The role of occupational therapy practitioners in educational systems is expanding

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1 National Survey of Occupational Therapy Practitioners Involvement in Response to Intervention Susan M. Cahill, Beatriz McGuire, Nathaniel D. Krumdick, Michelle M. Lee MeSH TERMS education, special educational measurement health knowledge, attitudes, practice models, educational occupational therapy professional role OBJECTIVE. We sought to describe occupational therapy practitioners perceived levels of preparedness for and involvement in school-based Response to Intervention (RtI) initiatives. METHOD. We mailed a survey to a random sample of 1,000 practitioners from the American Occupational Therapy Association s Early Intervention and School Systems Special Interest Section. RESULTS. Of 295 returned surveys (29.9% response rate), 19 were excluded because of missing or incomplete data. Three-quarters of respondents (77.6%) reported that their districts implemented RtI. Two-thirds of respondents (66.3%) indicated that lack of resources limited their involvement in RtI; two-thirds (67%) said that district guidelines that describe expectations for practitioners involvement would help increase their participation. Many respondents cited the need for continuing education and supported moving from a caseload to a workload model. CONCLUSION. Occupational therapy practitioners would benefit from specific district guidelines outlining the services they are able to provide within the context of RtI. Cahill, S. M., McGuire, B., Krumdick, N. D., & Lee, M. M. (2014). National survey of occupational therapy practitioners involvement in Response to Intervention. American Journal of Occupational Therapy, 68, e234 e org/ /ajot Susan M. Cahill, PhD, OTR/L, is Assistant Professor, Occupational Therapy Program, Midwestern University, st Street, Downers Grove, IL 60515; scahil@midwestern.edu Beatriz McGuire, OTD, OTR/L, is Occupational Therapist, Wheaton Public School District, Wheaton, IL. Nathaniel D. Krumdick, PhD, is Assistant Professor, Department of Clinical Psychology, Midwestern University, Downers Grove, IL. Michelle M. Lee, PhD, ABPP, is Professor, Department of Clinical Psychology, Midwestern University, Downers Grove, IL. The role of occupational therapy practitioners in educational systems is expanding beyond providing traditional services to students with individualized education programs. Practitioners are collaborating with teachers and other team members to support general education students within the context of Response to Intervention (RtI; Cahill, 2010; Cahill, Holt, & Cassidy, 2008; Clark, Brouwer, Schmidt, & Alexander, 2008; Reeder, Arnold, Jeffries, & McEwen, 2011). Response to Intervention is commonly defined as a team-based, multitiered problem-solving framework that relies on data-based decision making to support students who are at risk for academic failure because of learning or behavioral difficulties (Batsche et al., 2005; Brown-Chidsey & Steege, 2010; National Center on Response to Intervention, 2010; VanDerHeyden & Burns, 2011; Vaughn & Fuchs, 2003). Within the RtI framework, problem solving is a key component. The RtI process of problem solving has its roots in behaviorism, and the systematic implementation of the problem-solving process has much in common with the functional analysis process that also grew out of this tradition (Fuchs, Mock, Morgan, & Young, 2003). The problem-solving process consists of four steps: 1. identification of the problem, 2. generation of hypotheses that account for the cause of the problem, 3. development and implementation of a plan to address the problem that is conceptually congruent with the proposed hypotheses, and 4. evaluation of the effectiveness of the plan in diminishing the problem. (Fuchs et al., 2003; Telzrow, McNamara, & Hollinger, 2000) e234 November/December 2014, Volume 68, Number 6

2 Personnel who use the RtI framework rely heavily on continuous student progress monitoring supported by data for decision making (Batsche et al., 2005). Another key component of the RtI framework is that it is multitiered. The foundation of the RtI framework is Tier 1, which consists of a scientifically based curriculum and sound instructional practices, such as quarterly universal screenings with curriculum-based measures (Brown-Chidsey & Steege, 2010; VanDerHeyden & Burns, 2011). Fuchs et al. (2003) suggested that Tier 1 provides a quality control framework to ensure that all students receive a scientifically validated base for learning. Tier 1 instruction takes place in general education. The curricula and instructional practices at Tier 1 are to be appropriate and applicable for all of a district s students, including those who are considered culturally and linguistically diverse learners (Collier, 2010). In theory, 80% of students should have their learning needs met by interventions provided in Tier 1 (Batsche et al., 2005; Burns, Appleton, & Stehouwer, 2005); an estimated 15% 20% of students will not be successful with Tier 1 interventions alone (Burns et al., 2005). Students who do not make adequate progress in response to Tier 1 interventions receive Tier 2 interventions. Tier 2 interventions are generally provided in small, homogeneous groups based on continuous progress monitoring data (VanDerHeyden & Burns, 2011), which is designed to capture the student s progress as it relates to the group intervention at specific time intervals. Student data are then used to make decisions about whether more intensive intervention is warranted. Tier 2 interventions and data collection are intended to clarify which prerequisite skills and contextual factors a student needs to maximize learning on the basis of the student s response to systematically introduced group-based interventions. Data may be collected on a weekly or biweekly basis (VanDerHeyden & Burns, 2011). Only 2% 5% of students should require an additional degree of intervention beyond Tier 2 (Burns et al., 2005). Interventions at Tier 3 are intensive. Tier 3 interventions are based on an individual student s needs and are provided to students individually or in pairs. Data at Tier 3 are gathered weekly at a minimum (VanDerHeyden & Burns, 2011). In many cases, Tier 3 interventions are designed to provide the team with information related to the cause of a specific student s learning difficulty and, in some cases, a student in Tier 3 may participate in a comprehensive interdisciplinary evaluation to determine eligibility for special education and related services (Brown-Chidsey & Steege, 2010). Only 5% 10% of children in general education are expected to require intervention at Tier 3. In sum, the key components of RtI include a scientifically based core curriculum, data-based decision making, universal screening, progress monitoring for students receiving intervention, and evidence-based interventions that intensify based on a student s progress or needs (Bradley, Danielson, & Doolittle, 2005; VanDerHeyden & Burns, 2011). Review of the Literature Few studies have described how occupational therapy practitioners work with educators to support general education students in RtI models, and none have described practitioners perspectives on working in such initiatives. In addition to directives from the American Occupational Therapy Association (AOTA; 2007) that outline the functions practitioners may engage in while working in an RtI model, several articles have provided recommendations for practitioners at each tier (e.g., Cahill, 2007; Cahill et al., 2008; Chandler, 2010). These articles suggest that although occupational therapy practitioners can work effectively with team members at different tiers, more research is needed to understand the range of activities in which they may participate and whether team members value their participation. A search of the literature revealed only two studies that examined specific interventions that occupational therapy practitioners developed and implemented in RtI (Clark et al., 2008; Reeder et al., 2011). Clark et al. (2008) described a case in which an occupational therapist worked with a teacher to identify a first-grade student who was at risk for handwriting difficulties and to develop Tier 2 interventions to support the student. Although the traditional implementation of RtI models involves universal screenings given systematically throughout the school year to identify students at risk for learning difficulties, the student described by Clark et al. (2008) was identified not through universal screening but when her teacher presented her case to the school s teacher assistance team (TAT). (TATs were a precursor to RtI implementation teams, and many TATs have evolved to implement RtI; VanDerHeyden & Burns, 2011.) Once the student was identified as having needs, Clark et al. (2008) used the Iowa Writing Assessment and Norms (Clark, 2005) to compare the student s performance on handwriting tasks with that of her peers and administered the Print Tool (Olsen & Knapton, 2006), a functional assessment of handwriting that also provides corresponding intervention activities based on a student s areas of need. On the basis of the information from these tools, the occupational therapist, the student s teacher, the student s mother, and the school s support teacher developed a plan for remediation. In addition, this team established target handwriting outcomes for the student based on the Print Tool The American Journal of Occupational Therapy e235

3 (e.g., the student will correctly space words 90% of the time during the next Print Tool administration). The support teacher worked with the student in a small group and followed recommendations from the occupational therapist. The support teacher collected progress monitoring data every 2 wk for the handwriting outcomes developed by the team. After 8 wk of intervention, the TAT determined that the student exceeded the established outcomes and no longer needed Tier 2 interventions related to handwriting. Reeder et al. (2011) published a case study in which occupational therapists and physical therapists participated in the implementation of a four-tiered RtI model in a school district in Texas. The therapists volunteered to assist with screening 60 prekindergarten students using FirstSTEp (Miller, 1993), a screening tool used to evaluate preschoolers for developmental delays, at one of the schools included in the study. In addition to participating in the screenings, the therapists provided recommendations to educational teams and regularly attended problem solving support team (PSST) meetings at both schools. One outcome of the therapists participation was the development of a flowchart that outlined how and when they participated in RtI. For example, at Tier 1, the PSST identified students with sensory or motor concerns. At Tier 2, the therapists made recommendations that the teacher and other classroom staff implemented. At Tier 3, the therapists observed a student with the parent s consent and made specific recommendations based on the findings from the observation. The PSST added a fourth tier to the standard RtI model to determine whether this student needed to be referred for an initial evaluation for special education, including related services such as occupational therapy. In addition to the flowchart, other outcomes involved the teachers understanding of the role of occupational therapy. As a result of participating on the PSST, general education teachers requested technical assistance with fine motor skills and handwriting and support for students who were in constant motion (Reeder et al., 2011, p. 51). Twenty-one students received occupational therapy related RtI services during the course of the study; 8 received Tier 3 supports, and 13 received Tier 1 and 2 supports. The specific outcomes for the students receiving occupational therapy related RtI services were not reported. It was noted, however, that 8 students had needs related to handwriting, 6 had needs related to fine motor skill development, and 6 had needs related to focus or sensory processing. The results suggest that including occupational therapy practitioners early in the problem-solving process increased their ability to collaborate with other educational team members and identify children at risk of needing their services. None of the current literature focuses on the overall level of occupational therapy practitioners involvement in RtI and their attitudes toward being involved in such initiatives. We searched the literature to better understand the perspectives of practitioners related to working in RtI initiatives and did not find any studies. Purpose Previous research related to occupational therapy practitioners involvement in RtI has described case applications of the RtI framework to a specific district or specific interventions. AOTA implemented a practice advisory regarding the involvement of practitioners in RtI (cf. Bazyk et al., 2012), and educational agencies are adopting RtI models.eachstate,however,determineshowrtiwillbe implemented, and each school district exercises local control. Given the varied implementation of RtI, an examination of the RtI activities in which practitioners are involved and their attitudes regarding involvement in such initiatives is critical. Our purpose in this study was to describe how occupational therapy practitioners across the United States are involved in RtI and their attitudes toward being involved in such initiatives. Specifically, we describe four areas: current involvement of occupational therapy practitioners in RtI, beliefs of practitioners in relation to their participation, perceived barriers to practitioners involvement, and factors perceived as facilitating practitioners involvement in RtI. Method Research Design We selected a survey design because it allows for efficient data collection from a large sample (Fowler, 2009). Our study was approved and conducted in accordance with the guidelines of Midwestern University s institutional review board. Participants demonstrated consent by returning the survey to us in a self-addressed stamped envelope we provided. Participants We mailed the survey through the U.S. Postal Service to a systematic random sample of 1,000 practitioners who belonged to AOTA s Early Intervention and School Systems Special Interest Section (EISSIS). AOTA s membersampling database compiled a list of all practitioners who elected the EISSIS as their primary special interest section on their membership applications (N 5 4,354). The database was programmed to first select every fourth person for a total of 1,088 potential participants and then to randomly generate a list of 1,000 potential participants. e236 November/December 2014, Volume 68, Number 6

4 Respondents were included in the study if they returned the survey, indicated that they currently worked in a school system, and completed all of the demographic information. Respondents were excluded from the study if they failed to complete the demographic information or indicated that they worked full time in a setting other than a school system. Procedures and Data Collection We used a survey questionnaire to elicit information from practicing school-based practitioners. Potential participants received a cover letter describing the purpose of the study, a copy of the survey, and a self-addressed stamped return envelope; we did not send follow-up reminders. We screened all surveys that were returned within 3 mo for inclusion in the study. Survey Instrument and Data Analysis On the basis of a comprehensive review of the literature on RtI, we developed a 15-item questionnaire (14 closed-ended questions and 1 open-ended question) to examine practitioners involvement in RtI and to describe their attitudes toward being involved in such initiatives. Because RtI models vary across school districts, we developed questions to identify RtI activities rather than tier levels. The closedended items included 7 questions related to demographics (e.g., number of years in school-based practice; highest degree obtained; state in which they practiced; whether they worked in an urban, suburban, or rural setting) and 7 on specific attitudes being measured. Four of the 14 closedended questions allowed the respondents to mark more than one answer from a list of 10 possible choices (e.g., What do you believe or know to be the limiting factors with regard to occupational therapy s involvement in RtI? ). The questionnaire content was developed primarily by the second author (McGuire), an occupational therapist with 11 yr of clinical experience, including 10 yr in schoolbased practice and an advanced clinical doctorate in occupational therapy. The first author (Cahill), an occupational therapist with 15 yr of school experience, reviewed and revised the questionnaire. The questionnaire was intentionally kept brief to encourage participation. The survey results were analyzed using IBM SPSS Version 19 (IBM Corporation, Armonk, NY). The data were analyzed using descriptive statistics to answer the research questions. Results Participants We recruited 1,000 practitioners to complete the survey; 14 surveys (1.4%) were returned because of incorrect mailing addresses. Two hundred ninety-five responded to the survey, for a response rate of 29.9%. Of the 295 respondents, 17 were excluded because of incomplete basic demographic information, and 2 indicated that they did not work in school-based practice, resulting in a final sample size of 276 participants. Table 1 provides respondents professional experience and degrees. All respondents but 1 were occupational therapists; 1 was a certified occupational therapy assistant. Two-thirds of the respondents (66.7%, n 5 184) had practiced >10 yr in school-based settings, and 77.9% (n 5 215) had >10 yr of clinical experience. More than half of respondents (57.6%, n 5 159) had obtained a master s degree in occupational therapy or a related field. Most respondents worked in suburban settings (48.9%, n 5 135), with the remainder working in rural (31.2%, n 5 86) and urban settings (19.6%, n 5 54). Participation in Response to Intervention Most of the respondents (77.5%, n 5 214) reported that their districts were implementing RtI at some level. Only 10.1% (n 5 28) of respondents indicated that their districts were not considering the implementation of RtI, and 11.9% (n 5 33) reported that their districts were in the investigation or planning stages of implementation. Close to half of the respondents (44.2%, n 5 122) indicated that their districts were fully implementing RtI Table 1. Professional Characteristics of Respondents (N 5 276) Characteristic n % Type of practitioner Occupational therapist Occupational therapy assistant Experience in school-based settings, yr Clinical experience, yr Highest degree obtained Certificate Associate s Bachelor s Master s Clinical doctorate (e.g., OTD) Research doctorate The American Journal of Occupational Therapy e237

5 and that participation in such initiatives was part of their typical practice. The majority of respondents (69.2%, n 5 191) believed that participation in RtI is beneficial to the entire field of occupational therapy. However, 60.1% (n 5 166) indicated that school personnel do not fully understand the potential contributions that occupational therapy practitioners can make in these initiatives. Roughly half of the participants (52.9%, n 5 146) thought that their educator colleagues (i.e., administrators and teachers) desired their participation in RtI and reported that they would like to become more involved in RtI initiatives (52.5%, n 5 145). Nearly half of the respondents (46.7%, n 5 129) indicated feeling that their unique experience as an occupational therapy practitioner was not sufficiently used in RtI. Practitioners contributed to RtI by working with students in different grade levels and on a variety of areas of occupation. Respondents most often identified kindergarten (66.3%, n 5 183) and Grades 1 3 (64.9%, n 5 179) as the grades in which they contributed to RtI in their schools and districts, although prekindergarten (44.9%, n 5 124) and Grades 4 8 (40.6%, n 5 112) were also frequently endorsed. Respondents indicated that they most frequently addressed educational concerns (74.6%, n 5 206), activities of daily living (50.4%, n 5 139), social participation (49.6%, n 5 137), and play (48.2%, n 5 133) within the context of RtI. Table 2 presents the RtI activities in which the respondents reported participating. A majority of the respondents (56.5%, n 5 156) indicated that they were part of school-based problem solving. Approximately half of the respondents were involved in coaching and consultation (53.3%, n 5 147), and 139 (50.4%) were involved with direct one-to-one intervention with students receiving RtI services. Other frequently endorsed RtI activities included Table 2. Response to Intervention Activities in Which Participants Were Involved (N 5 276) Activity n % Participation in problem-solving team Coaching and consultation One-on-one intervention Identification of students for early intervening services and supports In-services Progress monitoring Data collection Universal screening Program development Leading and coleading groups Curriculum development identification of students for early intervening services and supports (47.1%, n 5 130), provision of in-services to educational personnel (39.9%, n 5 110), and progress monitoring (39.1%, n 5 108). Fewer respondents endorsed participation in universal screening (23.2%, n 5 64) and curriculum development (9.4%, n 5 26). Perceived Barriers Table 3 presents the barriers to RtI participation that respondents perceived. Approximately two-thirds of the respondents (66.3%, n 5 183) indicated that lack of resources (e.g., time, finances, personnel) limited their involvement in RtI initiatives. Notably, 29.7% (n 5 82) indicated that there was no precedent in their school or district for the involvement of occupational therapy practitioners in RtI, and 72 (26.1%) perceived a lack of administrative support for such involvement. Some respondents also perceived lack of specific policies regarding practitioners involvement (20.3%, n 5 56) and lack of knowledge on the part of practitioners (19.9%, n 5 55) to be limiting factors. Perceived Facilitating Factors Table 4 presents the facilitating factors respondents identified as having the potential to help increase their participation in RtI. Two-thirds (67.0%, n 5 185) of the respondents said that school or district guidelines that describe expectations as they relate to practitioners involvement in RtI would help increase their participation in such initiatives. Half of the respondents (50.4%, n 5 139) indicated that fewer students with special needs on their caseloads and decreased responsibilities (e.g., paperwork) would facilitate their involvement in RtI. Respondents also identified continuing education on the topic of providing services in RtI (44.2%, n 5 122), direction on how to advocate for a change from a caseload to a workload model Table 3. Perceived Barriers to Participation in Response to Intervention (N 5 276) Barrier n % Limited resources Lack of precedent for OT practitioner involvement Lack of administrative support Local policy that is not inclusive of occupational therapist involvement Practitioners lack of RtI knowledge Belief that RtI concerns are not within OT s domain of practice State policy that is not inclusive of OT involvement Limited practice models Lack of personal expertise National policy that is limiting Note. OT5 occupational therapy; RtI 5 Response to Intervention. e238 November/December 2014, Volume 68, Number 6

6 Table 4. Perceived Facilitating Factors to Participation in Response to Intervention (N 5 276) Facilitating Factor n % Supportive district and school guidelines Decreased no. of students on caseloads, decreased responsibilities Continuing education Direction on advocating for a workload (vs. caseload) model Guidance on how to interpret national policy Clearer language in state s practice act Greater administrative support Practice models Continued advocacy from national and state associations (43.8%, n 5 121), and greater understanding related to how to interpret national policy (39.5%, n 5 109) as factors that might increase the involvement of practitioners in RtI. Discussion Participants reported that the inclusion of occupational therapy practitioners in RtI initiatives was beneficial and that educators and administrators wanted them to be involved in providing RtI services. However, more than half of the participants indicated that school personnel typically did not understand the full scope of occupational therapy practice and that this lack of understanding limited the extent to which occupational therapy practitioners participated in such initiatives. These findings are consistent with previous research suggesting that teachers are unaware of the range of services that school-based occupational therapy practitioners can provide (Casillas, 2010a, 2010b). Although it was beyond the scope of this study, an examination of the association between level of education personnel knowledge about occupational therapy and established guidelines for occupational therapy participation in RtI would be beneficial. Federal legislation permits local education agencies to use up to 15% of their federal dollars to provide early intervention services, like those associated with RtI, to students who are at risk for failure, with an emphasis on students in kindergarten through Grade 3 (U.S. Department of Education, Office of Special Education and Rehabilitative Sciences, 2007). Not surprisingly, therefore, respondents identified kindergarten through Grade 3 as the grades in which occupational therapy practitioners most often contributed to RtI in their schools and districts. We were, however, somewhat surprised to see that >40% of the participants also provided RtI services to children in Grades 4 8. This finding was surprising given the emphasis in the federal legislation on providing services to children in kindergarten and early elementary school. Moreover, the majority of the participants (n 5 183) indicated that they provided educational services to students in the context of RtI. Lack of resources was the most frequently cited limiting factor to involvement in RtI. Support for moving from a caseload to a workload model was also seen as a need. Additional time and personnel paired with a workload model may provide practitioners with the flexibility in their workday they need to provide services to students with individualized education plans and those who do not receive special education services. Finally, the majority of the participants indicated that school or district guidelines that describe the expectations of practitioners in terms of their involvement in RtI would be helpful. Limitations and Future Research This study has several potential biases based on the nature of the sample. First, because the sample was limited to AOTA members of the EISSIS, it may not be representative of all school-based practitioners in the United States. Second, although this study had a fairly high response rate, the respondents may have had a uniquely elevated interest in the topic. Third, although the survey instrument was developed after an extensive review of the literature, no formal validation process was completed. Finally, the nature of the closed-ended questions may have limited the scope of participants responses. More research is needed to evaluate the grades to which occupational therapy practitioners most commonly provide RtI services and the academic areas in which practitioners tend to focus their efforts. Research focused on understanding the types of student concerns that practitioners address will assist in the development of intervention strategies and the provision of technical assistance to teachers. Research is also needed to determine the efficacy of occupational therapy interventions that are already being used in RtI. Such research has the potential to establish a precedent for occupational therapy practitioners as service providers to students in general education. Establishing such a precedent may encourage educators to invite occupational therapy practitioners to participate more frequently on problem-solving teams and within the context of RtI. Finally, more research is needed to determine the efficacy of workload models in terms of student outcome measures. Such research would provide insights into the capacity and training practitioners need to juggle the multiple responsibilities associated with providing services in both special and general education. The American Journal of Occupational Therapy e239

7 Implications for Occupational Therapy Practice The results of this study have the following implications for occupational therapy practice: Occupational therapy practitioners working in RtI participate on school-based problem-solving teams, coach teachers, and provide one-to-one interventions to students in general education. Lack of resources for RtI implementation limits practitioners involvement in such initiatives. School district guidelines that describe the roles and expectations of practitioners are needed. Moving from a caseload model to a workload model may support increased participation by practitioners in RtI initiatives. s Acknowledgments We thank the practitioners who volunteered to participate in this study and Alexandra Robinson and Lindsey Askins for their help with preparing the survey for mailing. References American Occupational Therapy Association. (2007). 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