Spring 2007 Table of Contents
Versión Español de este artículo (Spanish Version)

Making the Best of It: Getting More Bang for Your Therapy Buck

By Chris Strickling, OT, Ph.D., TSBVI Deafblind Outreach Consultant

Abstract: This article describes the role of occupational and physical therapists in school settings and offers ways to help them successfully participate in the educational programming of students with visual impairments and deafblindness.

Key Words: Programming, blind, deafblind, visually impaired, occupational therapist (OT), physical therapist (PT), related service, collaboration

For more than a decade, I have worked in Texas public schools as an occupational therapist who provides consultation to deafblind students and their educational teams. In my capacity as Outreach Consultant with TSBVI, I have traveled across the state and met many teachers, therapists and other professionals working together to create meaningful learning experiences for their students with visual impairments and deafblindness. As we learn more about deafblindness and visual impairment, and how both impact learning, instructional strategies change. There are now reliable alternatives to the Perkins Brailler that make writing easier and more efficient. Computer software is friendlier and offers more substantive content. Inclusion is a priority. It’s hard to keep up with the changes, but well worth the effort.

Even the way that therapy services are delivered has changed. Over the past few years, therapists have begun to embrace the educational model of service delivery. Their services have become more embedded into classrooms, which seems to be a move in the right direction because it means that therapists work side by side with instructional staff to share knowledge and insure that the student’s needs are met. Still, several common problems persist. First, almost all school-based therapists are itinerant. Because they are not in daily contact with the rest of the team members or the student, therapists often find it difficult to be fully integrated into the educational team. Second, most school therapists have caseloads of up to or exceeding 50 students, which means that services to all of them are limited in terms of time. Third, most school-based therapists have inadequate training related to the impact of low vision, blindness or deafblindness on functional, social and academic skills. I recently surveyed the five Texas universities that offer occupational therapy education and discovered that blindness and deafblindness are not substantially addressed in any part of the curriculum. In terms of educating therapists about the needs of these students, nothing seems to have changed since I graduated from OT school in 1978.

Despite this lack of formal preparation, many therapists do successfully participate in the educational teams of children with visual impairment and deafblindness. In most of the schools that I have visited, the OTs and PTs understand the need for related services and are advocates for the students. One significant problem, which is primarily an institutional issue, is that therapists are uncertain about what their role(s) should be with blind and deafblind students. Similarly, classroom teachers and teachers of the visually impaired, as well as O & M instructors, are often unsure about what the OT or PT could offer to the team. Many therapists have no exposure to the field of Orientation and Mobility, so it does not occur to them to collaborate with O & M instructors in serving the child. In much the same way, not all therapists know what a teacher of the visually impaired does with the child, or how low vision and/or hearing loss impacts learning, or how information from the Learning Media Assessment might be useful to them. Because they lack the time to familiarize themselves with the range of professional services the visually impaired student receives, most therapists focus on what they know and design their services based on their own skills.

In many instances, this works well, but in some cases it does not. For instance, sometimes a therapist will work individually with a student on fine motor skills (a medical model of service delivery), but will not teach the classroom staff how to carry over the skills or activities. Little is accomplished when activities designed by occupational and physical therapists are not carried over into the student’s daily program. It has been my experience and observation that when students receive only a few hours a month of therapy, that time is best spent by having the therapist set up a program, define an activity, or make an environmental modification that can be implemented by staff who see the student every day. School therapists do want to be useful, and they make excellent collaborators once lines of communication are established and information is shared. As a parent, teacher or other interested party, you may have an opportunity to enter into a dialogue with the therapist(s) on a student’s team and help determine how best to use the limited time they can offer. With a commitment to cooperation and collaboration as the top priority, here are some suggestions that might help physical and occupational therapists meaningfully participate in educational programming for students with visual impairment or deafblindness:

Make sure your therapist knows basic O & M skills, and which ones are in use with the student they serve. This can be done by offering them written information about basic O & M skills (see suggested references at the end of this article), or the therapist could schedule a visit with the child during an O & M session. A joint visit allows the O & M instructor to demonstrate travel techniques to the therapists and share information about what the student can see, as well as providing an opportunity for therapists to share information about the student’s coordination, muscle strength, endurance, etc. with the O & M instructor. This exchange of information helps to ensure that all members of the child’s educational team are consistently cueing the child to travel as independently and safely as possible, and that travel expectations are within the child’s physical capabilities.
Help your therapists to incorporate their knowledge and intervention strategies into the daily routine of the student. Physical and occupational therapists are skilled at adapting activities to meet the needs of the student and know how to design activities that help develop motor and cognitive skills. However, many lack training in how to translate their knowledge into a school setting. Sometimes it just takes a suggestion from a colleague to get this kind of integrated service going. Here’s an example of the kind of collaboration that works well:
A young girl with deafblindness is working on traveling an in-school route independently. She shows balance deficits when attempting to travel independently using her cane. Staff members cue her from the elbow while she walks. Peers talk to her, grab her hand and lead her from room to room, wanting to help. The physical therapist sees the child once a week for 30 minutes in a 1:1 setting in the school gym to work on strength and balance and the occupational therapist works on fine motor skills with the child twice each six weeks.
It would not be difficult to use that exact amount of therapy time in a different way in order to maximize the effect of therapy services. Instead of pulling the child out of class for individual therapy (or in addition to individual therapy), the occupational and physical therapists could design activities that she can do with her peers at recess, that would help her with balance.
Make sure that your therapists understand that therapy services do not always have to be individual. A good use of professional therapy services for many children with blindness and deafblindness would be to develop group gross motor activities for the student’s class, adapting as needed for the visual and/or hearing impairments, and teach the classroom staff to do these activities on an ongoing basis. Using this model, the therapist can check on the motor group periodically to change and upgrade the activities. Motor groups can be run by classroom staff, physical education teachers, or anyone else who is willing and available, and they are great vehicles for teaching spatial concepts (“under,” “around,” “through”) and language skills (requesting, moving in response to directional cues, naming and describing objects used in activities, etc.).
Therapists can be very good at helping a student integrate into PE class with their peers. Ask your therapists to observe in the physical education class and problem-solve ways to include the student with disability. For more on that topic, see “Including Students with VI in PE,” in Re:View, Fall 1999, vol. 31, #3.
Remind your therapists to apply what they already know about movement and developmental skill acquisition to the student with VI. Occupational therapists may not always know what is typical in terms of fine motor skills for students with visual impairments, but they do almost always recognize atypical muscle tone, difficulty with coordination, and tactile avoidance, and they know what to do about these problems. Physical therapists may not be aware of the gait differences, muscle tone and strength issues or other physical problems common to these students, but they do have a working knowledge of bio-mechanics and can be usefully recruited to help students in this population by simply applying what they know. Ask them to bring their clinical observation skills to the task of writing or reading Braille, or independent travel - you may be surprised how much help they can be.
Ask a therapist to think through and modify positioning systems to maximize student performance. All therapists know positioning, which is no different for students with visual impairment or deafblindness than for other students. Adjusting positioning to accommodate for tone, posture, muscle strength, or other factors will help the student every day, for hours a day, and is well worth a therapy session. Best practice would be for a therapist to observe, evaluate, then request modifications in equipment or schedule, and check back next visit to follow-up.
Therapists are great assets for building vestibular and/or proprioceptive activities into a student’s instructional plan. Whether the problem to be addressed is difficulty in establishing independent travel or inefficient acquisition of Braille reading and writing skills, these kinds of activities can be designed as preparation for the task. Ask your therapists to think through the skill you are trying to teach, and help you generate a few minutes of appropriate motor activity.
When it comes to functional skills training, occupational and physical therapists may be your most valuable allies. More and more, therapists are charged with providing services aimed at functional outcomes. They are trained to facilitate maximum independent function in everything from personal care and hygiene to higher level functions like literacy or community access. If you already do an assessment of functional skills, ask your therapists for input. If not, ask your therapists to survey the student’s level of functional skill and help develop goals and strategies for achieving them.

We really are all in this together: students, parents, family members, teachers, therapists, paraprofessionals, administrators. If we keep that in mind, and invite each other into dialogue and collaboration in order to serve our students, everyone wins.

Suggested Resources for Information on O & M Skills

Dodson-Burk, B. and Hill, E. (1989). An Orientation and Mobility Primer for Families and Young Children. New York: AFB Press.

Hill, E. and Ponder, P. (1976). Orientation and Mobility Techniques: A Guide for the Practitioner. New York: AFB Press.

Knott, N. I. (2002). Teaching Orientation and Mobility in the Schools: An Instructor’s Companion. New York: AFB Press.

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Last Revision: August 2, 2007