I was compelled to write this because as an occupational therapist who works in the schools I know that there tends to be a philosophy (among therapists primarily) that once a child leaves elementary school that direct OT services tend to stop or be changed to consultation.

This change is often appropriate.Some reasons:

1) The middle school schedules are so tight that it often means that students would miss a lot from one class if removed on a regular basis for therapy.

2)  By nature, teenagers are self-conscious, and having an adult provide therapy in the classroom would often add to that, which is counterproductive to learning.

3) Handwriting habits are often set and it can be difficult to make changes and corrections unless the child is highly motivated.

4) Organization: most middle schools incorporate this into the daily routine. Children are often given an agenda/planner and teachers have a system to help children learn to use them.

5) Visual perceptual skills are typically developed by age 11

6) Students are more likely to be using computers and word processors to complete written work and they may have this as an accommodation in the IEP.

These reasons are often valid for changing OT from direct to consultation or exiting a student from OT. However, this change seems to happen at times without reasonable justification and is based no more than on the fact that they are now in a new school. And it’s this lack of clear justification and explanation to parents bothers me.

If a therapist ever tells you that they want to make a change due to lack of progress, please ask for a second opinion. Human brains can and do change, which means we are capable of learning throughout our lives. What therapists probably mean when they say this is that specialized instruction of a therapist is no longer needed and teachers can provide the intervention (e.g. if a child forgets to space between words and they just need a reminder before they start writing then a teacher can do this; the instruction of an occupational therapist is not required). It seems to me that a therapist saying “lack of progress” would be tough to hear if it were your child, and as shame on therapists who would use these words!

In my experience I have found that middle school students don’t need as much direct support from occupational therapy to address motor skills. They often already have assistive technology to help them, and, as stated above, organizational skills are embedded into the routines by the teachers. Children in this age group are going through so many changes at this time (with puberty, new awareness of social pressures, new kind of learning environment where they have several teachers instead of one or two) that the attention level required to recall strategies learned in direct OT for handwriting or self-regulation is very challenging.  Unless the child is in a self-contained classroom where there is a consistent teacher to reinforce specific strategies, it can be very challenging to expect the child to recall how they should be forming letters or spacing between words. The success of interventions relies heavily on a child’s motivation to recall and implement them, which is why accommodations such as receiving pre-printed notes or using a word processor or computer for producing written work are often recommended for children in middle school. And with so much else going on at this time of their lives it can be very hard for them to remember to space between words or make their “f” a certain way. That being said, everyone (OTs included) needs to keep in mind that handwriting expectations do not stop with the presence of a word processor or computer. They often still need to complete worksheets or write small passages. There is assistive technology that can help students complete worksheets on the computer, but it is not practical for everyone, and middle school students are sometimes sensitive to having to use a device when their peers do not and will choose to try to write rather than type their work.

Teachers are also very inconsistent with expectations about handwriting, the most common area of intervention from OTs. Often children have the skills they need by this age, but don’t carryover the skills in the classroom. If a teacher can reinforce the expectation to write legibly that can provide the accountability which is often all children need.

What about working on self-regulation? I think this is a huge area that OTs can do more in at this level, especially for children who have ADHD, executive functioning issues, anxiety, and autism. This is not an area that is clearly defined in the schools for OTs, however, and there are some supports that teachers can and do provide for children with these issues, but it can vary from school to school and person to person. Because occupational therapists understand the neurology and sensory issues that go along with emotional and behavioral self-control we may be able to do a lot more than we are now. One of the problems with this, however, is that not all therapists are trained to do more than provide some sensory strategies or recommend accommodations. It can be hard to change mindsets and the status quo. My hope is that occupational therapists will read this and not have the initial reaction I might expect–that they are already busy and how will they fit this in, and how dare I suggest it. Sorry therapists, it isn’t about you, it’s about doing what the kids need. You keep doing your best and do all that you can, but ultimately it falls on the district to make sure you have the staffing, or to allow you time to use your expertise to provide training to teachers.

The IEP team needs to weigh the benefits and risks of not continuing direct services in middle school. When children have 7 classes per day then missing a 30-minute chunk of one of them once a week is pretty significant (plus the transitioning to and from for children who are on the autism spectrum). It may make sense to reduce the frequency to twice a month if direct services are still warranted. Therapists should NOT be making an automatic recommendation to stop OT or change services to consultation just because of the transition to middle school.  Make sure your child’s therapist has sufficient reasoning to justify this recommendation and remember that it is ultimately a team decision–not the therapist’s and not yours as the parent, everyone’s input is needed and contributes to the decision. Also, therapists should not only be looking at motor skills related to handwriting, but drawing and copying skills used in math.

When I started writing I intended this post to include information about both middle and high school, but once I started writing I realized that there was too much information to include both here. Look for a post about occupational therapy in high school soon.