot of OT evaluations like come across my desk, and I started noticing that I was not seeing that section that said occupational profile, and I remember one specifically that I got from another therapist that was actually it was working in our district but not on staff, and there was like two sentences at the start of the report, and then it just jumped right into like a visual motor test, and I kept thinking, I just really want to know, like, what does this student like, like, what's their favorite toy, or what's their favorite thing to do, and I wasn't seeing any of that, and so it just made me really want to explore, is it just these that I. Seeing, or is this going on in other places as well? Like, is it just me, or is it a practice issue? Jayson Davies Yeah, absolutely. To follow up on that, right, you brought up some questions that are in our occupational profile, like, you know, what does the kid enjoy, where what are their routines, you know, what client, what type of environment does their classroom look like? I know that's part of the occupation profile as well, but I'm going to be honest, I think when we're asking these questions to a teacher or a parent as a school-based therapist, what is your kid's favorite toys? What are their TV shows? What do they enjoy? What do they not enjoy? I sometimes wonder, like, are they like wondering why are we even asking these questions, so like I guess for us, as though as a profession, like why is that so important before we dive into the VMI or a different tool, Erin Gaby right? It's, I mean, I feel like a lot of it's about intrinsic motivation, like I really need to develop a rapport with that student. If we want to have, you know, a therapeutic benefit, we have to have that rapport, and so it starts, I feel like, with finding out, you know, what do they like, what's important to them, what works well for them, because we can use that, you know, to our, to help us, you know, like help that student. Alysha Skuthan I think it's definitely like you said, Erin, participation over compliance. I know that's a buzzword that kind of pops up lately, but yes, totally agree. Jayson Davies Yeah, yeah. For me, one of the reasons that I key in on occupational profiles so early on in my assessments is because I feel like it can guide me through the rest of my evaluation process, not only the rapport that we're able to build with not even just the student, the teacher, and the parent through the occupational profile, but also feel like it guides me because if I don't understand the real concerns from all the different parties, then how am I supposed to know where to go with my actual evaluation? Does that resonate with either of you? Erin Gaby Yes, absolutely. I mean, I feel like in the school setting, especially like when you're working with children in general, it's not just that child that you're working with, I mean, there's parents, there's teachers, there's classroom assistants, there's other therapists, I mean, it's, it's a huge team, and so it's so important to get, you know, all that perspective for sure. Jayson Davies Great. All right. Well, we take a very quick break. When we come back, we're going to dive back in with Aaron to discuss the components of an occupational profile, and also why some of us use it, but don't say we're using it. So, stay tuned. All right, we're back. Erin, you mentioned a few different components of it. We talked, you know, about rapport, participation. What are some of the key components to an occupation, occupational profile, especially when we're using it inside of the school-based realm. What do we want to collect? Erin Gaby I think we start with kind of the things that people traditionally think about, where you're trying to find out, is there, you know, medical history or their, you know, family history, you know, experiences that they've had, have they already had special education services before, any school therapies already previously, you know, or outpatient therapies. But then it goes, you know, we expand that and start looking more at the environment, like what are some supports that that child already has in place that could help them, and then also, what are some of those barriers or things that they don't have in place right now? Just like one example might be even like insurance or family supports in place, you know, what is their family life like? You know, is the parent working, you know, things like that. I mean, all those things that I think we, as OTs, consider, and we look at those details, even though others may see, like, you know, they may not understand why we're looking at those specific details, but then finding out, you know, what is that occupation of concern in the school setting, asking the teachers, you know, asking the student when you can, and asking the family, you know, what are your concerns? So. Jayson Davies Yeah, no, I think that's true. I always like to get as many people as I can to tell me both whatever the concerns might be, as well as, you know, what they view as the student's strengths, and so that way the more information that we have, it's data, the more data we have to then continue on with either the rest of our evaluation, eventually our actual recommendation synopsis, and then our intervention. So it absolutely does help you mentioned a report once upon a time, right, having two sentences. About the student in the ideal world, what does an occupational profile look like on an evaluation from your perspective? Erin Gaby I guess just going based on like how I've done my own is it's just the very first thing that I start with on my evaluation template, it's it's the very first page and I just go through, I usually start, you know, with the background information that I have, and then, you know, having that section on what are that child's strengths, and then a section of what are the challenges currently, and really that section is very key, because you're finding out right there in that moment what is the occupation of concern, and that you said it kind of guides you for the whole rest of the evaluation process. Jayson Davies Yeah, Alysha, what about you? Is there anything in particular that you really like to use in your evaluations? Alysha Skuthan I mean, I think it's intentional. I feel like the occupational profile can be conceptualized with intentional questions, right? Just kind of really looking in the moment, seeing the response of the child again, if applicable, right? If the kiddo can participate, and then diving into the additional personnel, but tailoring what I ask, so I can create that comprehensive perspective. But I always want to know what the kid likes, right? I always want to prioritize that on there, what they don't like, because if I come in with a bluey worksheet and it's going to be a mass hysteria panic meltdown, let me avoid that, right? Like, let's use our questions, so we can create a beneficial session for the children and for the whole team, right? And I know I mentioned before briefly, but I think the occupational profile allows me to facilitate participation with the kid that active engagement, which is so essential in therapy, by looking at the environment, knowing the parents' background, knowing the kiddos' background, right, more specifically outside of just the OT assessment results, right, or whatever assessments we end up selecting in that in that timeline, in that process. So, I think for me, the like session section is most important to paint that whole perspective, so if Erin's out of town, I can take over her, you know, caseload for the week, and I'm able to jump in where she left off. Jayson Davies Yeah, awesome. Thank you. Now, Erin, diving a little bit deeper into your, your actual work, Alicia, your work as well, you guys are co-authors on this work, you had some interesting findings: a) not everyone's using an occupational profile, and b) as I kind of hinted earlier, some people are using an occupational profile to a degree, but not calling it that. Let's start with the first part of that, and let's break that down. Why do you cited 65% of participants are completing an occupation or profile? I just kind of like, okay, well, that means reverse math, right? Did the math the opposite way. 35% of us are not conducting an occupation or profile. Let's first start with maybe the why. Did you glean any as to any reasons as to why it might not be being used? Alysha Skuthan I think, based on, you know, the results and things, why people don't use it, there were several factors that were listed, right, when we looked at all the themes from the responses that we gathered from participants, and one of the factors that I found most interesting was that the therapists themselves were a factor, right? One therapy, one participant, she said, you know, verbatim, I've never heard the term occupational profile before. Today, I graduated OT school in 1988 and I go, 'Whoa, okay. Like, as I'm reading, I'm going, 'Okay, like, I appreciate the honesty, and I'm so glad that people were reflective in that moment, right? That maybe it's something that they might not remember it from OT school, or maybe you know things have shifted obviously in the past. What would that be, x number of years, right? So I think that the therapist themselves can sometimes be barriers, because we're not required to take a CEU on the occupational profile to be practicing, right? We have to maintain up-to-date and evidence, but again, that's an opportunity for our profession to say, well, what does that need to be, so we can create that consistency, time constraints, workload, like my caseload is too busy, I don't have time to add this occupational profile to an already busy, we all know what IEP season looks like, right? We get it, right, but that was a common barrier listed, sometimes they would say lack of space or access to caregivers to parents to kind of get that again, that holistic perspective to support that profile. Right, I mean, I remember where I well write the note home to parent, you hope you get a response right. Obviously, we can use email communication, other methods, but I distinctly remember towards the beginning of my career I would send home a note and then never hear. I'm like, that's great, great communication, right? So I understand, right? Jayson Davies I want to ask you on that. I want to ask you on that really quickly, because that happens a lot, right? We send home a flyer in the backpack, or a question on the backpack, we hope we get it back. We send home an email, hope we get it back. Sometimes the email just initially, or it just comes back, like this email does not exist, it happens, or. We just can't get in touch with the parent. Do you allude to that in your report? If something like that happens. Alysha Skuthan Do we, Erin, talk? I know we mentioned that as something that the therapist indicated that they don't do, but I think it wasn't really the results of our study where it gleaned on what to do next. I think that'd be a little bit outside of the scope of just the study results, but as far as if you're asking, you know, clinically or my perspective on it, I feel like it's our job to get to know the family outside of only IEP season, so creating that intentional involvement, whatever that might mean, right? And Erin, feel free to jump in with what you think that might look like as well, of course. Erin Gaby Just when you were mentioned to you about the do you include that like in the report, I don't, I had read a school psychology report, actually just today, where she had noted, she said I, you know, reached out to the parents or by phone and received no answer, and she had actually typed that into the school psychology report, so. Jayson Davies Yeah, I've seen that too, and I think it was after I saw it in a school psych report that I was like, should I be doing this, and you know, I'm not saying it's in regular practice of mine that I put that into the report, but we all have cases where we know that something might go to trial and might be reviewed by others, and I go back and forth as to whether or not that helps hurt or does nothing for our evaluation, like it's kind of like throwing someone under a bus, but at the same time, if you don't put it in, then you get back to the whole if it's not documented, it never happened type of thing, and so if it's not documented that you tried to reach out to the parent, then it's not, yeah, so sorry to throw you both on the spot there, but like I think it's just something, it's one of those things that comes up, and we each have to kind of figure out what we're going to do in that case. Alysha Skuthan Agreed, and I think you're fine, throws on the spot, we don't mind, but maybe Erin. Hey, no, I'm kidding, but we're good. I think it's important we have to document it right. If we don't have that opportunity, then who else can we lean on here? Right, who else in the scope of the child's everyday participation in school can we then ask to facilitate what this occupational profile needs to include? But I think if we don't document it, then that can cause us to be in an ideal situation as we progress into, you know, our trajectory within the care for that child. Erin Gaby It kind of gets to circle back around, it could kind of just contributes to that occupational profile, because you're thinking, oh, okay, so maybe this child, you know, doesn't have maybe the same parent support in place, and that's being very judgey. I don't, I'm not trying to judge, just it's just something like a thought that might be something that you. Jayson Davies Makes you wonder. Erin Gaby Yeah. Jayson Davies Yeah, and maybe you follow up again, or you try, and I mean it's hard. Not every occupational therapy practitioner can can go to, like, back to school night and track parents down, or anything like that, but you know it's nice if we can be visible, and at least, like, it's nice to be able to put a face with a with a name and a parental face with a child face, and like, these two go together, and yeah, that's hard when you have 100 kids, I get it, teachers have 30, and it's hard for them, but you know we try, we try our best. So, all right. Alysha Skuthan as we can. Jayson Davies What were your initial reactions when you heard that 65% use an occupational profile, obviously alluding to 35% don't? I don't know which one of you was actually the first to see that data point, Alysha Skuthan that would be Erin. Jayson Davies Yeah, do you remember that moment? Erin Gaby Well, it's like we, where we use the Google form, it automatically made these cute little pie charts, the data charts. So I was a little, I'm kind of a nerd, but I was a little obsessed with, like, I would go in and check and see every time somebody was surveyed, I could say, oh, you know, you would see the pie chart shifting. Jayson Davies Yeah, yeah, I do the same. Erin Gaby Though. Yeah, but it's.. it's one of those things. Sadly, in some ways, I wasn't surprised. If that makes sense, I guess, just based on what I had seen on the reports I had reviewed before of OT evaluations, so I wasn't super surprised, but also it did is a little disheartening, I guess. Maybe. Jayson Davies Yeah. Erin Gaby To see that. Jayson Davies Yeah. Alysha Skuthan I thought it was going to be lower, to be honest. Jayson Davies Oh, really? Alysha Skuthan I did, yeah, because I think there's not the intentionality with integrating that particular phrasing on the assessment, so it might just be the perspective of, okay, you know, actually I might be doing components of the occupational profile, which likely does happen, right? And that's a limitation we talked about, was we weren't there, you know, explaining or there in moment, it was a survey, right, and so I think that there might be some. Participants potentially out there who are doing components of the profile, but it's just not through the lens of a comprehensive occupational profile. So, I was expecting it to be lower, just because I know the language isn't always available. As Aaron said, it's not something I see often. Jayson Davies Gotcha, gotcha. And, as we kind of alluded to earlier, some people use an occupation profile, but maybe don't call it that. Before we dive into the details of that, were those people included in the 65% who do, or the 35% who don't? I know it's been a little while since you looked at the numbers, but how would that, would that go? Erin Gaby I think the way we worked with the question was, it was just that, do you, com, you know, do you complete an occupational profile as a part of your evaluation? So it wasn't just, we didn't specifically ask, do you complete components of it, we just kind of asked in general, but then in the qualitative data people, some of the participant comments specifically would state, oh, well, I use components of it, but just not formally. You said. Jayson Davies Gotcha. Okay, that makes sense. So then let's talk about, did anyone share with you what they called it, instead of an occupational profile If they put it on their evaluation? Erin Gaby I think some of it fell under what you would consider like a background section, like background slash history section. Some people commented that they did that instead. Jayson Davies Okay, no, I think that's fair. I mean, like, for a long time I did have it, was just background that was the evaluation wording that you know was passed on to me from the OT practitioners before, and even if I had created, I probably would have thought to do the same thing, because we're not trying to use jargon, potentially. However, as occupational therapists, occupation is very key to what we do, and so I also see the value of being forward with it and making this our occupational profile and putting it as you kind of alluded to Aaron, like right there, front page occupational profile, boom, here it is, trying to try to figure out how to phrase this, but I guess, where do you both fall, and I'll let you both answer this one, like where do you fall on kind of the reason, or the reason not to call it occupational profile in our actual evaluation report. I don't know. I'll let you, whoever wants to speak up first. Alysha Skuthan Well, rock, paper, scissors. No, I'm kidding. Do you want to go ahead? Me, okay? I think it needs to be there, right? I mean, we are occupation, obviously. I'm very biased with my perspective on the importance of occupation, but. Jayson Davies Not at all. Alysha Skuthan If we, if we don't, not at all, right? Ha ha. But if it's not on there, then we don't have the opportunity to educate and to further reinforce the nuances and the beautiful thing that makes our profession what it is, right? So I think if there's a concern for therapists out there that it might be jargony. Okay, add a sentence that defines what it is, right? Give it - I'm not saying the whole OTPF definition, but give little components and say this is the background information to facilitate, or to, you know, allow us to do our therapy sessions, whatever we want to do to simplify, remove the medical air quote jargon, right? I include it, I think it should be there. Jayson Davies Yeah, and Erin, you, you already talked about, you put it on your first page. Do you call it occupational profile? Erin Gaby I do. In one of the references that we used in our publication talked about the importance, like, if with occupation-centered practice, is that you use that occupational language, and not only your words, your verbal words, but in your written language as well. And so I thought this is perfect example. Your OT evaluation report is that written language, and it's just two words, but it's so impactful, and I don't know why we're so hesitant, I guess, to use that language, because if we aren't using it, then no one else is, and if I could go on and on, this is kind of.. I could get on. Jayson Davies Advocacy here. Erin Gaby You know? If sometimes I think we, as OTs, are our own worst enemies, because if we're not advocating for our profession, nobody else is going to know. I mean, if other OTs don't know, then we can't expect, like, our teachers and parents and other school team members to understand that. Jayson Davies Yeah, I completely agree with that. I, there have been times, and I always talk about having in a while, but I often talk about using the IEP as a platform to advocate, like we get our 10 minutes of fame at the table in the IEP, and like everybody has to shut up and listen to us, and you know that is a great opportunity to say, hey, here's. My report. Here's my template. Yes, the first two words you see on their occupational therapy, right into that, you see occupational profile. Let me tell you what an occupational profile is. And here is, here's what I have learned about your student through, you know, all the important people in his or her life, and I think that is a great way to to advocate for our profession, while not being like overly like it's not like blunt in your face. Like, let me share with you what occupation means. Like, it's a nice little way to do it. So, yeah, I agree. I'm on board with that. All right. The occupation, though, DPF, the Occupational Therapy Practice Framework Number Four: list out three steps, basically, for an evaluation has to include three steps. In my opinion, it should be more. I go in depth in that in other places, but three steps: occupation or profile, basically an assessment of the skills of the client, and then a recommendations, essentially like a summary recap and recommendations synthesis is actually the word I believe they use. Number one is occupational profile. Does that mean that it is required in our evaluations? Erin Gaby Yes. Alysha Skuthan Yes. There's literature, it shows yes. Erin Gaby And I even look at, I mean, the the OT practice framework. The first edition was released in 2002 and so this is not a new thing now. Granted, before that was the uniform terminology, and you know that was something different. So, if you graduated during that time period, you know, maybe that's one thing, but this is, you know, any graduate has graduated since 2002 should have had that awareness, I guess. Jayson Davies Yeah, and a little bit of a follow-up, because the OTPF is not a researched paper, right? Like, it's not like someone went out and did research and then said, okay, you know, an occupational profile has been shown to be, you know, lead to occupation-based services and all that good stuff. So, Alicia, I want to come to you, because I think you're probably the one to have done some research on that. Like, where did the idea of an occupational profile actually come from? Because, yes, it's mentioned in the OTPF, but where did it originate? You, do you have that knowledge. Alysha Skuthan No. Jayson Davies No? Alysha Skuthan I don't. I know it's on OTPF, right? And I know the components that go into it. I know I facilitate it with my students, right? and the client children I work with, but I don't know where that specific phrase originated from. I wish I did. Jayson Davies We'll have to look into that. That'll be part two. All right. Alysha Skuthan let's do it. Jayson Davies If I were to ask you this, what makes occupation-based practice, or what is the research behind occupation-based practice as improving, you know, client outcomes? What would the response to that be? Alysha Skuthan So occupation-based practice and client outcomes, I would say that literature base is continuing to grow, and I'm working on it, but I don't think there's anything specific that states, you know, okay, occupation-based practice, you can't prove anything, right, causation, it doesn't have correlation does not prove causation, right, but there is a, there are a lot, there is a lot of information out there on I'm part of this occupation-based forum. This group, we have a whole website, we are saying, yay, occupation, because it's needed, and there's a growing body of literature and evidence in there where we're doing clinical trials, and we've gone in and we've given occupation-based tools, and we say, okay, clinic, now go for it, see how your practice changes, and there are positive outcomes reported by clients, by caregivers, by therapists. There is growing data out there to support the influence of intentionally using occupation-based practice and facilitating positive outcomes, but it's growing. It's not as if occupation is a new concept yet. In the literature, in the research, we still have a lot of work to do. Jayson Davies That is a very important, important point, because I was just gonna say, you know, whenever we think about learning about the history of occupational therapy, right, we go back to the wars, right, and talking about how soldiers were coming back and getting occupational therapy, and a lot of it was very arts and crafts, and, and like these, these little occupations that help people to improve, but that was before the age of everything needs to be research-based, and we're in that age now, and so just because something doesn't have research behind it from the 20s, 30s, 4060s all the way up until like now, right, doesn't necessarily mean that it is not an established practice that has shown benefit. It just means that maybe there isn't research behind it. Alysha Skuthan I would say not behind, you know, it 100% meaning okay, you. Assessment, then do this intervention, and you get this exact outcome right. And I think there will always be variability in it, because every therapist brings their unique therapeutic use of self to the situation, and every client, in our case, children, students, it's going to be different, right? But I think it's important for all of us to just reflect on, and I'm going to sound.. I guess I don't know, whatever. Have you to think about the theory, to think about the model that we are using to kind of guide what we're doing? Right, are we intending to focus only biomechanically? I see a deficit, I'm going to facilitate a deficit, or can we take something like the dynamic model of occupation-based practice? Right, can we take something where it intentionally allows us to prioritize occupation by saying, okay, this is my framework, I'm coming in as the OT, I'm here to look at your occupations and how can I facilitate your engagement in occupations, that's why I'm here, right, that's that's my job, versus thinking about it, where, okay, I'm only looking more specifically at this particular deficit and how I can facilitate it, right, and there are other models out there too, of course, right, and we can argue how they can influence the occupation-based practice, but I think it comes about intentionally selecting a theory or a model, and that allows us to guide our occupational profile, right, thanks AOT for developing that, it allows us to, you know, take those next steps in that practice trajectory. Jayson Davies Yeah, it's so interesting. It's so interesting how things come to be in this world, and you know, like our profession is called occupational therapy for a reason, and there have been debates on that, right, on the name and our choice of name, and how that impacts us one way or the other as a profession, but we have always used occupation as a means, as an end, and it has kind of driven the way that our profession has moved forward. So, yeah, no, I like that, and yeah, it absolutely leads right then to that occupational profile. So, let's come back to your research a little bit here, Alicia. You started to talk about some of the kind of, like, the difficulties of getting an occupational profile together, but I don't know if those came directly from the research or if those were some of the things that you just kind of, you know, have experienced yourself. What did the research, what did that qualitative data that you collected say was difficult for the practitioners to put together an occupational profile? Alysha Skuthan Yeah, absolutely. So the specific ones the therapist identified that they were inhibiting factors themselves, right? Maybe it's a lack of knowledge on their part that was one that was indicated from our qual findings, time constraints, workload, physical lack, or access to parents and caregivers, right, which we've talked about already. Obviously, at this point in time, participants did mention the students themselves, right. So, sometimes students might be non-verbal, right, or it might be where there's a limited opportunity to allow them to be an active part in the acquisition of the information for the occupational profile, and then some participants also mentioned how components of the occupational profile, meaning the overall one, not one that you guys have created that's tailored more to school-based practice, or the ATA one that they also have that's directly, you know, linked to occupation, or excuse me, school-based practice, they participants said it would be too lengthy, or it's considered to be, you know, too long to include this whole overarching occupational profile. Lastly, the last, you know, when participants indicated that they didn't use it, they had said it was because they needed more education on what the occupational profile look like in practice, so that was another limitation that was indicated by the qual studies in our, in our findings. Jayson Davies Gotcha. Okay, and now let's kind of skip to those people who do use it. What did they report as some of the benefits to using the occupational profile? I know I shared a little bit about how it helps to guide my evaluation a little bit, you talked about, like, the rapport building. Anything else? Amazing Narrator you want to say anything, Erin? I feel like I've been talking. I can. I'm happy to keep going. Erin Gaby Some of the comments were about how helpful it was to kind of paint a fuller picture of the child, and another comment, which I really liked was that they mentioned how it picks up some of that information that might be missing that you might miss out on if you just use a standardized assessment, like if that's all you did with the child, you might be missing a lot of that child, but then they must, the comments were very positive of the participants that do use it consistently. They found it was very helpful. Jayson Davies Yeah, yeah, I think that's why we use it. Yeah, so Aaron, I want to ask you this, as a practicing school-based OT practitioner. What are some things that you've done it to make it easier for you to implement it? I mean, we talked about how difficult it can be to get a hold of parents. We've talked about the time constraints and some of the other constraints that people have experienced. What are some little tiny systems or things that you've done just to make it a little bit easier to get the information and put it into your report. Erin Gaby As much as possible, just like communication, just like communication one on one, and if a lot of things kind of all fall back on to just having good basic communication, so for example, if you have a student at school that the team is referring for, you know, like maybe that initial comprehensive assessment, if there are some concerns that they're thinking, "Hey, I might need the occupational therapist, you know, to see this child, you know, including them in that initial meeting when your first meeting to talk with the parent to get that initial consent, like that's an ideal time, if you can be invited to that meeting, you've already got the parent right there. The teachers there, we're all, you know, it's so hard to get everybody together. It feels sometimes like we only meet as a whole team like once a year at the IEP. So if you can get in on that initial meeting, that's a good, I feel like way to start the process. Jayson Davies Yeah, yeah, I agree. Are you, and this is for both of you. Are you pro technology or a little bit kind of, may I prefer to call and send a letter home in the backpack? Erin Gaby I find email has been pretty helpful, or even just a text, I mean, I know sometimes there's that being a little hesitant about like using your, your personal phone number, but it just seems like this parents are more responsive a lot of times I've found just with a text or an email than they are if you just to call them, but. Jayson Davies Yeah, and to be honest, it's really easy to create a Google Voice number and send a text message through a Google Voice number that is that you can delete at any time if things get a little, you know, too needy or personal. Of course, you have to be a little careful with HIPAA and FERPA and all that fun stuff, when you go that route, but yeah, I mean, you kind of have to go with whatever is comfortable for the people that you're trying to get the information from. Anyone use Google Forms or Microsoft Team Forms or anything like that? Alysha Skuthan I have, I will, I think sometimes too, when I'm doing, if I have the chance right to interact with the parents, I'll ask them right as part of my initial, hey, like, how do you like to be contacted? How can I best facilitate this with you? Do you want to text? Do you want me to knock on your door at 3am Like, what can be arranged here? I kid, of course, but I think for the parents who, when I've asked me, they want a phone call, I'm like, okay, great. I'm going to craft this time in my day, because I know that that's what they want to help this particular student, but yeah, I have used Microsoft Teams or Zoom, or whatever might work best in that moment. Jayson Davies Yeah, yeah, okay. So that's the collection of the information. What about when it's actually putting the information into your report, I know we all have a template. Is there certain pieces that you like to put? I mean, do you just basically list occupational profile and then just narrative, narrative, narrative, narrative? Do you try and break it up? Does that make it easier? What have you found just makes it easier to get the information onto the page? Erin Gaby I tend to do narrative format, but that's just my, my preference or my style of writing. But I know one of the participant comments in our study said that they made a chart, and so they just had like this organized chart, which I know on your website, Jayson, you do have that free under your free tools, like the OT profile template, so I really like that. So, even just, you know, a chart, something like that, might be a good way to keep it organized visually. Sometimes that's easier for other team members to, to read. Jayson Davies Yeah, yeah, that's your chart. I mean, everybody uses different tools, right, and a chart can can be helpful. Narrative can be just as helpful. I'm not currently practicing, but if I were today, and if I could figure out a way to basically get the raw data, whether it be from a Google form or just, you know, a paper pencil form, or however, or you know, from a conversation on the phone, I think we could even plug that information de-identified into a chat agent, Chat GPT, or Clot, and say, "Hey, here's all this information, can you just organize it for me into a nice clean narrative? These are there's many ways that this can be done to make it less time. Consuming, because we know that's a barrier, and I mean, honestly, that's probably the biggest barrier, aside from getting the information from people, like that's a barrier too, and I think those are kind of the two main points that we're addressing. Do you ever find, Aaron, that you feel like you forget to ask questions of, you know the teacher or the parent, is there a way that you kind of have it set out in your head or somewhere, or do you just look at the ot file, maybe to kind of remember what to ask, you know, the team. Erin Gaby Sometimes in the moment it is easy to forget things, but just I'm still old fashioned of pen and paper, too, like I said. If it's at the consent meeting, I've got my pen and paper, and I'm like writing down, like, notes, and you know, asking questions. But I do feel, too, after you've met, at least that one time in person, sometimes you'll.. it's a little easier to have that parent or teacher respond back to you, because you've already kind of started to establish that relationship, so it's not like I'm just a random person you've never met, and I'm calling you to ask you about your child, so. Jayson Davies That's important, right? We have to build rapport with the with the parents just as much as we have to build rapport with the student, and yeah, it is so much easier to call someone once you have that face to face, you know, you've shook in their hand, or you've seen them in person, it's a little bit easier to pick up the phone and make the call. I will say, I've never regretted picking up a phone and calling a parent. I have regretted not picking up the phone and calling a parent, especially when you get to that IEP and you just have so much more information versus not having that information, it really does help. Alysha Skuthan Absolutely, it saves a lot of potential confusion or surprises, right? During the meeting, which I know we've all been a part of, and they go, 'What? Like, I have no idea. And you're going, 'Well, you know, this is what's been happening. So, if there's any way to proactively facilitate that update or that exchange of information. Jayson Davies Absolutely, yeah, yeah. Any other, you know, findings that really came out of your research that we haven't discussed today, that is just really important, and it's really something that a school-based OT practitioner should know about. Alysha Skuthan I mean, I think we said it. Please don't be afraid to use the occupational profile, you write as a heading, don't be afraid, don't be afraid. A OTA wants us to write our specific guidelines, they say yes, do it, we can do it. I think that was our biggest finding, is just to support the profession in creating more consistency with that, not only for our students, but also for fellow therapists. Jayson Davies Perfect. Erin Gaby Just sharing the awareness that it is something that we are supposed to be doing. I think that was of our quantitative findings, that was like the biggest, had the largest effect size, was just having did the therapist have that awareness that it was requirement. So this is like another reason, like we're so thankful that you invited us onto this podcast, because it's, it's helping to promote that awareness, and we're really, that's the heart of what you know we need to be doing, so that we're all working towards that more occupation-based practice. Jayson Davies I am just happy to find a pair of OTs who will shout it from the rooftop as much as I will that we need to use an occupation profile, so thank you so much for being here. Because I, gosh, man, I think you know what the very first episode of this entire podcast, episode one, was the evaluation process in school-based OT, and I did not go back and listen to it or read the transcript in preparation for this, but I can almost guarantee you within the first 10 minutes we are talking about collecting an occupational profile, because yeah, like it is like I mentioned, it drives my entire rest of my evaluation, right? Like we have to do assessment tools beyond the occupational profile, but if you don't do the occupational profile, you're at risk of using assessment tools that are just wasting your time and not taking you in the right direction, versus if you took the time to do an occupational profile, you would actually know to go looking for the right assessment tools that are actually going to measure what is important for the student's referral reason, concerns, and strengths. So can't stress it enough. Go do it all right. Well, let's bring this back full circle. Here you all shared with me some tools that you used on day one as a school-based OT practitioner. Now, what is one occupation-based assessment tool that you might use today instead of that one that you used ahead of time, so if I recall, PD, which one of you was using the PD? Alysha, right? Alysha Skuthan That's what I saw first. Yes, today I love the SFA. I love the SFA yeah. Jayson Davies Still asking people if they need to use a floppy disk. Erin Gaby I think they are supposed to be updating. Jayson Davies I agree. Alysha Skuthan They're updating it, they're updating it. But what I love, agreed, agreed, and at least we all know when the floppy disk is, right? Like, let's, let's say no, but I like it because it really, it forces you to look at occupation, right? Yeah, and no matter what, despite the floppy disk, right, there's gonna be a question or two that will allow you to really paint that holistic picture. So that's why I would say the SFA, even though it needs this update. Jayson Davies Agreed. All right, so Erin, I believe you said the Peabody, and maybe one other one, is there a tool that you maybe prefer more now, because it's an occupation-based tool. Erin Gaby I do have, like, the PD, but we have to have a computer adaptive test version, is what it is now, and so it's, it's very simple to use, but that is a good one to use, and because it's for, you know, it crosses a broad span of ages, so from like our young and kids to older kids too. But I am really looking forward. I would love to see the SFA be updated. I hope that happens. Yeah, it's supposed to be. Jayson Davies Yeah. Alysha Skuthan It is. It's supposed to be in the PD. Great, great choice. Jayson Davies Yep. Yes, so I, yeah, we got to be one of the first ones, I think, to kind of break the news a little bit about the SFA a while back, and I'm excited for it. They're supposed to be, and you know, everything is supposed nothing is set in stone, but supposedly they're going to expand it up to high school as well, and so it might be appropriate beyond sixth grade, or is it eighth grade? I can't remember off the top of my head, so that would be nice. And maybe I'll talk a little bit more about email and social media than a floppy deal, so we shall see. One can hope, one can absolutely hope. All right, I have one more fun question here, and this might surprise you a little bit, but Erin, I have to talk about your dream of an HGTV show that revamps a classroom with consult from an occupational therapist. I love that idea. We need to make it happen. Erin Gaby I have not reached out to them yet, but I really truly, in my heart, I'm like, I would love for that to happen. Maybe they'll ask me. Alysha Skuthan that is awesome. Erin Gaby So, does anyone listening with connections with HTTP, let us know, because we think it's awesome. I personally like, back in the day, gosh, maybe 1215 years ago, this is a little more, a little less inspirational, more satirical. That satirical, is that even the right word? Anyways, we thought about having a, and it kind of exists now, is more of the office version of, like, the special education office, like, like, that'd be good, but that's kind of what they have with the teacher show, right? That Abbott Elementary, not special education necessary, but at least in an education world. So. Good times. All right. Well, we've talked a lot about a lot of things today. We discussed the office, HGTV, and then, of course, the occupation profile and occupation-based assessments. Alicia, Aaron, thank you so much for being here. Really appreciate it. Thank you for the fun conversation, as well as the insightful conversation. Really appreciate having you here. Erin Gaby Thank you so much, Jayson. Thank you. It's been great. Thank you. Jayson Davies Absolutely, we will see you next time, and keep in touch. Take care. All right, let's give a big thank you to Dr. Alysha Skuthan and Erin Gaby for joining us today and breaking down exactly why the occupational profile matters so much in our school-based OT evaluations. I hope this conversation inspired you to maybe relook at your report and how you're incorporating the occupational profile into all of that that goes into your evaluation, right? It's not just about using the bot two or using the SPM, it's about getting a well-rounded picture of our student and putting that all together. Sometimes that occupational profile can really help you when you're synthesizing your results and deciding what services you actually want to recommend, plus it's also required by AOTA within that OTP F. All right, and if you need additional help with completing your occupational profile, we have got you covered. Head on over to OT schoolhouse.com/episode 202 for all the tools, the articles, the links we reference to in this episode, including that occupational profile that I adapted specifically for school-based OT. Well, be sure to put that link over at OT schoolhouse.com/episode 202 if you want to keep learning about occupation. Based practice assessment tools, and everything else that makes school-based OT both challenging and rewarding. I'd love to see you inside our OT schoolhouse, school-based OT collaborative, that is our online community where you can access professional development courses, get mentorship and resources from myself and others, as well as connect from other school-based OT practitioners from all around the world, head on over to OT schoolhouse.com/collab to learn more and start collaborating. Thanks for listening, and I'll catch you in the next episode. Until then, keep putting occupation at the center of everything you do. Amazing Narrator Thank you for listening to the OT School House podcast. For more ways to help you and your students succeed? Right now, head on over to OT School house.com Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 201 of the OT Schoolhouse Podcast. When a student refuses to eat at school, it affects everything—academic performance, regulation, social interactions, and the afternoon meltdown that follows. In this episode, Jayson Davies sits down with Alisha Grogan, MOT, OTR/L, founder of Your Kid's Table, to talk about feeding challenges in school-based OT. Alisha brings over 20 years of experience working with extreme picky eaters and shares what school-based practitioners need to know about supporting students who struggle with lunch and snacks. You'll learn how to identify when picky eating crosses into extreme territory, why the cafeteria environment can be so overwhelming for sensory-sensitive students, and what accommodations actually help. Alisha also clarifies the often-confusing scope question: what can school-based OTPs reasonably address versus what requires outside support? Whether you're freezing up when feeding comes up in an IEP or wondering how to support a student who won't eat at school, this conversation offers practical, realistic guidance grounded in both clinical expertise and respect for the school setting. Listen now to learn how to make lunchtime less stressful and more successful for the students on your caseload. Learning Objectives Learners will identify the clinical indicators that distinguish extreme picky eating from typical developmental selectivity.
Learners will identify and address environmental barriers in the cafeteria that prevent students from eating at school—and implement appropriate accommodations.
Learners will identify scope of practice for feeding intervention in schools by understanding what is appropriate for school-based OT versus what requires outside clinic-based or medical feeding therapy. Guest Bio Alisha Grogan, MOT, OTR/L is a licensed pediatric occupational therapist and the founder of Your Kid’s Table, a platform providing education and resources on sensory processing, primitive reflex integration, executive functioning, and feeding challenges to parents and pediatric therapists. She has over 20 years of OT experience working with children with developmental delays, autism spectrum disorder, ADHD, and a wide range of sensory and regulatory difficulties across a variety of settings including school-based, early intervention, and private practice. Alisha also founded and runs a unique week-long sensory summer camp in Pittsburgh. Quotes "At school, the number one goal is just them getting the nutrition that they need." — Alisha Grogan "School is one of the things that always comes up for parents. Often kids will not eat at school, even if a parent is sending their preferred items." — Alisha Grogan "I don't know that I agree that it's a school-based therapist's job to improve the variety of foods that they're eating, but it is their job to help them have a successful meal, lunch, snack time with what they are eating." — Alisha Grogan "It's nice to hear you say some of this because we all want to support the kids as best as we can... but if we don't have the tools at our disposal, we maybe don't have the training... it gets tricky." — Jayson Davies Resources 👉SOS Approach to Feeding 👉Your Kid's Table 👉Mealtime Works (Affiliate Link) 👉Feeding Therapy Printable Episode Transcript Expand to view episode transcript Jayson Davies Hey there, and welcome to episode 201 of the OT Schools podcast. All right, you already saw the title of this episode, and you clicked play anyways. Therefore, you definitely already know that today's topic is a hot one in the schools. My goal for today's episode is to help you see just how dynamic all of the feeding concerns that you may come across in school-based OT, actually are, and to help you understand how you might support some of your students in that sensory intense cafeteria on your campus. To do that, we are diving into feeding challenges in school-based OT with someone who has been a trusted voice in the pediatric feeding space for over 14 years, Alisha Grogan is a fellow occupational therapist and the founder of Your Kids Table, where she's helped countless families and therapists, both in the clinic and in the schools, navigate extreme picky eating, sensory processing challenges, and feeding difficulties. In this episode, we are getting real about what school-based OT practitioners can and should address when it comes to feeding. We'll talk about why some kids refuse to eat in the cafeteria. We'll talk about simple accommodations that you can implement tomorrow in the schools, and we'll also discuss where you can draw the line between school support and clinic level intervention when it comes to feeding. This conversation will give you the confidence and clarity that you need to support those picky eaters that you have on campus, as well as explain the intricacies of feeding on campus in those tough IEP meetings. So, let's go ahead and get started with Alisha Grogan. 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 Alisha, welcome to the OT School House podcast. Thank you so much for being here today. And how are you doing? Alisha Grogan I'm, I'm doing great, and I'm so happy to be here with you, and talking to your, your people. It's great. Jayson Davies I can't say my people, because I believe that my people are your people, your people are my people, especially in this online space. Alisha Grogan That's true, that is very true. It's a small OT world that we live in, right? Yeah. Jayson Davies Yeah, yeah, and you have so many wonderful resources. I really appreciate them. And you know, I, as we were kind of talking a little bit before this, you know, when you really got started with your online blog and everything that you're doing, it was really early on, and you were one of the few out there. Alisha Grogan Yeah, it was 2012 early 2012 when I started, and so, yeah, actually, just this past month we hit 14 years, which is kind of crazy, and there just wasn't a lot of people, any really, there was just very few therapists present, any type of kind of specialties online, there was a lot of mommy bloggers, and so I was also, they were very, very popular at the time, people were following them every single day, kind of this was the precursor to social media, and I was cringing sometimes at at the well-meaning but misguided advice that was often being given because you know we know the complexities of development, and you know sometimes there was just, gosh, you know, I just read through these comments and I would just think, oh my gosh, there's so much we're not talking about here, and I, at the time, I really did feel this like kind of call to just like I need to be a voice pouring into stuff that's going to really help parents, or you know, there are all of these other challenges that this well-meaning blogger is, that is a parent, is meaning to cover from their own personal experience with their child, who is likely pretty typically developing, and doesn't have extra challenges, so the suggestions and the strategies are not going to probably be effective for another child that maybe has a diagnosis or has more complexities, or and families feel really unseen in that, yeah, you know, so that was such a big reason that I started in the first place. Jayson Davies Absolutely, as an occupational therapist who graduated right around that time, I really appreciate it, because I know there wasn't. I looked for podcasts and they weren't there, and even I think it was you and Kara, Kara Kosinski. Alisha Grogan Who actually graduated at my site. We went to the same university in Pittsburgh, which is crazy. Yes, Jayson Davies yeah, that's awesome. And the two of you, so helpful to all of us, you know, OT practitioners that were just kind of getting into the space at that time, because you're really too, like, the only ones out there to really look for, you know, other than research, which is a lot more difficult to read. Then the nice friendly blogs that you all write, so we appreciate that, but you know what, let's take a step back, you know, before 2012 and I just want to kind of let you share and ask you, like, what drew you into pediatrics, and maybe even more specifically into feeding. Alisha Grogan Yeah, that's a, that's a great question. When I was in high school. This is the mid to late 90s, and this was when inclusion became became a new method for teaching children of different disabilities, and I sat in my ninth grade classroom, and they came and gave a presentation about the kids that were our peers that had special needs, and how what it would look like for us to have friendships with them, and I was so moved by this presentation, and I got involved with the special needs classroom, and just ended up spending a lot of time there, I found it just so meaningful, and so it was really my work, and they were my peers, really, at the time, but I just, I fell in love with that work in that kind of population, and so when I headed to OT school, so you know, a couple years later, I had several people suggesting to me, have you thought about being an occupational therapist, because they saw what I was doing with these kids, and so when I went to OT school, I really knew that I wanted to work in pediatrics, and I know a lot of people say that, you know, you talk to most, I feel like a lot of OTs, in you know, in their first couple years, say they want to work in pediatrics, but I really knew in my heart that I would, yeah, yeah. Jayson Davies And then, so you began working in the pediatrics, what did you go straight to clinic schools contract gig? What was that? Out of school. Alisha Grogan I had the most amazing first job in Washington, DC, at a private practice. The owner was in semi-retirement, Lynn Israel. Shout out to her, I'm sure she's enjoying retirement. She's.. she was California-based at the time, but she was one of Jean Eyre's apprentices, and so I had just such an incredible experience there. There was just a mentorship program set up. We had trainings every single week. I was immediately put into an environment where I was completely supported and got this really deep foundation in sensory processing and reflex integration that truly became a lens that I looked at the rest of my career through, and still I still is so foundational to me, and how I look at everything with kids. I then ended up moving back to Pittsburgh, and worked in private school, and actually, in that private practice, we, we ran a summer camp, we worked in private schools, we ran the clinic, so I was in a variety of settings within that one practice, which was really awesome and unique. So, I, my days looked different, you know, depending on what day of the week it was, which was great. When I moved back to Pittsburgh, I was in an approved private school. I shortly started early intervention on the side, home-based care, zero to three. Eventually, that became my full-time gig, and when I moved to early intervention, my caseload became full of picky eaters, and so, because, yeah, because speech therapy, I mean, so many kids from zero to three need speech therapist for speech, so they were completely out of capacity to treat feeding at all, and so they never, and I mean never treated speech unless it was like a really specific swallowing issue, and so it was completely on OTs, and many OTs, myself included, did not have training in feeding, you know, it was a, it was one class in my pediatric, in my pediatric course in grad school, that I think we talked about a nook brush, like I don't know, I mean, I was like super vague, and I had a little bit of exposure with feeding, for sure, in my approved private school, we were working with kids that had significant physical disabilities, so the feeding looked different there, it was more of a mechanical type of feeding that I was helping them with, more of a self-care skill, also not this kind of picky eating where my kid is literally eating two foods, and if I don't drive to McDonald's and get him this food, he is not going to eat a single thing, and the parents, yeah, I'm like showing up at their house and they're looking at me like they're not taking weight. Yeah, well, we, yeah, like, what? Like, tell me what to do. Tell me what to do. And so I had to figure it out. And so I just, I started reading the research, or reading the books, started talking to mentors, I started taking every feeding course I could take, and I just kept. I kept trying everything until it, like, and then it became distilled down to a system where I could just see, you know, this kind of pattern emerge of what was really effective, what what really was helping kids, and so once I started, once I once I started getting results with these kids, my caseload soon became full of them, because then, of course, every feeding kid was put on my caseload. So, but there's a huge, the way that I treat feeding, there's a huge sensory component, obviously, that often goes along with that, and so there's, yeah, there's a really big sensory component to most of my treatment with feeding, Jayson Davies Wow, and at the time, this is, I'm assuming, kind of like the early 2000s mid 2000s ish. Alisha Grogan Mid mid to late 2000s yeah. I graduated in 2004 Jayson Davies Okay, so then at that time, I mean, were there OT lead feeding type of intervention courses? Is that kind of what you, what you went to, or did you have to go kind of go outside the world of OT to get some training? What did that look like? Alisha Grogan Well, it was, it was shifting, and that's when SOS came out. That was that was the course that really shifted everything for me, which, of course, is taught by Kay Toomey, who comes from a psych background, but, but she very much valued the role of OT and speech, and she really saw a team approach. So, I'm sure many of your listeners have taken SOS. It is, it is as, as many therapists should. I recommend that to any therapist that is, that is really doing a lot of work in feeding. SOS is just one of the, the best, the best comprehensive courses that you can take, particularly if you're in a clinic or a home-based setting. Little tricky in a school setting to implement SOS approach, but she really was multidisciplinary, and so she had such a solid understanding in this, she pulled a ton of sensory stuff in, hence, like, you know, sequential oral sensory is what SOS stands for, so the oral piece, you know, she's seen the kind of the speech end, and even just the mature end that you know OTs can cover as well, but then also this huge sensory component that was going on for so many of these kids, and so even within the even within the niche of feeding, I really became, you know, and what I, what I often use is the term, you know, extreme picky eating, or very picky eater, or because you know, obviously feeding itself can even be a pretty wide umbrella with all of the challenges, yeah, that kids can have, so you know, I wasn't really treating, although, of course, those kids would end up on my caseload from time to time, kids with cerebral palsy that had significant difficulties with chewing and coordination. Most of the kids that I were treating, although they sometimes, for sure, had oral motor stuff going on. Many of the kids that I've worked with, in person, in real life, and the families that I have serviced around the world through your kids table, have been families that these kids kind of look quote unquote typical, or they have some neurodivergence going on, you know? Maybe they have autism, maybe they have ADHD. There's no diagnosis, there's all this sensory stuff going on, and their eating is stressful, they're eating very little, they're highly specific, and there's a ton of anxiety around food, though. That's kind of that, like, is my niche within the niche. So, oh yeah. Jayson Davies Good deal. And now I think you know a lot of people, we think of feeding, we think of that clinical side of things, and you just kind of talked a little bit about that clinical side, but I'm actually interested to hear from you a little bit. When you talk to the parents, maybe even when you talk to students, do they talk about school? Do they talk about school being difficult because of this and that? And what have you heard? Alisha Grogan Oh, 100% School, school is one of the things that always comes up for parents. Often kids will not eat at school, so even if a parent is sending their preferred items, a child is not eating. This, this comes up so often, and that you know, and there are a variety of reasons that that happens. We can kind of talk through those if you want, but then also sometimes parents don't even know what to send, so sometimes that's an issue, like my kid is so inconsistent, and at home I'm standing in front of the pantry and saying, do you want this or this or this, so when I pick in the morning and I send it, I I'm guessing at that moment if that's going to be what they feel like eating and if they. Don't they're not eating all afternoon, so their academic performance goes down. They're getting dysregulated, so in social interactions are suffering. They're coming home often, having a meltdown, because they're pushed past their capacity, because they literally have not eaten, and so this becomes a significant stressor for parents, because they're worried about their school performance, understandably, and this really difficult transition that can happen when they get home, because they're now starving, and then the other element that happens is they're starving, so you have to, they're coming home, they're not having a snack, they need, they need a meal, and so now they're eating a whole meal at maybe 330 or 4o'clock when they get home from school, and then dinner is sabotaged because now they've just eaten this entire meal, and so now one of the, you know, one of the principles that I teach is sitting down to eat together, which is a huge step for a lot of families, and there's a lot of ways that I break that down into smaller steps and help families get there, or just focus on it for certain nights, if that feels like an overwhelming task, but then we're like totally missing out on any opportunity for dinner, so you're having like this, you know, weird after school huge meal, and then, and then they're hungry before bed again, you're trying to get them ready for bed, it just, it like throws off the whole cycle, so. Jayson Davies Yeah. Alisha Grogan This comes up quite a bit, I think, for these parents with kiddos that are struggling to eat a variety of food. Jayson Davies Yeah, absolutely. And I'm sure you've had a lot of, you know, parents reach out to you. I guess what, trying to figure out how to word this one. My kid, right? I have a four year old, he is typically very good with food, but every now and then he gets a little picky and stuff, and then you obviously have the population that you've been talking about a little bit. Have you ever had parents like come to you, I guess, and say, "My kid is really picky? And then, to a degree, to yourself, you're kind of like, "You're no, your kid might be picky, but not in this way. Like, I guess what I'm trying to allude to, or get to, is like, how do you determine, like, really what is more of a concern versus what is a kid who, yeah, it's picky every now and then, but maybe not as much of a concern. Alisha Grogan Yeah, I mean, this is this is something that we teach all the time, because picky eating is a subjective term that is used very easily in our culture. It's also very common. It is, it is a, it is a typical part of development for kids to be more selective from around the time they are one until usually around three and a half, and even up to five years old, where you kind of will just see some of this natural pickiness, and there's all kinds of reasons for that, like their taste buds enhance at that point, you know, when we think about what's happening with them developmentally, and they're starting to see themselves as their own entity, they're exerting some sense of control of, hey, look, I can say no to this. I'm not just, you know, passively taking this in, and what happens if I say no? And there's all.. there's all these cognitive and developmental aspects that are going into that. When a child is kind of just in a natural picky eater stage as a toddler or preschooler, when we look at kids that are more extreme picky eaters, we're really looking at this as having a significant impact on their life, either on their nutrition, on their health, on their quality of life, either for themselves or for their families, that there's sometimes a financial stress, you know, if your kid is only eating from McDonald's, and you have to pay for McDonald's every day, instead of being able to use a house, you have to get in the car, you have to use gas, you have to do all these things, you can start to feel really trapped by that, so when, when all of those, when those elements are in play, we really start to look at this as tipping more towards extreme picky eating, and there are some diagnoses now that sometimes kids get if it is in the severe state. I would say that these diagnoses are still not kind of culturally known, you know, so I still think we're still kind of generally saying picky eating, but what I'm really looking at, and this, this actually goes back to Kay Toomey's guidelines, and I have, I have used this for years, and it's when a child is eating less than 20 foods in their diet, and that does mean everything, because sometimes parents will say, well, okay, I'm counting cheese as one thing, but they eat five different types of cheese. Now, I would probably count five different types of cheese if they're eating, you know, if they take American cheese, if they take mozzarella string cheese, like those are different foods, so if we're looking at 20 foods or less, where. Looking at trying to control the food, and that you're going to see that there's a, there's distress if they do not have a food that feels safe or like something that they can eat, and you will usually see when they're in this extreme picky eating category, where it's like, hey, you know what? Maybe we need to get more help with this. We need to start approaching this from a different standpoint. You are usually going to see again some kind of gagging, shuddering, extreme anxiety when food is sometimes put on the table for some kids, like it could just be on the table and they're just looking at it. For other kids, they have to taste or touch it to get that reaction, but if, if you're, you know, if you're seeing a kiddo and they gag at foods, I mean, if there's, if there's one food, you know, like, I mean, there, we do kind of all have, you know, these unique sensory systems, and for some of us, there's a, there's a food that just really is like, oh, that, like, nails down the chalkboard, I'm talking like you're seeing this pretty much with like anything outside of their safe foods. Jayson Davies Yeah, gotcha. Thanks for sharing that. We're going to take a quick break, but when we come back, we're going to start to talk more about feeding in the school-based OT room. So, stay tuned. All right, Alicia, I want to start talking more specifically about school-based OT. I know you've worked in the private schools, but you also mentioned, you know, really you've worked with all the kids, obviously the kids go to school, and you mentioned school-based. You also mentioned some reasons, maybe why kids might go to school with their preferred food but still not eat. I'd love to hear a little bit more about that. Alisha Grogan Yeah, so what commonly comes up for kids when they have their preferred foods and they're still not eating is that they are super overwhelmed in the cafeteria environment. So that can come from a couple different places, and so obviously, as OTs, it's our job to figure out what, where is the overwhelm coming from. Number one is this a light and sound type of situation, which it absolutely can be. I have certainly worked with kids where it's just, it's so over stimulating in the cafeteria from a noise standpoint that they're getting very dysregulated, they're getting very agitated, and you know, once we get so dysregulated, our appetite shuts off, so even if you have not eaten well, you, you lose your appetite, and so it sometimes is just the noise, sometimes it's the lights, sometimes it's peers, you know, bumping into you. Some kids, they're just so dysregulated by the time they get to lunch from everything they've been doing all morning that they're just kind of shutting down, and now they're kind of in this chaotic environment, on top of everything. There's just.. there's not a chance for them to kind of calm and to be able to eat. Another big factor, though, is a lot of these kiddos that are struggling with this, you know, again, we'll call quote unquote extreme picky eating, which again in itself is kind of just an umbrella category, because they may have, you know, this diagnosis of ARFID or PFD, which is pediatric feeding disorder. If they have one of those diagnoses, and maybe, maybe they don't, they are likely to be disgusted by other kids' foods, and so even just seeing other kids, and especially if there's kids at the table that are encouraging them to try something, or maybe making fun of the food that they're eating, that also happens sometimes, because sometimes the things that they're eating are a little bit unusual, or they're eating the same exact thing every day, and kids are just going to comment on that, and so when another child, when that child is really sensitive to it, or feels like they're being watched or seen, there's just a lot of anxiety around eating, and so it just becomes a lot easier to just not eat, and to close that, to close that lunch box. Jayson Davies Yeah, and there are a ton of smells, and the cafeteria, it often kind of mushes together into this really weird smell, but a lot of kids are more sensitive to smells than I am, so. Alisha Grogan Yeah, right, absolutely, absolutely, Jayson Davies Yeah. So I kind of want to walk through this process where we talk a little bit about what you've done from kind of the clinic side to support these students at school, and then our work kind of work our way up to like what you feel would be the best thing ever for like for feeding and school based OT, but like I said, I want to start with kind of what you've done. So, what are just some of the popular things, the more common things that you've done with some of your students, not as a school-based OT, but to support them at school? Alisha Grogan Right, so we talk about having a plan with the child, so even though it's the morning, and we have to take into consideration, too, if the morning is chaotic and hard for these kids. Again, a lot of times these kids are sensory kids, they're neurodivergent kids. So going through the routine in the morning has all these it. Own stressors, like getting that arousal level up in the morning, is hard, and so we do a lot of talk about regulating in the morning, so that they're starting the day from a really regulated standpoint. Now, of course, if there is a school-based OT that is working with that kid, if I know that there's a sensory room at that school, if I know that there's bandwidth, if there's an aid, if there's somebody that's able to get them to the sensory room to start off their day, that's definitely becomes part of the plan. I would say more often than not, that is not what I'm working with. So I'm working with a family to say, even if we have five more minutes, how can, like, how can we use that time well to help get your kid regulated, so now we're talking about sensory strategies, you know, we're talking about, you know, crossing midline activities, really just getting getting the brain in a regulated place when they leave, which can actually have an impact on lunch. If they're regulated, they can also help make a choice about what they're going to eat for lunch now, that that can work the night before too, and for some families that does that. We're making a plan. Hey, this is what's going to go in your lunch. What options do you do you want to have? This is one time. Normally, I, my goal is, is that at every meal for kids that are so sensitive to these foods is that we're working towards, or they already have at least one food on their plate that they don't typically eat, so that they're getting comfortable with it, they're getting used to it. That might be a bowl that's like sitting halfway across the table at first, that might be one pea on their plate in a divided plate, where it's sure not to touch anything else. But yeah, but this at school, that is all off the table, like there's just no point, like there's no point in like making sure, so this is the one place I tell parents, like don't try to send the peas to school, like at least at this point there is definitely benefit for that as you're making progress, and then it's and then it becomes a point where it's helpful for a child, even if they're not going to eat it, to say, oh yeah, those are in here, and that's okay, and I can still eat my lunch, and you know, maybe working towards that, but for school, what I always tell parents is that the number one goal is just them getting the nutrition that they need, so that they can do what they need to at school, so whatever that is right now, that's what we need to start with, and we just start with them having a plan. We also do other things, like putting notes in, you know, if a kid is old enough to read, like something really encouraging, a joke that's going to make them laugh, that's on the, that's on the really low end of support, of like this is, this is like basically what we're doing, then if that's still like we still need more support, then I'm looking into, are there things that we can do and that are appropriate, and the child is going to respond to, like, our noise canceling headphones a good option right now? Is that going, are they are they missing out on peer interactions, or are they so upset that they're not interacting anyways, and at least this is going to allow them to be calm, and they're still with their peers, and they can, you know, eat here. Is it a weighted lap pad that's going to help them? Do they just need a fidget in their other hand that they can just kind of squeeze while they're focusing on eating? So we look at some of those supports, if it's still in a really difficult place, I have worked with parents to help them have it added to the 504 plan to have the teacher get on board, the school basically get on board with them having a quiet room to eat, and so some schools have done this where they pick a friend to go eat with them in the quiet space. There's a ton of social dynamics, and this varies so much from school to school, like what faculty is willing to do. There's, there's obviously such a concern, and even as I say it, the last, you know, like, they're just, gosh, we don't want them eating by themselves, we don't want to like pull them out, it's this social experience. This is supposed to be a fun time, but if a child is not eating and they're totally stressed, sometimes as a temporary measure to help them reset and start getting comfortable eating at school, that can be a really good solution. Or maybe they're staying and eating in the classroom, you know, they're staying in eating classroom teachers in their eating, or they're just kind of hanging out. It's just not so overwhelming. And then we start working up to them being able to tolerate it. Now, of course, if they're in feeding therapy, or they're using a home program, and they're working on these kind of underlying sensory processing sensitivities, they're following a program, this isn't life sentence. This is okay. This is where we are right now. We know that it takes time, especially with feeding, to see progress, and so as that progress is unfolding, we have hope and expectation that this lunch situation is going to get better. Also. Jayson Davies Yeah. Alisha Grogan Yeah. Jayson Davies Wow, yeah. I mean, it's amazing how much you can actually do without even technically being in the schools, but that then also leads me to wonder, because I am sure in the last 14 years you have heard from many school-based OT practitioners, and you've probably heard similar things that I've heard, like A, I want to address feeding. I don't know how. B feeding doesn't belong in school-based OT, and countless others, I am sure. And so I'm wondering, from all you know, from all the things that you've heard, and you know it's probably changed in the last 14 years. What are you seeing as current practices? What are OTs coming to you and saying, like, this is what I'm already doing or not doing as a school-based therapist. Alisha Grogan Yeah, I do. I mean, again, in my world, I'm fortunate because you know I have people taking our picky eating program, which is called Mealtime Works, and so when they come into Meal Time Works as therapists, even we've had many school-based therapists, they're open and willing and wanting to learn, so I think I do hear more often from the therapists that are wanting to help and. Jayson Davies Optimistic. Alisha Grogan Yes, optimistic, wanting to help support, they always want support in how do I make this work in this school environment, because a lot of the suggestions that I make have to happen at home too, and the thing with feeding is, oh, it is tricky, because I did early intervention for such a long time, so I was in the home, and when you're this is so different than when you're working on fine motor skills, or you're working on handwriting, or you're working on sensory processing. It's kind of like this isolated thing that this kid is going through, and the family is coming along and supporting them. Eating is very personal to people, the way that they eat, how they eat as a family. Do they eat in front of the TV? Do they eat together at all? Do they have these homemade recipes that we're making when we look at different cultures and the types of foods that they're eating, the expectations that are there. So, when we start coming in and saying, hey, it might be good to sit at the table when we eat, that can be unbelievably difficult for some families, and if you're not working with the family on an ongoing basis, like in a home setting or in a clinic setting, where you're really having a lot of that contact to support them, you really can feel like you're hitting a wall there. And I think that's where a lot of school-based therapists come, because they start learning strategies, and some of these things that I'm talking about, you know, we teach a five-step system, and so, like, our first two steps are really structure routine to just start forming this foundation. It's like steps three and four are when we get into the sensory pieces, the feeding techniques, but for most kids they really just need this foundation. And so I think for school-based therapists, as they start learning these strategies, it's like, okay, I can work on the sensory stuff as a prep activity, and like, have this be dual purpose. I can incorporate fine motor into that and make it like align with my goals, but how the heck do I start having a family start to eat together, serve non-preferred foods, you know? And I would say there's a significant.. there's a hurdle there, but I think every one of us, even if you're in the home or you're in the clinic, you're feeling that because you're you're up against an individual family's culture, and you have to be a respectful of that, and b show them the benefits of why maybe working towards some of these changes would be are really going to help their child start eating more food, which is what they're really looking for, and so I bend rules, my own quote unquote rules, all the time, because they need to work for people, they need to, you know, it can't be a totally rigid system that it's like when something is stressful that I'm asking a family to do, they're not going to do it, so for school-based therapists, and what we teach in our program is, you know, I mean, we just, we have a lot of handouts, we have a lot of visuals, we have a lot of clear step by step, so that parents feel supported in that on the on the home front. Now, I would agree with their, I mean, I agree and disagree with therapists that say feeding isn't school-based, ot it's not appropriate. Well, it is because they eat lunch there, unless they're not eating lunch. It is one of their activities, Jayson Davies Or even snack time. Alisha Grogan Right? If they're eating at all there, it is. It is part of it, but but that is way different than trying to have an impact on all of their eating throughout the, you know, 40 meals that they're eating every week, that is, you know, I think for school-based therapists, if you have a family that is motivated and is looking to you for guidance and you're able to provide. Um, handouts and visuals to them to help get them started, that that's appropriate, but it does become beyond the scope to try to make significant change in the home environment when you know, because of what you're seeing at school, and so I think that the supports, like, have to, I think I hope that it gives the school-based therapists that are listening to this, a little sigh of relief in that if you're addressing it at the school-based level and you've offered some resources to the parents, that I think you're doing an amazing job, because that's what's appropriate for your role in that setting. Did I answer that all the way? Jayson Davies I think so. I mean, my only.. I guess my follow-up would be, you know, there are some times where we get asked by the parent or by the IEP team to further address the issue inside the cafeteria, and you know, earlier you, you mentioned a few different things about the cafeteria, right? The smells, the sights, the sounds, all of that. Let's kind of frame it this way, like in your perfect world, how could a school-based OT practitioner have an impact in the cafeteria, maybe directly with a student in the perfect school-based OT feeding world. Alisha Grogan Yeah, and so for me that's number one, are identifying what the triggers are in that environment, you know. Again, we talked through all those, like, which, what is going on there, you know. We tend to see patterns, I mean, it can vary from day to day, you know. Maybe, you know, whatever, the triggers could look a little different, but if a kid is really struggling with smell, they're probably going to be really struggling with that smell most days, you know. And maybe they cook something that day that's particularly stinky, that isn't always in there, that's a little bit more triggering, but again, for the most part, you know, you're going to see a pattern, and I think that's where, you know, we need to come in and really look through that sensory lens of, and just really overall nervous system regulation, what is going on that is making it really hard for this kid to eat, and I think I think that's where we, we use our clinical reasoning assessment skills to just say, look, this is this is what I think is going on, let's try out some of these supports and to see how we can help this child eat. I don't know that I agree with that. It's a school-based therapist's job to improve the variety of foods that they're eating, but that it's, it is their job to help them have a successful meal, lunch, snack time with what they, with what they are eating. So I think that that may also mean having conversations with the parents, maybe the parents are saying, I mean, most parents are not doing this, quite frankly. When you have a child that's in this extreme picky eating category, they know that their kid is not going to eat anything out. Else, you know, parents that try, they'll wait it out and see, which is what some doctors, unfortunately, still say, oh, well, you're just giving in, you're giving them whatever they want, just wait it out, they'll get hungry enough, and they will eat. That is false. Kids that are in this extreme picky eating category, because this is like they are having serious anxiety, sensory processing difficulties with this food, or oral motor challenges, maybe even physical challenges. There are so many kids that have undiagnosed physical stuff going on that like reflux and EOE and all of this stuff that is. Jayson Davies Worth the hunger. Alisha Grogan Yeah, yeah. And so you're gonna, you're gonna, you don't give me what I can eat, fine, like I'm not gonna eat, and they will not eat. I have had countless families who have followed that advice, who have ended up in the ER because their kid was like at the point of passing out, and they're on like day two, you know? I mean, the parents always end up caving because they can see this isn't working, like this is not, this is not working, like we are trying to wait it out and see. And so that would be the only thing, if you had a, if a therapist listening right now is like, oh my gosh, I have a family that is just insistent that they're not sending the x, y, or z foods that their kid really likes, then that's an education piece. I would say again, look, it's at school, this is so important, after school time to work on this, but right now we just need them to eat, and let's start here. So, I think that that's where the therapist speaks into that. I think it can be an appropriate goal if a child is significantly struggling with lunch. You know, this is an ADL. It's happening in this setting, so it is very appropriate to say to help that child eat lunch. So, again, yeah. Then, what are the supports? Does that mean we're taking a break? Am I doing therapy while during lunchtime? If that's, if that's a primary goal, or we're I'm rotating through, you know, maybe every third session is we're one on one at lunch, and I'm assessing, and I'm trying to, I'm testing different supports and strategies, so that this child. Feels more comfortable and is able to eat the food that is being sent. Jayson Davies Yeah, I feel like in the past, for me, a lot of our quote unquote feeding goals that we would sometimes address would be more access related to the food. To be honest, it's kind of a fine motor skill, right? So, like, to open up the bag, so that they can get to the carrots to open up a milk carton to be able to put the straw into a juice box, something like that. To me, I honestly, a lot of times, froze up when it went a little bit further than that, like I didn't always have a plan, and, and it's kind of honestly a little nice to hear you say, right, that education piece is, to a degree a lot of what we can do and what we should be doing at schools, and kind of not putting necessarily the onus on us to try to expand food, because that is definitely something that does come up in IEPs, and sometimes parents are comfortable sharing that, other times they're not. I think, like you mentioned, food eating is such a personal experience in every culture, every person does it a little bit differently, but it's nice to hear some of the things that you're saying. You know that for some things we need to have more than what we can do in a cafeteria, and I appreciate that, and I'm sure other school-based OTs appreciate that as well, a little bit. So, thank you. Alisha Grogan Good. Yeah, Jayson Davies I want to switch the subject a little bit. I'm going to be a little selfish here, because I just talked a little bit about some of the difficulties that I had when I would freeze up when it came to eating, but there was one other kid, and I can see him vividly in my mind - third grade at the time when I was working with him. I still see him around town. You see those kids, right? We also, well, you all see our kids outside, okay. Anyways, he seems to be doing good when I see him, but this always made me feel uncomfortable again. And it was more along the pica world, and I don't know how familiar you are with that, but this was a kid, he, he had picky eating, and on the flip side, he would come to school, and I don't know if he had a formal diagnosis of pica, but he would eat erasers, he would eat glue, other odds, and in school, and I just want to pick your brain on that, and kind of what you have experienced, what you've, what you know about it. Alisha Grogan Yeah, I mean, clinically I probably have a few families online I have worked with that have pica, but clinically I have, and especially in approved private schools with kids that have often multiple diagnoses and multiple things going on. Yeah, it's, it's really, it's really tricky, and I do think that there is something neurological going on with it, in just terms of that it always feels very neurological to me, as in, like, there is some confusion around what is edible and what is not, and like, legitimate, like, confusion around that, and also that there is a, there's a huge sensory component, I think, also, so with, with texture, with, you know, gosh, if you think of, like, you know, if I think of a kid chewing an eraser, you know, I think of a dense amount of proprioceptive input that they're getting from that, that might be pretty, pretty rewarding, and make a kid want, make a kid want to do that, you know. We emphasize, like, whenever I'm working with a kid with pica, I do work on sensory integration a lot. We're doing a lot of deep work in texture play. I have a, like, I have a protocol, because I think earlier in my career, you know, you just like, "Oh, play in a sensory bin, and I did that for a long time, and it's good. It's so good, like, I'm not saying don't play in a sensor bin, play in a sensory bin, it's so good. I think there's so many ways to adapt it. I think we should be doing it with so many older kids, because so many kids have texture sensitivities. I think kids now more than ever don't get their hands dirty, and it totally affects all their sensory processing and all of that stuff. But I do think we need to get kids in deep textures, they need to get their feet in the textures, they need to, they need to play in the textures for a while, and they need to be in like gritty textures that are helping kind of their tactile system start to process sensations more than they even need messy textures, they need gritty textures like sand and bird seed and rice to really be playing in deep bins to kind of help their brain start to process the sensory input better, and also, you know, and then that's pulling in even sensory integration, because again, you know, I couldn't say like what pathways are particularly activated, but when I start working on sensory integration and reflex integration, and I can get to some like deep neurological stuff. We can, I have seen the needle move with some of these kind of odd challenges, that it's like, what is going on, like what is going on here? Jayson Davies Yeah, yeah. Thank you for taking on that, that question. I know that it was not an easy one, and it's not one that I prepped you for, so I appreciate that, and I completely agree, and it is really like we were really kind of at a loss, and this IEP team, you know, we would meet, gosh, probably three times, if not four times a year, because this was always coming up, and it was really hard to, like, I just felt like we continue to try to use cognitive behavioral strategies and. Alisha Grogan That's great too. Jayson Davies Yeah, but it's just so limited, like you're limited in what you can do, right? Like, especially, you know, this was a third grade. I also worked with him in fourth grade, I believe, and there's only so much time that you have eyes on a third grader and a fourth grader, right? Like, this isn't a small preschool program where you're constantly, you know, teacher has eyes on the kid all the time. I mean, he would sneak off into the cabinet in the classroom, and no one would even notice that he got it until later in the day, like it was just really hard, and you know, not, you know, you mentioned sensory integration, and you know, this is a big topic in school-based, obviously, you know, we, we don't have all that in the schools, and so that makes it more tricky as well, and, like, I don't know, part of the reason I bring this up too is just to share with all the practitioners out there, like, these are not things that happen overnight, and these are not things that we can always address as the school-based OT, and sometimes we need support outside. Sometimes we need to, in a very crafty way, suggest support from outside occupational therapy in a way that's not going to put the district really mad at you. Like, these things happen, and it's tough. And so that's why I like having these tough conversations a little bit, right? Alisha Grogan Yeah, absolutely, because it's not, it's yeah, like, if you don't have, gosh, if you don't have the equipment and the ability to treat, it's, I mean, some, yes, some of these, some of these challenges are beyond the scope of school-based practice, it just is, you know, and that's, but like you said, I know that there's a lot of politics behind kind of, kind of saying that in, in a setting, and unfortunately, I do think sometimes school-based therapists are looked at as, well, you're no tea here, so just, you know, fix it, yeah, like, yeah. Jayson Davies Yeah, another topic, another day, another podcast. We've had that topic on the podcast before. I'm sure we'll have it again. It's a tricky one, and again, like I said earlier, it's a little comforting to hear you say some of this, because we all want to support the kids as best as we can, and we all, like, we think the same way that you just kind of said, right, we're OTs, we want to be able to support these things, but if we don't have the tools at our disposal, we maybe don't have the training, we don't have a classroom full of rice bins and all the fun stuff, it gets tricky. So, Alicia, I think we're going to wrap up today, but I really appreciate your time. I really appreciate you willing to have some, some real tough conversations. I know it's not always easy, but we always appreciate, appreciate it here on the podcast. Really quickly, you did mention your course. I would love to let you share where everyone can go to learn more about that. Alisha Grogan Yeah, absolutely. So, we do. We have several courses. We have Meal Time Works, is our picky eating program. So we do go a little deeper in there, you know. It focuses on these kiddos with extreme picky eating, but it is a plan. It is a program. We have dozens and dozens and dozens of handouts in there that are all written for parents that are beautifully designed, visually appealing, that you get to use forever with your caseload, so they're yours, like when you become a student. But yeah, it's a.. if you're looking to get more help on feeding and want to feel like you have some training in it, I would definitely suggest trying that out. You can find it at your kids table.com you can just kind of click on classes, or yeah, I'm sure that'll be in the show notes, at least the website, yeah, so yeah. Jayson Davies Yep, we will link to that, we'll also link to the SOS program, as well as some of the other resources that you've mentioned, and make sure to make it super easy for everybody to find, and yeah, Alicia, thank you so much. I hope we get to do this again sometime, because it was really great learning from you. Alisha Grogan Yeah, it was great to be here. Thanks so much, Jayson. Jayson Davies All right, and that is a wrap on episode 201 Alicia, thank you so much for joining us today and sharing your incredible expertise on feeding challenges in school-based OT as well. Was in the clinic from all the school-based OT practitioners, in fact, all the pediatric OT practitioners who have had to learn a little bit about feeding. We greatly appreciate all the tools that you have put out for all of us at YourKids table.com If you want to dive more into feeding and helping picky eaters, be sure to check out Alicia's Mealtime Works program over at Your Kids table.com And, of course, to you, thank you so much for being here. Really appreciate all the work that you are doing, and all the work that you're putting in to supporting your students more. You definitely don't have to spend your time listening to an OT-related podcast, you could be listening to Serial, a true crime podcast. Maybe you like to watch the news or listen to the news via podcast, but you were here today learning about feeding, learning about improving yourself as an OT practitioner, and I really appreciate that. If you're looking for more resources, more professional development, and more mentorship to support your school-based practice. I would love to invite you to join us over at the OT School House's school-based OT collaborative. Inside the collaborative, you'll get access to our full library of resources, professional development sessions, as well as a community of school-based OT practitioners who get exactly what you're going through and are ready to support you. Check it out at OT schoolhouse.com/collab That's OT schoolhouse.com/collab Until next time, keep making a difference in all the students that you serve in their lives, and take care. Amazing Narrator Thank you for listening to the OT School House podcast. For more ways to help you and your students succeed. Right now, head on over to OT School house.com Until next time, class is dismissed. Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast

Click on your preferred podcast player link to listen wherever you enjoy podcasts. Welcome to the show notes for Episode 200 of the OT Schoolhouse Podcast. This course explores the evolving landscape of school-aged mental health in a post-COVID world and the expanding role of occupational therapy in supporting students’ emotional, behavioral, and functional participation. Dr. Monica Keen examines current mental-health trends, trauma-informed care, behavior changes following the pandemic, and evidence-aligned OT strategies for school settings. Participants will learn practical, occupation-based approaches for addressing emotional regulation, engagement, and school participation within a tiered model of support. This course is part of the OT Schoolhouse Collaborative Community, where school-based practitioners come together to deepen clinical reasoning, explore meaningful topics, and translate evidence into real-world practice. If you’re looking to earn CEU’s for this course and access a full library of professional development opportunities, you can join the community here 👉 https://www.otschoolhouse.com/collab Learning Objectives
—Learners will identify three mental illness diagnoses of school-aged children.
—Learners will identify reasons/events for childhood mental illness and how it impacts occupational engagement.
—Learners will recognize the role of OT in addressing these mental health issues in the school setting Guest Bio Dr. Monica Keen is the Program Director of the Doctor of Occupational Therapy Program at Presbyterian College and has been a licensed OT for 36 years. After a long career spanning mental health, acute care, skilled nursing, and 27 years in school-based practice, she transitioned to full-time academia in 2022. She also teaches pediatrics and mental health labs as an adjunct at Baylor University and previously taught for seven years at MUSC. Dr. Keen has authored book chapters and presented widely on school-based OT, mental health, and handwriting, including multiple webinars and a doctoral capstone on OT’s role in supporting children’s mental health. She has been featured on the OT Schoolhouse Podcast and presents nationally on school-based mental health. She currently serves as Co-Chair for Mental Health within the South Carolina Occupational Therapy Association. She holds degrees from MUSC, Boston University, and the University of St. Augustine. Her professional passions include mental health, trauma-informed care, pediatrics, and autism. Dr. Keen lives in Greenville, SC, and enjoys running, hiking, college football, and spending time outdoors with her two Boston Terriers. Quotes “Trauma results in fundamental reorganization of the way the mind and the brain manage stress.” —Dr. Keen
“Adversity is not experienced the same by all people.” —Dr. Keen
“A mass exodus… and people not wanting to go into teaching because of low pay and the burden from the pandemic.” — Jayson Davies, M.A., OTR/L Resources 👉The Body Keeps the Score (Book) on Amazon: https://amzn.to/4s4CiUm (affiliate link) 👉The Body Keeps the Score (Audio Book) on Spotify 👉 Collab Episode Transcript Expand to view episode transcript Jayson Davies Hey there. And welcome to episode 200 of the OT school house podcast. It is great to have you here today. And wow, I have been waiting to say episode 200 ever since, like, Episode 185 about and I hope it would happen, you know, during ot month. But we're close enough, you know, just the beginning of May. And today, I am super excited to hit this milestone with you all, whether you've listened to all 200 episodes or this is your first one, I'm happy to be here to celebrate with you, and I'm also excited to share a very special episode with you. Today, we're dipping into the school based ot collaborative professional development archive to share with you a fantastic a ot a approved course by Dr Monica keen. In this course, Dr keen dives into the world of post covid school age mental health, and she explores how we can use what we learned from the covid era and continue to use those strategies in our schools. Today, you'll get practical tips on supporting students emotional as well as their functional participation. And trust me, this episode is packed with insights, and Dr King's energy is like just inspirational. Trust me, you will be fired up by the end of this episode. Now what you're about to hear is the audio version of Dr King's presentation, and if you are a member or decide to become a member of the school based ot collaborative. You can actually hit pause right now head on into the collaborative and catch the video version with all the slides and resources directly inside the community. Or you can continue listening and then go into the community and take the quiz to earn your CEU certificate for this audio version. We've snipped out the Q and A for you know, privacy, but our community is buzzing with experts like Dr keen and others ready to answer your questions all about ot inside our OTP lounge. I also want to give a big shout out before we get started, to every single person who joined us at a ot a inspire, as well as the school based ot meetup that Jamie from Miss Jamie OT and I hosted. It was fantastic. Getting to meet so many of you. I wish I had the opportunity to have like, a 10 minute conversation with every single person. There just so many good things there, talking about case loads, talking about things that are going great, as well as some of the things that are not going as well. I like talking about all of it, your stories, your support. They mean the real to me, and you all made me blush a little bit every now and there, when you talked about how this podcast, how the articles, how the collaborative even have really helped you in your school based ot journey, I cannot thank you enough for coming up, having the courage to say hi and and sharing with me everything that's going on in your school based ot career. You made my weekend a blast. So thank you, and I have to give one more final thank you to everybody who came to my session at a ot a you know, we talked about services in the least restrictive environment, which is not always the most fun topic to talk about, but I appreciate you being there. We had a packed house. Really had fun with it, and I hope you all had fun, as well as learned a lot about helping students or helping you to determine services in the least restrictive environment. All right. Well, we are going to jump in with Dr keen right now. Thank you so much for being here again. Appreciate it. Happy 200th episode to all of those of you who will celebrate it. And yeah, enjoy this episode. I'll catch you at the end. 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, CLASI is officially in session. Jayson Davies Please help me in welcoming Dr Monica Keen. Dr. Monica Keen Hey, how's everybody doing? Thank you so much for tuning in. Tonight. I am coming to you guys from Greenville, South Carolina, so there is a huge time difference. And as you can see in the background, my Christmas tree is all lit up and it is dark outside. So it's really cool to know that I am reaching you guys where you're still experiencing sunshine over in California. So thank you so much for having me. It's always a pleasure to to partner up with Jayson and to talk about school age, mental health, children, children mental health in general. Just a brief little disclaimer before we get started. I always the day of my presentations, I get into this frame of thought about, you know, what do I really want to focus on? What is a point that I really want to get across? And in this particular presentation, you know, I find that occupational therapists are always looking for an. Activity, an intervention, you know, something hard and tangible that they can do to address something, and I appreciate that more than people will ever know. However, I am going to challenge you guys tonight to think about how we need to start modifying our approach with our clients, particularly our children. I'm still focusing on mental health in a post covid world, because when I began this research, it was during the covid crisis, and I've been eagerly awaiting the results of how mental health is in a post covid world. And so as I was sharing with Jayson, as I was preparing for this, I learned a bunch of new stuff about how mental health has changed in a post covid world, for our children well, and really for the world at large. So without further ado, let's jump in. We're going to do a brief review. Let me see come on in advance, would you? There we go. All right, so some learning objectives for tonight. I want you to be able to walk away from this presentation to be enlist three significant mental illness diagnoses that our school day children are facing at this point. And let me be clear that when I say school aged, I am talking about ages three, from the time when children can start in public education all the way up to age 21 and of course, when we start at the age of three, we are coming in with some special needs. We have qualified to be able to come into school practice. Number two, I want you to be able to identify reasons and events that impact child mental illness and how that impacts their ability to engage in occupation. And then, number three, recognize the role of occupational therapy and addressing these mental health issues. So covid, 19 has had some lasting impacts on everybody, and I know that some people are probably feeling that, oh, my goodness, you're still talking about covid. Yeah, I am, because it is still having great impacts, not only on our children, but public education as a whole, when I retired, it was in 2022 and I was really excited, because that was the year in 21 everybody was coming back into the school, and I was excited to have everybody back. And I was like, things are going to be back to normal. And oh my goodness, how wrong I was. That was the year that I saw the most challenging behaviors, not only in special education, but in regular education as well. And it was because of that that my desire to learn more about what is going on here, to make these significant changes in behavior, what's going on, and that is what got me to studying about how did covid impact our kids so but in order to do that, we have to look at three different sets of people. So I want you to envision, if you will, a triangle, and at the top of the triangle we're going to have teachers. In the middle of the triangle, we're going to have parents, and then at the bottom of the triangle, we're going to have children. And as I talk about this, I want you to understand that the anxiety and depression that's happening in our teachers rolls down to our parents. The parents picks up what is going on with our teachers, along with their anxiety and depression and stress, and it's coming down on the shoulders of our our school age children, and so just bear that in mind as we talk. So mental health continues to be a challenge again for all three of these groups of people, teachers, parents and students, and because of that, we are continuing to struggle both with things that have happened in the past as well as new issues that have arisen because of the changes that have come along because of covid. So new considerations have been surfacing, and it really does help us to better understand why there has been a shift in behavior. And I would love to know, you know, for those of you who are school based practitioners. Have you seen the same thing? And if so, I would love to hear what in particular that you're seeing. So let's do a little bit of review. Let's go back to March of 2020, when covid just literally stopped the world on its on the dime. Life as we knew it was no more. I mean, it would. I'll never forget. You know, I come home from work on a Friday, and then I get notified over the weekend that the school is closed indefinitely, that we're going to online learning, and they'll let us know when we can go back in the building. And as you sit. Process that you have to remember that none of us had a say in what was going on. So from teachers to parents to kids, we lost all control through no fault of our own, and as a result, too, public education took a massive hit because of covid, and because of that, it impacted mental health. Because think about it, where do our school age children spend the majority of their time? That is their occupation, that is their job. Is going to school. And so picture, if you will, that occupation has been taken away from them through no fault of their own, and they have no control. So as we were talking, the world has stopped. One day you're at work, the next time you're isolated, to be in your home for an indefinite amount of time, you've had no say in what is going on. You've had no control. You've lost it. And what do we like to do as human beings? We like to be in control of what we can be in control of, and that's very little. But when we've lost what we lost during covid, that's going to impact our income, that's going to impact our health, that's going to impact our socialization, and again, we had no say. Times were at best, uncertain. Parents were wondering, you know, am I going to continue to be the breadwinner? And on top of that, they also had to take on the responsibility of being the teacher, to ensure that while they're doing their job within their home, they also have to ensure that their child is on the computer, remaining engaged and getting and understanding the lesson that the teacher is doing through hybrid means. Children's occupation, again, school has been taken away, and now new norms and routines were thrown upon society. And to think about, you know, you've been clipping along all of your life, doing the same routine week after week, day after day, and all of a sudden you've got to come up with something new. Is really challenging. It's very stressful. So I know I'm just touching the tip of the iceberg, but please try and appreciate all of these challenges that happened. So everything's changing. What happened to our teachers? Our teachers were forced to transition. Let me move this over here. Transition in an erupt in an abrupt, short period of time, very little training on how to use digital resources, and in most cases, did not even have the equipment to adequately be able to do online teaching. Of course, I can only talk about the district that I was in, but you know, the teachers, they didn't have a choice. It was, you're going online, you're going to remain on the standards that we're expecting you to maintain. You're going to teach everything. And sorry, we don't have all the resources we're working on getting that out. Just a mess. And that was just in the district that I was in. I can't imagine what was going on in your part of the world. Research does show, and this was from one of my previous presentations, in order to master the art of teaching in a hybrid means typically takes a year and a half to master all of those skills, and we were told to have it mastered over a weekend. So let that sink in and give you some perspective. Okay, so as a result, I think this teacher's face pretty much says it all. We have our teachers who are now retiring and resigning at higher rates because of covid. One of the studies done by Rand in 2024 out of 1500 participants, a quarter of those teachers were still dealing with stress again. This is post covid. 60% of those 1500 are quote, unquote, burned out. Many report that stress and disappointments of teaching just simply is not worth it anymore. 59% of teachers reported being stressed, versus 78% in 2021 so it looks like the stress might have gone down a little bit, but nonetheless, greater than 50% that's a significant amount. Female teachers have more stress than their male counterparts. I found this really interesting, that teachers of color are less likely to report difficulty with stress or coping. Don't know the the reasoning behind that, but I thought that was a very interesting statistic. 22% are probably going to leave their job at the end of the year. 17% they're just going to stop teaching, that career, that profession, altogether, which just really hurts my heart. And then overwhelmingly, there was just a quote of. Quote, deep undercurrent of discontent. If you can get into the chat, tell me, do you still feel that there is an air of discontent in our schools today? This is going to be frustrating. Jayson Davies No worries. Money, money. I got you, um, I personally, I was just writing into the chat that like, in addition to all this, you also have inflation, and teacher wages not necessarily keeping up with inflation, so you had a mass exodus, and then people just being, like, not wanting, I think, to go into the teacher industry as much because lack of pay, plus the burden that they know teachers had during the pandemic, Dr. Monica Keen you are so right, and we're actually going to talk about exactly that in just a few slides. We're still in review, and we're talking about how the prevalence of anxiety skyrocketed from 10 to almost 50% in our teachers. Depression went from almost 16% to almost 30% and then stress overall from 12.7% to almost 51% those are gargantuous leaps and some very important mental health areas. So what about our families and again, iceberg for the teachers. Now let's go on to our families. The middle of that triangle. Here are some questions that I thought many parents were probably thinking about and just appreciate how this impacts their ability to keep a household up and running. Do I have a job? Am I going to work from home. How am I going to pay the bills? Am I going to work and be my teacher, my child's teacher? Am I How am I going to maintain the structure and routine now that everybody is home under the same roof, 24 hours a day, seven days a week, how am I going to take care of my family members that are sick? Why can't I go and be with my spouse who's in the hospital? How many of us know of friends or family who lost family members to covid while they were in the hospital and we could not even go in and visit with them? I miss my kids, or the children aren't handling this well, how am I going to be able to help them? Just think about this, if we as adults were so unsettled within our own selves, can you imagine how unsettling it had to be for our children? Some concerning statistics about what was going on in our families. In our homes, there was an increased concern about domestic violence. There was increased anxiety within the home, increased depressive symptoms, and 8.3% actually reported having suicidal thoughts and feelings. The increased negative interactions between our kids, including conflict, was higher and it resulted in the maltreatment of our children in the forms of yelling and shouting disciplining when disciplining was not needed, and the use of harsh words. And let me tell you something, as a person who has under you know, been verbally abused over my lifetime, the use of harsh words can be very devastating, and so here we are again, stuck in a home with these people, 24/7, no means of escape or a break. So let's talk about our little ones. Seven years and younger, increased clinginess and fear, not being cooperative, misbehavior, boredom, needing more attention. And we have to remember attention comes in both positive and negative forms. They just wanted more attention and then increase in anxiety. But yet, our children going into the teenage world, the puberty age, look how high the anxiety skyrocketed, almost from 2% to almost 24 Depression, depression in the ages of seven to 13, from 2% to almost 12% Post Traumatic Stress Disorder, three, 3% I Think that is significant simply because we're talking about an age bracket of seven to 13. Most problematic with our kid OTs were the changes in behaviors, the need for constant attention and reassurance, difficulties with academics. Let's talk about that for a minute. I can tell you that I am not the best hybrid learner. I'm a kinesthetic learner, where I need to see it, touch it, manipulate it, smell it, feel it, whatever, in order to get the best learning experience for myself. Well, that's not the case during covid at hybrid learning, our children were not able, some of them. We're not able to grasp the concepts. And I don't know if you have found this over the course of your career, but when you have a child who is not able to keep up with what's going on the in the classroom, I've noticed one of two things happen, either they shut down or they misbehave, and so we're having a situation where the children are also being advanced to the next grade when they haven't even mastered the concepts of the grade before them, and so once they get into that next grade, it just continues to pile on, on, on, putting more stress on our children, resulting in increased anxiety, increased depression, so on and so forth, and that is going to result in the misbehavior, anxiety, social isolation, when they just simply shut down and depression. All right, let's move on up into age adolescence. You know, during this time of adolescence, this is when they need the more most, quote, unquote, normalcy, right? And that was the least of what they were given during the times of covid. Studies showed that in our adolescence during covid, they were showing increase in depression, again, anxiety, PTSD, misbehavior, poor attention, increased impulsivity. You're going to see over and over, how these the areas of anxiety and depression just keep going up the ladder. So what is research showing? Now? This is where I got excited, because I've been waiting for this for a long time, and this is what I found out so far. All right, let me preface this by saying this is not, this is not a political agenda that I'm about to go over. When I did this in my last presentation, I forget where one of the comments said I think she was pushing her political agenda. And no, this came right out of research. So this is what our teachers are facing the end of federal pandemic relief funding. And so that means that the financial burden for them to bring supplies and resources into their classroom, a lot of it continues to fall on them. A new political agenda targeting public education, as we know, the Department of Education shut down, and that is where we get a lot of our help. For our educators. We are committed as educators to diversity and equity and inclusion, and especially as OTs, that is what we are driven to do. And so you know that has been threatened, deepening of inequities and access and support, and then evolving teaching as a profession. What Jayson was just talking about many of our teachers, again, they're just saying it's just not worth it. I'm finding over and over again that the support for our teachers is just becoming less and less, which, if they're not getting the support that they need, that is eventually going to bleed over into the classroom and with our students again. If you've got some comments about that, I would love to hear what you're noticing in your area of work. For our parents, our research is showing now that they're bringing in this concept, the reality of aces, adverse childhood experiences, and they are finding that if our parents had history of having had adverse childhood experience, and we're going to go over these specifically more in just a little bit that was going to directly impact how they handled themselves during the covid 19 pandemic. These adverse childhood experiences can have an impact on the individual's resilience, ability to cope, and how they regulate, how the parents regulate during their times of stress. Those who experience child maltreatment as an adverse childhood experience was more likely to carry out that same type of behavior on their children experiencing re traumatic events reported to have an increase during the isolation phase of covid, and mothers who experienced adverse childhood experiences were more likely to have less resilience, yeah, poor resilience during the covid experience. So now let's look at our children and our adolescents. Okay for our children, if they did not have a mental health diagnosis prior to covid, they were point one 5% more likely to develop one within two years post covid. If. They had a mental health diagnosis before covid, they were point 2.026% more likely to acquire a new one. And for our children, those usually played themselves out in developmental disorders and anxiety disorders, specifically ADHD and in some cases, conduct disorder. But when we looked at our adolescents again, if they did not have a mental health disorder prior to covid, they were point one, 9% more likely to develop one within two years. If they had one, they were more likely to acquire a new one in point zero 5% and for our adolescents that came in the form of anxiety disorder, substance abuse disorder, mood disorder, ADHD and increase in suicide attempts, that's very sobering, in addition To what this previous slide has shown you, in addition to depression and anxiety, again, our children, adolescents and teenagers, the gamut of the of our kids during their school, school age, time, PTSD, loneliness, I think that that is a very significant one that We need to pay a lot of attention to because how often do we hear children telling us that they're lonely? Psychological distress, anger? It's no to me, it's no wonder that these children do have anger, especially if they're not able to keep up in the classroom, especially if they have experienced something traumatic while they were forced to be home all of the time, and we have to remember as well that our young children do not have the verbiage to be able to express verbally how they're feeling, and so many of The times that expression is going to come out in the form of behavior. And we all know as OTs, behavior is a huge form of communication. There was an increase in irritability, increase in boredom, increase in fear and stress. And I thought this was fascinating as well. Eating disorders may have been reactivated secondary to covid, and that is because covid could have been a triggering event for those who had eating disorders previously, increasing the anxiety and the stress, thus causing them to fall back into what was familiar being their eating disorders. Any questions so far Jayson? Jayson Davies no questions. There's been some comments in there, but I was just going to say also, kids were at home all day. They were, you know, a stone's throw away from all the cupboards with all the food in it, as opposed to having to find eating times and defined school time. Dr. Monica Keen Exactly, and the parents as well. We have to remember, you know, they're trying to do their job. They're trying to make sure the kids are at, you know, sitting and attending in the classroom. It was just really chaos for a lot of homes. So I found this study, this meta analysis to be absolutely fascinating, notice, if you will. It was a cross sectional or a longitudinal study between America, Greece, Norway, Australia and Canada. They looked at children between the ages of eight to 18. They specifically looked at what were the levels of anxiety, pre covid and then post covid. So for anxiety, they gave specific results for America, Canada and Greece. And I'm not going to go over the numbers, simply because you can, you can read, but in each one, they increase. So for USA, 4.67 to 5.37 and then the same for Canada and Greece, it went up for depression, pre covid and post covid, they looked at America, Norway, Greece and Australia. And again, across the board, we are still seeing increased percentages in depression in all of those countries. So our children are not getting the interventions that they need to learn how to regulate and deal with the events that happened during covid, and they're still processing that. Jayson Davies All right. I hope you are enjoying this episode with Dr Monica keen. We're going to take a quick break, but when we return, Dr keen is going to dive into updated research as well as some practical strategies that we can use in the schools right now. Stay tuned. Dr. Monica Keen Okay, so now we're going to break into looking at aces trauma and resulting behaviors. And this is where I really got interested, because prior to the new statistics coming out about anxiety and depression, nothing was ever mentioned about adverse childhood experiences or traumatic events. It was this is what's going on, and this is why we're seeing an increase in anxiety and depression. But now they are saying that adverse childhood experiences did play a direct role in how our children were impacted during covid. So what is an adverse childhood experience? It is a preventable, potentially traumatic event that occurs in childhood. Now, when I read the word preventable, I read it as the child may not been able to prevent it, but it is something that did not have to happen, if that makes any sense. Some examples would be sexual abuse, verbal abuse, emotional and physical abuse, neglect, domestic violence, etc, etc. And there is an association when there has been a conglomerate accumulation of adverse childhood experiences and poor mental health, that goes to reason. But let's look at some specific things that happen when there is a buildup of those aces, emotional abuse, sexual violence and physical violence during dating was associated with increased substance abuse. If you experienced one to two aces during the pandemic, it doubled and possibly tripled your chances of falling into substance abuse. And if you experienced four or more of some aces during the pandemic, you had a higher chance of alcohol use, higher chance of binge drinking, and then a higher prevalence of increased alcohol during the pandemic, as well as a higher use of using marijuana. Now, thought this was really interesting as well. I learned that there are 10 original aces, and we now are looking to add more, which is going to be in the next slide. But let's look at what the original aces are, physical abuse. And again, these were labeled as preventable activities, not by the child, but the adult could have not done these things, physical abuse, emotional abuse, physical neglect and emotional neglect, two totally different things, but both carry impacting results. Parental separation, then divorce again, two things that are alike, but yet so totally different, domestic violence against the mother. Now, yeah, I'm sure that it is important if there's domestic violence against the father, but there's something more specific when the children witness it happening to the mother that it impacts them at a deeper level, substance abuse of a household member, mental illness of a household member, or incarceration of a household member. So these are the 10 original aces. And if we go to the previous slide that we looked at, remember we were talking about, if individuals had experienced these in an accumulation four or more, one or two or one, it will impact and increase their chances, as we talked about for alcohol abuse and substance abuse. So here are the ones that they are considering adding peer victimization. What does that boil down to? I think, for a child that's going to be bullying, whether it's cyber bullying, whether it's in person, peer victimization, battering, gambling problems in the household discrimination. And I want to kind of sit on discrimination for just a few minutes. Discrimination goes so far beyond the color of one's skin. In the previous presentation that I've done, there were specific statistics about the LGTBQ community for our adolescents and teenagers during the covid time, which pointed out that they had increased suicidal not only attempts, but also suicidal ideation. Because that community found its comfort and found its socialization and its peer connections in school, and so that was taken away, and they were back in a home where probably a lot of the parents didn't agree with the lifestyle, and so they were being judged, they were being condemned on a pretty consistent basis. And so when we see that word discrimination, let's make sure that discrimination covers a lot of different areas and not just race. The next two that we're going to talk about are really gaining a lot of traction in the world today as it relates to how it impacts our children's mental health. So contact with protective services that's not even talking about when they remove the child from the home, the mere fact that child protective services have come in into a situation in the home, again, where the child has had absolutely no control, and here they are being threatened to be removed from the home, even though that might be in that child's best interest, that is still the environment that that child is used to. That is their norm. That is where they have consistency, even though it might not be, probably is not positive consistency, the mere fact that that is being threatened and they're going to be removed from their parents, that is now considered an adverse childhood experience, foster care placement, again, being taken away from something that is so familiar to these children being put in an environment where they don't know anybody. They don't again, don't know the rules, the regulations, the schedule, the routine, and they are expected to adapt so very stressful poverty they want to add to the list of adverse childhood experiences, because poverty is going to directly impact their ability, the family's ability to get to resources, the things that they need, whether it's health care, food, being able to keep the lights on in the home, Being able to keep the water on when I talk to my students, when I'm teaching or when I'm presenting, especially to school practitioners, I always try to zone in on the fact that for children, for some children, school is the only place where they're going to get hot meals. Two of them, school may be the only place where they have electricity and running water, and so school is a safe haven for them. And so it's no wonder that poverty does play a role in being an adverse childhood experience. And then lastly, neighborhood violence is going to be added to the list as well. And I think that, you know, when we think about neighborhood violence, that comes in so many different ways, whether it's drug dealing, whether it's, you know, where active shooting is going on all the time, just neighborhood violence, where they see a lot of fighting in the streets, a lot of murders, neighborhood violence is going to be considered and with good reason to be another adverse childhood experience. All right, so in this particular study, mercera et al was looking at not only American children, but also Dutch children, and I found these statistics to be pretty disturbing as well. Almost 63% of high school students have experienced at least one adverse childhood experience out of the original framework that we talked about, the original 10 by the age of six, approximately 70% of children that from the US study longitudinal had experienced three or more out of eight of the 10 original aces for Dutch children nine to 13 years of age and regular ed. Regular ed reveal that approximately 45% had experienced at least one ACE in their lifetime, and 11% of those had experienced three or more of the 10 original aces. So again, we're not even looking at the other ones that are going to be added to the list, that for sure, we're going on in addition to the 10. So I put this in red because it's so important, adolescents who reported aces were more likely to experience depression, anxiety, drug abuse, antisocial behavior, suicidality and cognitive difficulties. All right, did you know that covid is now. Considered to have been a traumatic event. And I think that it should go without reason that that qualifies as a traumatic event. What I've done on this slide, and if I had the book with me, I learned it to one of my students. If you have not read the book, The Body Keeps the Score, oh, my goodness, please go get your copy tomorrow. That book was life changing for me, because it validates the fact that exposure to chronic trauma literally changes the biology of our brain. It alters our neural pathways and it causes different wiring within the brain, not that it can't be reversed, but to know that exposure to this trauma literally changes the makeup of our brain truly does validate why and how behavior is being impacted. So these were some of the direct quotes that I took from the book that I thought really hit home. Trauma results in fundamental reorganization of the way the mind and the brain manage stress. Recalling an emotional event from the past causes us to actually re experience that trauma, and we go back to the original sensations that we felt during the original event. Suppressing those inner cries for help doesn't stop our stress hormones from mobilizing the body when something terrifying happens, we will retain an intense and largely accurate memory of that event for a very long time. And lastly, and we've already spoke about this briefly, finding words to describe what has happened to you can be transformative, but it does not always abolish or stop the flashbacks or improve concentration. So again, think about our little ones who do not have the words to be able to talk about what happened to them and not express what happened to them and how that made them feel. So again, if you've not read the book The Body Keeps the Score, please get you a copy and check it out. So covid and trauma. As I said, covid 19 is now recognized as a traumatic event in the lives of some children, not all children, but some. And so with trauma comes trauma informed care, and I'm not certified in this form of intervention as of yet, but the components of trauma informed care are things that we can do at any given time in our interventions. And one of the things that I think is so wonderful about trauma informed care is that no longer do we look at the individual and in our situation, our children in the schools and say, What's wrong with you? Instead, we are now taking that approach of Tell me what happened to you. And that is such a huge shift in the approach that we're taking with our clients in order to make that relationship with them so that we can help them get past or deal with and better regulate their emotions trauma. Informed care also wants us to focus in and promote the resilience of our clients. We need to help them get back in touch with their ability to get better, their ability to regulate their emotions and their feelings, we need to get them back in touch with their ability to be to remember that they are resilient. The other wonderful thing about trauma informed care is that it really is client centered, and so you know, just like from Question one, we want to know what happened to them so that we can find out how that impacted them as a client specifically, and as OTs, when we pull on our mental health education and Our experience, we're going to help them to be be able to better navigate through that trauma, hopefully be able to give them some better cognitive strategies on how to reframe and rethink how they handled the trauma. So again, client centered care, it prioritizes a trauma. Informed care promotes and prioritizes trust and collaboration and so again, in order to have this with our client, we've got to build that relationship, and building relationships with individuals who have had trauma go on in their life is not and it's not meant to. Be an easy thing. We have to go back into our intentional relationship model and build that trust with that individual so that they feel comfortable sharing with us what's going on, and then we also you when we use trauma informed care, we want to promote the client's strengths. So instead of focusing on what they're having so many challenges with which is bringing down their resilience and it is causing increased anxiety and stress, we want to find and zone in on the things that they're doing well. We want to look at the things that they are strong in, and help them focus on that so that the other areas will come and improve with time. All right, the other thing about trauma informed care, and I know we're almost finished a trauma, informed care also has an acronym called cares, and it stands for context. We always want to understand what is the context of where our client is coming from, and so in this presentation, the context was, How did covid impact them? We want to ask questions. We we want to talk openly about the event so that they can identify the things that happen to them which are directly impacting their behavior or impacting their ability to engage in occupation and again, that's not going to come overnight. That is going to come from us using that intentional relationship model through therapeutic use of self to build that trust, respect and that friendship with our clients. Resiliency and resources is what R stands for, and we need to again, remember that we are focusing on their strengths, and we want to reinforce the resilience so that that, in turn, will decrease their stress. E stands for educate, and this is so incredibly important y'all, we have the privilege of being able to educate not only our clients, but the caregivers as well about how the trauma has impacted our clients, ability to engage in occupation, how it's impacted their behavior, If we don't understand why we're doing what we're doing. It makes it very difficult to appreciate the strategies that we are offering to our caregivers and our clients as to why they need to do certain things that that makes sense so by understanding or appreciating what our clients are going through as a result of an adverse childhood experience, as a result of trauma, that is going to help us better appreciate or understand what they are going through, and we can help open their eyes to the situation that they're in and teach them how To better regulate themselves. And again, this is for any age. School Based three to 21 we can we can work with any of those ages and educating and then self care. We want our clients to recognize that that trauma does produce stress, but we also need to remind them and empower them that engaging in self care, engaging in leisure activities, is going to help them better face the challenges that they are having, because self care always helps us feel better about ourselves. My question to you guys is, are you doing your self care, especially at this busy time of year? All right, wrapping things up, we're going to talk very quickly about internal versus external behaviors, and I do feel that we as practitioners probably cue into these things better than a lot of other professions internalized behavior. That is, of course, when we keep everything inside and we don't verbally express what's going on within ourselves, but it does come out in the form of being fearful, somatic complaints. I've got a headache. I've got a tummy ache, my neck hurts. You know, how many times have our kids in school come up to the teacher and said, on a daily basis, my tummy hurts, and we put two and two together, and we realize it's happening during a time when they're covering a subject that they don't understand. So somatic complaints are big worrying withdrawal, withdrawal and isolation, those are all examples of internalizing behaviors, whereas externalizing behaviors are going to be disruptive, aggressive, impulsive behaviors, and again, these are the children expressing how they're feeling through their behavior, and not so much through their verbiage. And what we need to do as the practitioner is not to react, but to respond and. And instead of getting upset to take that step back and to think about, what has this child gone through? What are they dealing with on a day to day basis, we need to be more aware of what is going on in our clients lives, so that we can better meet their needs through our interactions with them. And then lastly, what is our role as OTs? And so these are the things that I thought are so very important. Number one, please remember that every interaction is an intervention. I feel that we as OTs sometimes think that if we don't do an assessment or a test on a particular thing, then we're not addressing it, and that is so far from the truth. Every time we work with our kid OTs, we are addressing their mental health needs. Anytime you are hanging out with your friends, you're addressing their mental health needs. Every interaction that we do, we have the privilege of being able to know that we've done an intervention number two, that intentional relationship model be intentional in your relationships with everybody, but with our clients, especially those who have gone through trauma, when we're intentional and they can sense and that they know that we are truly interested in what's going on in their lives. That's where the trust is built, and that is where the relationship is formed using that therapeutic use of self. So so very important, we are the masters at that understanding the value of occupation. Now there's a difference in understanding what the value of occupation is versus engaging in occupation. Our goal is to get our clients to engage in occupation. So always know there's a difference between the two, but both of them are very important. What occupation is important to our clients? And once we've identified that, let's get them engaged in it. Know the occupation of your clients, and of course, we're going to figure that out through the occupational profile. And I would dare Gander to say that every time you go to get that kiddo out of the classroom to work with them, you need to be updating that occupational profile, because every single time you go to see that kiddo, they're not going to be the same. Their likes and dislikes might be the, you know, the same. They might vary a little bit, but we don't know when we open that door to get Johnny what kind of morning he's had. We don't know what Sarah had to deal with before she got to school. We don't know how Larry did on that test, and that just absolutely he bombed, and that's ruined the rest of his day. Always have that occupational profile being updated, become certified in tic trauma, informed care. I'm one that needs to fill that goal, but we can educate ourselves about what trauma informed care is, and we can go ahead and implement those the principles of trauma informed care. Always update the occupational profile and then lastly, but I think this is so important, appreciate the totality of your client's situation, being mindful of how the totality of what our little ones are dealing with will impact their behavior, and we can help them navigate beyond that journey. Help them to become successful in regulating their behavior and their emotions, but we must first understand, appreciate and gather the totality of what our kid OTs are going through with that the importance of occupation. This is the last slide. Occupations are the activities that people do every day to give their life meaning and purpose. Those can be done alone or with family or with friends. They can be done at home, at work, at school or in the community. Again, occupations are everywhere we go. Persons respond through adapting and innovation, whether occupations have been challenged or been threatened. This next one is so important, Adversity is not experienced the same by all people. That's one of the beautiful things about being an individual is that we experience things differently, and just because we experience things differently does not make our experience any less or any more than anybody else's. We as ot play a huge role in helping our clients adapt to their to occupations, as well as we are their biggest cheerleader to engage to participate back in those occupations, especially during their time of hardship and loss of OT, loss of engagement and occupation will not can it? Will impact the psychosocial well being of all individuals. So with that, I say thank you, and I am really interested in knowing if anybody has comments or questions. Jayson Davies All right, that wraps up episode number 200 thank you so much for tuning in to this special episode with myself and Dr Monica keen every time we have Dr Monty on the podcast. I love hearing from her. She teaches me something every single time, whether it is here on the podcast or in the collaborative like you just heard her presentation from plus, you know the knowledge is fantastic. I love it, but she is just also so inspiring, like she wants, she makes me want to do really cool things after every single time that I hear from her. Remember, if you want to dive deeper into this topic, and you want to earn one hour of a ot a approved professional development and access all the slides and resources from this course, you can do so by joining the school based ot collaborative at OTSchoolHouse.com, slash collab, you'll get this course as well as over 30 other courses, along with unlimited resources, our goal bank, our AI tools, everything to help make your life as a school based ot practitioner easier. Plus, if you do decide to join impact tier members also get full access to our back to school conference coming up this August that is packed with even more great content and more presentations to help you kick start your school year. Thank you one more time to Dr keen for sharing her expertise and for everything that you do for the school based ot community, and thank you for being a part of this 200th episode celebration. Thanks for tuning in. Really appreciate you being here, and I'll see you next time in Episode 201. Until then, take care. Amazing Narrator Thank you for listening to the OT school house podcast for more ways to help you and your students succeed right now, head on over to OTSchoolHouse.com Until next time class is dismissed Click on the file below to download the transcript to your device. Thanks for listening to the OT Schoolhouse Podcast. A podcast for school-based OT practitioners, by school-based OT practitioners! Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs. Subscribe now! Thanks for visiting the podcast show notes! If you enjoyed this episode, be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts. Click here to view more episodes of the OT Schoolhouse Podcast