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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in

Occupational Therapy



Focused Question:
Is a consultation treatment model an effective service delivery method for children receiving
school-based occupational therapy services?

Prepared By:
Josee Lundquist and Hayley Meredith

Date Review Completed:


Clinical Scenario:
The consultative approach was gradually introduce to school-based practice in the early 1990s
(Reid, Chiu, Sinclair, Wehrmann, & Naseer, 2006). This new service delivery model was
designed to facilitate the developmental needs of students and improve their occupational
performance in school. A consultative approach can enhance the quality of life of the students in
their natural environment, thus supporting the Individuals with Disabilities Education Act which
mandates educational services be provided to persons with disabilities within the least restrictive
environment (Case-Smith & Cable, 1996). The model has since been used to guide occupational
therapy services to children attending school with a variety of disabilities (Reid et al., 2006).

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

School-based occupational therapists have the difficult task of tailoring every intervention to the
needs of individual children. Service delivery is based on the students current level of ability and
desired Individualized Education Plan (IEP) goals agreed upon by educators, parents, the student,
and other members of the IEP team using a collaborative approach. Occupational therapists can
choose one of two models for services delivery, or choose to combine them. One would be to
provide direct services, with the child removed from the classroom or integrated. Or consultative
services within the classroom, involving the teacher and other members of the teaching staff.
Consultative service delivery is considered integrative therapy because it occurs in the classroom
and involves aspects of the therapy role to other professional (Case-Smith & Cable, 1996). Based
on the collaborative consultative approach shared team goals, team decision making and planning,
and outcomes-based interventions are possible.

Specifically, Clark County School District in Nevada continues to face persistent personnel
shortages in special education and related services (Nevada Speech-Language Hearing
Association, 2014). The NV Coalition has eight targeted projects which align with and address the
Nevada Department of Educations vision and mission. One of the eight targeted projects is
specifically designed for general consulting in education. This includes supporting the specific
needs of special education teachers and related service providers by increasing and expanding
professional development (Nevada Speech-Language Hearing Association, 2014). Advantages of a
collaborative consultation approach to the Clark County School District includes closer
interactions with teaching staff and parents to determine how therapy can be incorporated into
activities of daily living, and opportunities for the therapist to continually provide appropriate
handling and positioning activities within the classroom.

Clark County School Districts enrollment is over 300,000 students and 33,129 of these students
have an IEP (Institute of Education Sciences, 2014). In 2013, a total of 2,821 students were
receiving occupational therapy services. Of these 2,821 students, 1,804 received direct services
from the occupational therapist, with only 23 full-time and part-time occupational therapists
employed (Clark County School District, 2014). With a large amount of students requiring
services, and a limited number of therapists employed with the school district, the consultation
service delivery model is imperative to ensure that the students are receiving the support they need
within the classroom to promote IEP goal attainment.

Summary of Key Findings:

Summary of Levels I, II and III:
Remedial and compensatory interventions were equally successful across performance areas with
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

collaborative consultation. (Kemmis & Dunn, 1996, Level II)

Consultative models of practice were advantageous for the teachers and the students.
Accountability and outcome evaluations were not issues in implementing current models of
integrated practice in classrooms. OTs value direct service delivery, one-on-one interactions with
students, and to establish relationships with students. (Case-Smith & Cable, 1996, Level II)

All children in the study achieved nearly 3/4ths of their IEP goals.This study suggests that an
intense level of interaction between OTs and teachers resulted in a positive outcome. (Dunn, 1990,
Level I)

Mean percentage of IEP objectives met per student was 61%. The respondents written comments
indicated that collaborative team practices were frequently conducted informally and within
immediate school areas. Successful problem-solving strategies for students were developed
through these discussions. In contrast, formal team meetings appeared to be difficult to implement
for many teachers and therapists. (Barnes & Turner, 2001, Level II).

OT consultation was followed by positive changes in students performance and satisfaction by

their school teachers, as well as increases of teacher knowledge and implementation of OT
strategies. Ultimately, increases in COPM scores were associated with increases in teacher
knowledge. Thus, the consultative model suggests that the OT-teacher relationship may be an
important intermediate step to enhancing occupational performance problems of the students.
(Reid, Chiu, Sinclair, Wehrmann, & Naseer, 2006, Level III)

Both models of intervention were found to help students meet their goal at approximately the rate
expected. Consultation group: met or exceeded expectations on 56% of goals. Directindirect
intervention group met or exceeded expectations on 50% of goals. (Dreiling, & Bundy,2003, Level

Significant difference in pre-test to posttest measures on the written communication subscale of

the VABS-C and on the written work subscale of the SFA. Significant pretest to posttest difference
was found on the using materials subscale of the SFA. (Bayona, McDougall, Tucker, Nichols &
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Mandich, 2006, Level III)

Summary of Level IV and V:

There are two fundamental conditions necessary for collaboration between educators and
occupational therapists to be successful. The teacher needs to fully understand the role and
responsibilities of the occupational therapist, and the therapist must understand school policies, the
curriculum and the practice of the individual teacher. (Villeneuve, 2009, Level V)

Results showed that to establish fluid service delivery models, therapists need to: -Plan
collaboratively with teachers so the model selected meets the teachers preferences
-Designflexible scheduling systems that emphasize inclusive practice --Maintain precise
documentation about when and how services are provided. (Case-Smith, & Holland, 2009, Level

Contributions of Qualitative Studies:

Supports the occupational therapy school-based consultation (OTSBC) service used in Part 1 of
study. OTSBC is beneficial to students with fine motor difficulties. (Wehrmann, Chiu, Reid,
Sinclair, 2006)

Bottom Line for Occupational Therapy Practice:

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

The clinical and community-based practice of OT: The OT providing services through a

collaborative consultation delivery model must identify and define the problems in terms of
expectations for students. This is necessary to negotiate effective service delivery approaches to
achieve those expectations. It is vital the students needs are individually determined to provide
the best delivery model to help the child successfully meet their IEP goals and related
educational outcomes. Working with students in their natural life environments, provides
additional opportunities to apply their expertise. Everyone involved in the collaborative
consultation model must have agreement regarding each others roles. It is crucial the IEP team
agrees with the OT services because the interventions must be carried out by the school staff
including teachers. To allow the OT to provide services to an increased population, the
consultation model is a viable intervention approach and is as effective as a direct-indirect

Program development: Utilizing the collaborative consultation delivery model provides a strong

foundation for successful IEP goal attainment. The service delivery model will vary according to
the desires, needs and preference of the student and teacher. Consideration of school board
policies and curriculum are important factors to support the development of an educationally
relevant approach to services.

During the initiation of the services the nature of the consultative model should be explained
clearly to the school and family. Clear communication is key to ensuring the teachers have
awareness and understanding of the students occupational performance. The IEP team involved
in the consultation process should organize informal and formal team opportunities within the
school settings to assist the student to reach their goals.

Consultative service delivery model has been found to require the same amount of time or more
that a direct intervention to initiate the service delivery model. However, the amount of time
required will decrease with program maturation. A more holistic approach using team decision
making with the teacher may help to integrate the intervention recommendations into the
classroom and provide teachers with a greater satisfaction with the services

Societal Needs: With a significant need for OT services within the school-based setting,

dissatisfaction is common in regard to the wait time for services and the frequency of visits. With
a consultation based service delivery, this complaint can possibly be addressed. It is also
important to provide these services to children to eliminate the risk for secondary mental health
issues and educational issues including poor social competence, academic problems, behavioral
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

problems, and low self-esteem.

A consultation service delivery model can provide increased support for children with disabilities
and ultimately be more beneficial than limited direct services. Collaboration between the teacher
and therapist is essential to provide an individualized delivery model to meet the needs of
students and teachers and provide effective interventions. Consultative meetings can be
beneficial to the teacher to provide resources to support interventions and progress towards the
childs IEP goals.

Overall, a consultative service delivery model can allow the OT to provide services that benefit
more children with fewer resources and less time, while still providing effective and better

Healthcare delivery and policy: Direct and consultative services provide unique benefits to

children, and a flexible service delivery model allows OTs to meet the evolving needs of children
within dynamic environments. Education and health administrators should provide sufficient
time for teachers and OTs to combine expertise to support inclusion of students. All team
members should meet regularly for formal and informal consultation meetings to establish
strategies for intervention and ensure the best service is provided to the student and teacher.
Education professionals with more expansive strategies may serve OTs as well as agencies who
re-evaluate priorities for financial, space, and program allocation in a changing political
environment. Individualized needs determine how OT services are delivered, and then the true
intent of the Individuals with Disabilities Act can be met.

Education and training of OT students: OT students should be educated on their roles as

consultants, and the benefits and differences of school-based integrated / consultative and direct /
pull-out practice models. Including teachers as a stakeholder in the school-based
interdisciplinary IEP team will foster collaborative service delivery within the classroom. This
will be essential to fulfill a successful intervention plan. OT students should be able to
strategically consider the number of objectives that will be carried out by the educators and use
effective communication to have successful collaborative implementation of OT services. The
choice to provide direct services and/or consultation is frequently based on the therapists past
experience and training; therefore it would be beneficial for a new OT graduate in a school-based
setting to have an experienced mentor.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Refinement, revision, and advancement of factual knowledge or theory: In order to better conduct

research regarding OT collaborative consultation service delivery model, a definite definition of

needs to be developed. Further research should be completed with increased sample sizes and
various diagnoses to allow for generalizability. Outcome measures of quantitative data should
include IEP goal goals with percentage measurements to increase the sensitivity, and more
randomized-controlled trials be completed to examine the possible benefits and consequences for
clients receiving OTSBC services. While qualitative data should reflect open-ended questions to
improve understanding of results with definitive explanations as to why subjects used particular
service delivery models or why they held certain attitudes. The amount of intervention provided
at home by parents should be controlled to ensure outcome measures reflect school-based OT
service delivery specifically. OTs should consider the potentially broader impact of their
consultative services beyond the immediate child outcomes achieved from traditional service
provision strategies.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Review Process:

Identified focus question

Dr. Costa reviewed and approved focus question
Key terms were identified and a exhaustive literature review was completed
Article abstracts were reviewed by one group member
Articles not meeting inclusion criteria were eliminated
Critical Appraisal worksheets completed on each article and reviewed by second
group member
CAT Evidence Table was completed
Critically Appraised Topic (CAT) worksheet was completed

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

All levels of research

Research completed in the past 24 years (1990-2014)
Articles written in English
School-Based pediatric population
Full Text Academic Journals
All disabilities
Qualitative studies
Quantitative studies
Articles published in the United States and Canada

Exclusion Criteria:

Clinical consultation
Physician only consultation
Systematic reviews

Search Strategies:

Key Search Terms

Patient/Client Population

Children, pediatrics, school-age


Consultation, delivery services, school consultation,

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

occupational therapy, school based, service delivery


Fine motor, IEP goals, teacher ratings, strategy implementation

Databases and Sites Searched

EBSCO, ProQuest, CINAHL, PubMed, OTSeeker, and Google Scholar

Quality Control/Peer Review Process:

Focus question was developed with collaboration of group members and course instructor
Weekly searches using key terms were completed and logged on course discussion board
18 articles were reviewed by both group members, and narrowed down to 10 studies
Each group member completed 5 critical review worksheets and the worksheets were reviewed
by other group member. The final reviews were submitted to course discussion board
Critical Review worksheets were reviewed on discussion board by course instructor to receive
Evidence table was completed by group members, and submitted to course discussion board for
suggestions and comments from course instructor
CAT was completed by both group members, and submitted to course discussion board for
suggestions and comments from course instructor
Edits were made to CAT and evidence table in response to suggestions
The CAT and evidence table was submitted by the Masters of Occupational Therapy students

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of

Study Design/Methodology of Selected Articles

Number of Articles

Systematic reviews, meta-analysis, randomized



Two groups, nonrandomized studies (e.g. cohort, case

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05


One group, nonrandomized (e.g., before and after,

pretest, and posttest)


Descriptive Studies that include analysis of outcomes

(single subject design, case series)

Case reports and expert opinion, which include

narrative literature reviews and consensus statements

Qualitative Studies




Limitations of the Studies Appraised:

Levels I, II, and III
Small sample sizes, convenience samples, survey development, narrow subject
population (AOTA members only), limited question designs, reporting strategies
(met/unmet), lack of control group, limited data collection (area covered), insufficient
measurement tool (TAS), incomplete pretests, variable diagnoses, cognitive and
behavioral development not controlled, and unable to account for amount of direct
services received

Levels IV and V
Lack of control groups, unrealistic interventions, limited context relevancy, and unclear
definition of consultation

Subjects from same stakeholder group, services provided by single organization, and
study timing

Articles Selected for Appraisal:

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Barnes, K. J., & Turner, K. D. (2001). Team collaborative practices between teachers and
occupational therapists. American Journal of Occupational Therapy, 55, 8389.

Bayona, C., McDougall, J., Tucker, M., Nichols, M. & Mandich, A. (2006). School-based
occupational therapy for children with fine motor difficulties: Evaluating functional
outcomes and fidelity of services. Physical & Occupational Therapy in Pediatrics, 26, 3,

Case-Smith, J., & Cable, J. (1996). Perceptions of Occupational Therapists Regarding Service
Delivery Models in School-Based Practice. The Occupational Therapy Journal of
Research, 16(1), 23-44.

Case-Smith, J., & Holland, T. (2009). Making decisions about service delivery in early childhood
programs. Language, Speech & Hearing Services in Schools, 40(4), 416-423. doi:

Dreiling, D., Bundy, A. (2003). Brief report--A comparison of consultative model and directindirect intervention with preschoolers. American Journal of Occupational Therapy, 57, 566569.

Dunn, W. (1990). A Comparison of Service Provision Models in School-Based Occupational

Therapy Services: A Pilot Study. The Occupational Therapy Journal of Research, 10(5), 300-320.

Kemmis, B., & Dunn, W. (1996). Collaborative consultation: The efficacy of remedial and
compensatory interventions in school contexts. The American Journal of Occupational

Therapy, 50, 9, 709-717.

Reid, D., Chiu, T., Sinclair, G., Wehrmann, S., & Naseer, Z. (2006). Outcomes of an
occupational therapy school-based consultation service for students with fine motor
difficulties. The Canadian Journal of Occupational Therapy, 73(4), 215-235.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Villeneuve, M. (2009). A critical examination of school-based occupational therapy

collaborative consultation. Canadian Association of Occupational Therapy, 76, 206-218.

Wehrmann, S., Chiu, T., Reid, D., Sinclair, G. (2006). Evaluation of occupational therapy
school-based consultation service for students with fine motor difficulties. The Canadian
Journal of Occupational Therapy, 73, 4, 225-235.

Other References:
Clark County School District. (2014). Occupational & physical therapy services. Retrieved from
National Center for Education Statistics. (2014). Common core of data. Retrieved from
Nevada Speech-Language Hearing Association. (2014). NV coalition. Retrieved from

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05