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My first months working in school based therapy as a new OT left me feeling ill equipped and insecure in my skills as a therapist. Nothing humbles you quite like being a new graduate working in the schools does (any of your currently going through this stick with it. IT WILL GET BETTER I PROMISE!). Back when I was a new graduate and had just taken a contract position in Hawaii, I remember feeling WAY in over my head. I was to have a mentor help me become better acquainted with the ins and outs of providing occupational therapy in the school setting. However, due to heavy caseloads and distance between schools, I rarely got to meet her in person or talk to her on the phone. I was left to figure it out for myself. One of the many challenges I faced was collaborating to write, or working to write, GOOD IEP goals. I often came across goals such as the following: Jacob (pseudonym) will demonstrate improved fine motor skills in order to copy simple pre-writing shapes such as a circle, a square, a triangle, a cross and an X with 80% accuracy utilizing a tripod grasp in 4 out of 5 opportunities observed. I also have been guilty of writing cringe worthy IEP goals myself. Just taking a look back at some IEP goals I wrote three years ago, although well meaning, measurable, they were not. How I learned: Following a due process case, during which the settlement process I rewrote my OT related goal three separate times, I decided I had to do better. I had to make sure I was not absent minded and coming up with goals on the fly. I started thinking of it in these terms: Assessment --> Determines areas of concern --> goals --> services. Therefore, I needed to make sure that if I was recommending services for a student, the services needed to align with the students projected progress toward the goal. That lead to to discover SMART goals. A S.M.A.R.T. IEP goal Stands for S- Specific M- Measurable A- use of Action words R- is Realistic and Relevant T- Time limited Listen to our Podcast on SMART goals where we add an E to create SMART-E goals. Check it out on Here or on iTunes Let’s break these down from an occupational therapy perspective. S- Specific Often times, it seems simple enough to create a specific goal; however, without being specific about the academic or functional progress you would like to see, you are unable to also make this goal MEASURABLE (which is the next part). When I look at how specific the goal is, I’m looking at a functional occupational performance area that is relevant to the child’s academic success. If the child is unable to grasp a pencil appropriately, how does that impact their performance? If a child is unable to regulate themselves within the classroom, how is this impacting his or her performance within the classroom? BE SPECIFIC! If the child is fatiguing when writing due to the poor grasp, is the grasp impacting writing legibility? If the grasp appears odd, yet it is not impacting the child’s occupational performance, does it need to be changed? Get specific about how the child’s pencil grasp is impacting his or her occupational performance. M-Measurable Goals need to be measurable in order to monitor progress. If you are seeing a student for occupational therapy services once a week and write a goal that the child will perform the task in 4 out of 5 opportunities observed, how are you going to ensure you can measure this? Could the teacher measure this? (I have been guilty of not considering these factors in the past…. Which is why I learned to adjust and be more aware of my goal writing) Let’s assume that we’ve collaborated with the classroom teacher on Jacob’s goal. I plan to work with Jacob by pushing in and collaborating with the classroom teacher 2x month x 30 minutes to provide collaboration for Jacob to work on developing a more functional grasp as his current fisted grasp is limiting his control for writing letters with more refined movement and legibility. Proposed goal: By his next annual IEP Jacob will independently sustain a functional digital grasp (i.e. a tripod grasp) with writing and coloring instruments when performing classroom writing tasks in 3 out of 4 opportunities observed over a 2 month period. Being that I’m in the classroom 2 x month for 30 minutes, unless the teacher would be measuring this goal consistently, writing “4 out of 5 opportunities in a one week period" would not be measurable. furthermore, "4 out of 5 opportunities" observed could be measurable, but over what length of time? So be sure to get more clear on how you will measure your goal. You will find it helps to determine you service level and service type (consult, collab, individual-direct) as well. A- Action The action word in the above goal is "independently sustain". This indicates that the child is not being directed by the adults within the classroom. The goal is that he be able to pick up and position writing and coloring instruments with a digital grasp without adult intervention. I have a personal preference for writing goals in which the child is able to complete the gaol at a level of independence or with no more than one prompt or redirection. I do this because as an OT I’m focused on developing the “Just Right Challenge” for students in order for them to be successful and advance their abilities. This leads to the next part of S.M.A.R.T. goal criteria. R- Relevant and Realistic The Goal needs to be child centered, therefore it should inherently be relevant. The goal should be relevant to the child’s educational setting and address the identified areas of concern. Realistic is developing the “Just Right Challenge”. We want to develop a goal that is challenging enough to advance the child’s skills to the next level; however we do not want the goal so difficult the child is unable to meet the goal within the given time frame. Developing a realistic goal relies on establishing a baseline for the child or looking at his or her present levels. When I write a goal for a student to be independent in a skill, it is because I see prompting as a means of teaching the skill or getting the child to learn the task. If the child would be unable to perform the skill without “hand over hand” or even “moderate assistance” it may be that the goal is not at a “Just right challenge” and we may need to take a step back and look at the child’s present levels of performance. By keeping the “Just right challenge” in mind, we can make sure that the goal is relevant as well as realistic. How do you make sure your goals are relevant? Download our School-based Occupational Profile form and you will be on your way to knowing exactly where to start when developing SMART goals for your students. Just hit the subscribe button to get the Occupational Profile form plus two other freebies that will help with you and your students! Subscribe T- Time limited Writing an annual goal is SOOOOOO difficult. I mean it is ONE ENTIRE YEAR AWAY! That is why we not only write an annual goal, but also develop short term objectives as well. When looking at this step, establishing a baseline is crucial even if the student does not perform the task at all. It may be that prompting and cues are within my short term objectives; however they would not be in the actual annual goal. A Baseline for Jacob needs to contain similar verbiage as the goal. Jacob’s Baseline might read: Jacob independently holds writing implements with a functional digital grasp in 0 out of 4 opportunities observed over a 2 month period. Note: I did not write a baseline stating Jacob holds his pencil with a fisted grasp. Or Jacob has difficulty holding his pencil. The reason is that this is not establishing a baseline from which to measure the goal. When considering short term objectives I may incorporate adult support in the form of prompting For example: By reporting period 1 When provided with demonstration cues from an adult Jacob will demonstrate functional digital grasp (i.e. a tripod grasp) of writing and coloring implements when performing classroom writing tasks in 3 out of 4 opportunities observed over a 2 month period. By reporting period 2 When provided with verbal cues from an adult Jacob will demonstrate functional digital grasp (i.e. a tripod grasp) of writing and coloring implements when performing classroom writing tasks in 3 out of 4 opportunities observed over a 2 month period. By reporting period 3 When provided with no more than one verbal cue from an adult Jacob will demonstrate functional digital grasp (i.e. a tripod grasp) of writing and coloring implements when performing classroom writing tasks in 3 out of 4 opportunities observed over a 2 month period. At the final objective he would become independent. So remember: S- Specific M- Measurable A- use of Action words R- is Realistic and Relevant T- Time limited Here's a color coded version of the goal for you to reference to you. By his next annual IEP Jacob will independently sustain a functional digital grasp (i.e. a tripod grasp) with writing and coloring instruments when performing classroom writing tasks in 3 out of 4 opportunities observed over a 2 month period. Final words: I absolutely loved writing this short article. It made me more aware of my own process when establishing IEP goals. I hope it helps with your goal writing in the future. I typically try my best to collaborate with teachers, parents, and even the student when developing relevant goals and hopefully I am not the only individual responsible for measuring the goal. The majority of the skills OTs work on are performed everyday within the classroom setting. Writing S.M.A.R.T. IEP goals will not only make your job easier in the long run but it will help to better assist the team in monitoring child progress, needs, and help to determine the continued need for occupational therapy. I hope reviewing S.M.A.R.T. IEP goals helps with your next IEP as I’m sure writing this blog post has made me more aware of my own goal writing! If you enjoyed this article and would like to know when we post another, subscribe below! When you subscribe, you will also receive a digital download of our Gray-Space paper package which includes 9 pages of adapted paper to help kids with writing in at all grade and skill levels.

As many of you following OT School House on Twitter and Facebook know, this past weekend Abby and I had the opportunity to attend the Occupational Therapy Association California (OTAC) Conference in Sacramento. One session we both attended was titled “School-Based Telehealth: Bringing Services to Any Child, Anywhere” presented by Joann Sorg, M.S., OTR/L Although neither Abby nor I practice via virtual means, we both came away from this session actionable lesson learned that us "traditional" SBOTs (Yes, I am making up a term to shorten School-Based OT) can greatly benefit from. With the obvious difference between traditional and telehealth school-based OT being the location of service, Joann quickly emphasized the necessary organizational skills required. But, there were five key takeaways that stuck with me that I thought we could all benefit from. So let’s jump into it! 5 Tips Learned Don’t Waste Time! Neither Yours, nor Your Colleagues As a telehealth provider, Joann is not able to simply pop into a classroom. She has to schedule a time with a teacher or paraprofessional who then has to log the student into her virtual classroom. If there is lack of communication, this process can take up valuable time. Unnecessary conversations with aides, teachers, or other staff can also cause a child to be waiting for her to login at another school site. Like Joann’s time, your time, the teacher’s time, and also the student’s time is unfortunately limited. And we cannot afford to waste any of it with high workloads and several schools to be at. In order to prevent wasted time, we must be organized and set boundaries. There should be dedicated times scheduled for treatment and dedicated times scheduled for collaborations, IEPs documentation, and other functions of your job. Stay tuned for a post about how to complete a workload study to help justify needing another OT or COTA! If you need to collaborate or consult with a teacher, schedule a time in advance with the teacher. With technology now, it's so simple to communicate and plan a consult. Likewise, make sure you schedule your services with the IEP team to ensure no overlapping services or wasted time while waiting for a student to come back from recess. I used to have one parent who required a calendar of all service times for her child. As much as it frustrated the IEP team to have to do this, it was nice knowing that that student would be expecting me or the COTA every Wednesday at 9. It was our time and everyone knew what to expect. We All Need to Change Our Mindset About Service Model Delivery Do you default your service frequency to 2 or 4 times a month for 30 minutes per session in a pull out setting? If so, how are you justifying the same treatment frequency for each Individualized Educational Program (IEP)? Do they all really need the same amount of time, or is it just easier to schedule in 30 -minute blocks? I am definitely guilty of this. Occasionally I will change my minutes to 15 if it is a consult or a young kid who has a limited attention span, but for the most part my kids are mostly scheduled for 30 minutes even though I know some require more than others. It’s time to get out of this rhythm and really evaluate how much time is necessary to meet the child’s goals. Remember, goals drive services, and if you can help a student meet their goals in less than 30 minutes per week, then go for it! Having the Right Materials The first question that popped into my head while listening to Joann was “How do you know what materials the school site has to work with? Do you mail them materials?” The simple answer: No, she doesn’t. She simply uses what is available at the school and in her office She actually has the benefit of having her own office at home with all the materials she could possibly need (and then some, with all the tools on the computer). But what I took away from this was that even though she was on a computer, Joann still had a room to work with the student and the on site aide had materials at her disposal should Joann ask to use them. I don’t know about you, but I might give up my right leg to have a room with adequate materials at each school site... Later that night at the conference, someone compared OTs to surgeons. They said, “You wouldn’t ask a surgeon to operate outside an operating room, so why should we be asked to treat in a closet?” I feel like this is true and I’d love to hear how you all are advocating for our need to have an appropriate work space and materials. I have figured this out at some schools, but not all. Drawing With Letters Okay, this one is pretty straight forward. I just thought it was a really cool idea that I was surprised I hadn’t heard of before. And it really is simply drawing with letters! As you can see in the 2 links below, these resources help kids to learn their letters through pictures in a similar way teachers use animals and objects to teach sounds. Check them out by clicking on the affiliate photo! Don’t worry, they will open in a new page so you can finish reading ;) And finally (and possibly my favorite lesson learned) Building Capacity in Teachers and Aides! I feel as though us OTs often take our perspective and knowledge for granted. This often leads us to not communicate valuable tips to teachers, aides, and parents even. For instance, we might see a student and think to ourselves “this kid needs a footstool so that he can support his trunk and improve upper extremity use instead of holding onto the desk for dear life.” But we just say he needs a footstool… That there, was a missed opportunity! We could have explained to the teacher why we are doing what we are doing and what they can look for in other students who may require similar supports. By explaining to our colleagues the reason behind our seemingly odd suggestions, we help to build capacity in their ability to help many other children who we may never encounter. Likewise, we can build capacity through inservices. I’d like to challenge you to approach your principal and ask if you can give an inservice at an after school teacher meeting. Maybe it’s a simple 15 minute lesson on ergonomics for both students and teachers. Or maybe it is more specific like an Autism Awareness training at a site that has several students with autism. Either way, you are building capacity in the people who really do have the power to help make your job easier and help more students. So, to finish this one up I hope you feel encouraged right now! Hopefully, some of you will even take me up on this challenge and let me know how it went. Or, if you already have done this, please share your experiences below. I look forward to hearing how you all are making a difference at your sites. Until next time, Jayson

Cutting to the stickers Cutting stickers on a line or shape can be a huge motivator for a kid who’s already bored of trying to cut to a highlighted dot . Especially, if you’ve got some really cool stickers. This is a great activity for both kids just starting to cut or those trying to improve their cutting skills. Cutting around stickers For other kids, trying to cut on a line in order to prevent cutting a sticker can be a huge motivator. Grab yourself some of these emoji stickers and your kids will go wild. This is also a great activity that can be shared with you teachers as an RTI/MTSS strategy Place a sticker where the student places their thumb when cutting For those kids who can use the scissors, but struggle to manipulate the paper with their non-dominant hand or try to hold the paper with their thumb down, place a sticker where the child should put their thumb while cutting. Connecting the stickers Just like you can cut from one sticker to another, you can also have your student connect the dots with their favorite color writing utensil. Add some letter or number stickers to add an academic flare to it. Sticker chart/card When used with fidelity, a sticker chart in the classroom can have great benefits. However, since the students often come to me, I have them carry a sticker card. Every time they come to therapy and complete an agreed upon task, they earn a sticker. Be sure to follow up with the agreed upon reward when they get all their stickers. Spelling words Another great activity to introduce to your teachers and kids. Building spelling words with stickers not only makes the task more fun, but also provides a fine motor skill building opportunity. Typing There are a few ways stickers can be used to promote typing skills. One way is to cover up the letters on the keyboard with stickers. That way, the kids have to rely on remembering where the letter should be and what finger to use. The other way is to code the keys with stickers that identify which finger to use. For example, keys, y, h, n, m, j, and u may have red stickers signalling that my right index finger is to be used. You can find stickers specifically for this use on amazon. Spacing words Does your student have difficulty understanding the abstract idea of a space in between words? Let them add a sticker in between each word until they are able to space without them. You can also have them write a few words or even a sentence and then see if a sticker will fit in between each word. Place the sticker on the _____________! The simple act of peeling and placing a sticker on a pre-determined spot, whatever the spot may be, is a great fine motor and visual motor integration activity. Incorporate body parts, classroom tools and multiple steps to work on a variety of different goals. Starting dot for letters Just like us adults need a little help to get started on a new goal, so do our students. Stickers as starting dots for their letters help them to develop a top-to-bottom, left-to-right approach. Be careful with some of your “Magic C” letters though. There’s more than one way to start a circle at the top. Finger twister Check this out! One of my favorite games from childhood now comes in finger size. Great for small groups, this game will help your kids to build manual dexterity skills along with gamesmanship and body awareness skills. Purchase it HERE, Or you can use a few different stickers, like I did over here --------------> and save yourself a few bucks. So, grab some stickers and go have some fun with your kids. They’ll love the fun and you’ll love the progress they make. Check out these cool Emoji Stickers to get you started! What are some of your favorite therapy treatments involving stickers? We’d love to hear about them!

If you are starting a business, you need an elevator pitch. That two sentence routine statement that states what your business is and why it is going to be successful. If you are a school-based OT... You need a staff room response. This staff room response is a way to ward off the unnecessary and misinformed staff room referrals. You know, when a teacher you barely know sees you in the staff room and asks if you can assess a child in his/her class. The teacher states the student cannot stay in their chair and absolutely hates writing. So what do you do? Give the teacher a referral packet to fill out with an assessment plan. Give the teacher a strategy that make help the student and ask them to get back to you in a week. Tell the teacher to schedule an IEP for the student to discuss the concerns. I have used each of these strategies at one time or another. And in this particular case, I propose that option 2 is your best solution. I’m not going to get into what your strategy might be in this post, but if you can give the teacher a strategy that has a positive effect in this student’s ability to stay seated and write at their desk, then you may have just saved yourself however many hours an assessment, IEP, and treatment would have taken. If it doesn’t work, well then you have options. Try another strategy for a week or two, or you can propose as assessment. Options 1 and 3 are both viable solutions, but may result in the same recommendation from you, but only after several hours of evaluating and weeks of the child continuing to have difficulty in the classroom. So to get back to your staff room response. It may look something like this: “Oh, hello Mrs. Appleseed. Thank you for bringing this concern to me. Have you tried using some theraband around the legs of his chair so that he can fidget in his seat appropriately? No? Would you like me to provide you with some theraband so you may try it? Also, here is a simple data sheet you can use to track how many times he is up and out of his seat in a day.” This plays directly into the RTI/MTSS model and would be considered a level 2 strategy. It also allows something to be put into place immediately rather than in 60 days after you have assessed. Click here for more information related to OT and RTI/MTSS Whether the this is a general education or special education student, this still applies. One disclaimer, I guess you could call it… You want to try and prevent the teacher from identifying who the child is. Under RTI/MTSS level 2 strategies, OTs are not to provide strategies for specific students. Rather, it is meant to be used for general concerns. The concern being a student having difficulty with completing work due to being out of his/her seat in this case. So I hope this helps you save some time this school year and allows you to help more students at your schools. As always, we’d love to hear your feedback and would like to help in anyway we can. Comment below and don’t forget to subscribe so we can let you know as soon as the next post in this series is available. Until next time, -Jayson

Multi-Tiered System of Supports (MTSS) & Response to Intervention and Instruction (RTI2) If you have never heard of these two terms, prepare to have your mind blown because they are designed to help all students, no matter what level they are at or what type of class they are in. They even incorporate Universal Design, which I find amazing. They just call it UDL (Universal Design for Learning). In this post, I am going to give you a brief description of these models and show how you can insert yourself into the system to help more students while completing less assessments. Already familiar with RTI & MTSS , check out this post for specific Tier 1 strategies you can use. Getting to know RTI and MTSS So a little background on RTI2 and MTSS. Originally RTI2 was just RTI, or Response to Intervention. They then added the second “I” (Instruction) and made it look really cool with the 2 superscript (that I don't know how to do) and RTI2 was born. RTI2, as is sounds, is directly related to academic instruction and establishes a 3 tier system. Multi-Tiered System of Supports was then developed and basically said RTI2 is cool and all, but you forgot the non-academic side of things such as the social well-being of a student, UDL, and the non-teaching staff at the school, like us OTs. Thus, MTSS inherently incorporates RTI2. Also, both models relate to students in both general education as well as in special education. Thus, this system should help to keep students with an IEP in the least restrictive educational placement, that we all know is super important. The 3 Tiers RTI2 and MTSS both use a 3 tier system that is best depicted as a pyramid. OTs are uniquely positioned to be a part of all 3 tiers as you will see. Not only to we have the strategies that students can benefit from, but we also have the knowledge of how to research strategies and to use data to track if a particular strategy is working. So let’s break it down as it relates to us OTs! Tier 1: General Strategies Designed to Assist ALL Students & Staff The title says is all! Tier 1 is about researching and educating all parties so that we can best support every student under the watch of every school employee. This post, in fact, is a Tier 1 approach. Everyone reading it is learning about how to better the outcomes of their students. Likewise, trainings, conferences, inservices, webinars, staff meetings and collaborations are all tier 1 strategies. One example of how you as an OT can participate and lead in a tier 1 strategy at your school site(s) is to lead an inservice at your sites about proper posture and ergonomics in the classroom. This way you are teaching 10-to-20 teachers how to walk into their classroom the next morning and adjust their seating arrangements to help 30 students each. Or you could attend an administrators meeting and introduce them to a handwriting curriculum for the primary classrooms. You could then collaborate with teachers to co-teach a few lessons of the program in the classroom. That way they feel more comfortable and can ask any questions they might have for you. Both of these types of inservices are a great investment in your time and could save you plenty of referrals over the years. For 3 specific and targeted Tier 1 strategies, check out this post! Tier 2: Targeted Group Collaboration For the students who don’t respond to the general strategies in tier 1, they may need a more targeted approach. This may look like a small group instruction, classroom observation, or a specified collaboration with a teacher or administrator. For instance, you may have a 2nd grade teacher approach you and say I have a group of students who are just not understanding how to space their words. They use a handwriting program daily, but these 3 students just are not getting it. As a tier 2 intervention, you could observe this 2nd grade class and provide targeted strategies to use with students who appear to be struggling with spacing. You could also provide co-teach a lesson within the class regarding spacing. You could also check with the administrator and teacher to see if they would be open to you doing a small group center in the classroom for a few weeks. For those who are still not responding (hopefully not many), there is tier 3. Tier 3: Targeted Individual Collaboration When I think of Tier 3, I think SST, or Student Study Team. For a student who is not learning through general strategies or targeted group collaboration, an SST is the next option, if not an evaluation for an IEP. As part of a tier 3 strategy or SST, you as the OT may complete a classroom observation with parent permission in order to watch the student. *With an SST you must have gotten parent permission to do this.* After the observation, you should meet with the Student Study Team and put into place a goal and strategy that can be carried out by the team. You may recommend a goal or goals and instruct the staff on what can be done to help the student meet his/her goal, but without a formal assessment, it is my opinion that, skilled OT services should not be implemented. Click here to see how you can respond to a teacher asking you in the staff room to assess a student A few Things to Remember RTI2 and MTSS are relatively new models that are still being worked out in their relationship to IDEA. Thus, make sure that you are checking this source with your state OT guidelines and your district policies. A lawyer once told me, “When in doubt, assess!” While I do use this motto in my decision making, the 3-Tier system has helped me to reduce my referrals and spend more time treating students and collaborating with teachers. The process outlined here is a powerful and beneficial tool to help understand and leverage the system in order to improve your school based practice. I hope this article helps you make some clinical decisions in your OT department and maybe even help to structure your district's referral policies. You can continue on to the next post in the Reducing Referrals, Staff Room Referrals and Your Staff Room Response! Let me know your thoughts in the comments below. For more information about how to improve your school-based OT practice Subscribe now below! Until next time, -Jayson

I don’t know about you, but I’ve never met a school-based OT who isn’t inundated with initial referrals and triennial evaluations. If it’s not one, then it’s the other that has you burnt out looking like this -----------------> Last year, the ‘16-’17 School year, I completed 61 assessments with 25 of those being initial assessments. The year before that, I was closing in on 70 evals with 38 of those being initials. When I look at those numbers, I see two things. I see a nice decrease in the number of initials. But More Importantly, I see the hours wasted assessing kids when I could have been providing effective & proactive treatment. From the file review and interviews to the observations to standardized testing, they all take up time. Then you have to score the testing, synthesize the results, and write it all up! Don’t forget the IEP you now must attend. You are easily looking at several hours worth of time put in for each assessment. Time to make the Change! What would it look like like if we were to back some of that time assessing and replaced it with occupations that could be helping far more kids while preventing new referrals? As I like to put it, I can help a single kid, or maybe even a small group of kids, once a week for 30 minutes after completing an assessment. Or, I can assist a teacher for one hour a week and help who knows how many students. 30, 60? It really only depends on how long that teacher teaches for. My Proposition: Help Your Teachers! You have got to help the teacher, your principal, or whoever it is who is thinking about referring student to you. You can’t wait for them to come to you with the name of a student. You are too late at that point. A Special Education Lawyer will tell you, once an educator has approached you with a concern about a specific student, you are required to do an assessment. Even though you feel the student obviously doesn’t need skilled OT, you are obligated to completing that eval simply because a teacher has asked you for a child-specific solution rather than a general strategy. With that being said, over the next few weeks we are going to share specific actions you can take to reduce the amount of referrals you receive while helping more kids than ever. This will not, and is not meant to, get rid of all referrals, but it should help to prevent a few unnecessary ones. It helped me to reduce my referral count by 13 or about 30%. Isn’t that what we all want in life? Less evals and more fun therapy time? So, why wait? Let’s get started! Click Here to read the first installment of the Reducing Referrals series. The first article in the series in about full classroom RTI2 /MTSS groups and how you can get started reducing your referrals today! Also, please do share below what you are doing in attempt to reduce the amount of referrals you receive. Share us on Social too!