Case Example – Occupational Therapy in School-Based Practice

This case example is intended for educational purposes only to demonstrate common occupational therapy
practices within a particular setting. This is a fictional case and does not represent any real individuals. Individuals
referencing this case should always use their own ethical and professional reasoning when implementing
occupational therapy services.

Case overview/introduction

Client name: Fabian Client age: Eight years-old (8) Practice setting: Elementary school

Main situation, injury, or condition prompting need for OT services: Social skill challenges that impact
occupational performance & social participation at school. Fabian participated in Multi-Tiered Systems
of Support (MTSS) services through whole group and small group social skills instruction, but his
teachers and parents still have concerns about his social participation. He is currently being referred for
a special education evaluation because he continues to demonstrate challenges when participating
socially.

Overview of client’s occupational profile:

Fabian is an 8-year-old child who is currently a second grader. He was referred for a special
education evaluation because of concerns with his social participation. His first-grade teacher started
noticing concerns before the pandemic when they were in-person. Behaviors noted include repeatedly
getting up during class, talking when others were speaking, talking without raising his hand, and getting
too close to his peers when talking and playing. Due to the COVID-19 pandemic, Fabian completed full-
time distance learning (also known as E-learning) from March to August of last year. He then
transitioned to a hybrid learning model, which includes two days of in-person learning for four
hours/day (Tuesdays and Thursdays, 8:00am-12:00pm), and E-learning for the remainder of the week.
His parents and teacher reported that he did a good job adapting to the transition from in-person to
online, and that they believe he retained information well. When asked about how he felt about E-
learning and hybrid learning, Fabian said that “he likes seeing his classmates on Zoom but it is nice to
see them in person, too” and that he “likes his teacher because she is nice and funny.” Fabian expressed
that he wishes he was at school every day because he wants to see his classmates more. He wants to be
with his friends so they can play games on the playground such as man on woodchips, tag, monkey bars,
and four square. When asked how he feels about in-person school days, he said, “It is boring but
sometimes fun when we do activities.” He said he is sad that he cannot play with his friends like he used
to because they have to socially distance. Once he transitioned to the hybrid model, his second-grade
teacher noted that he “kept getting up during class to talk to his classmates,” and “is having a hard time
maintaining a safe physical distance from his peers.” Additionally, his teacher reported that he
frequently talks without raising his hand or being called on. When talking to his classmates, he tends to
dominate conversations by talking about what he does at home on E-learning days, and does not pay
attention when other students are talking to him.
 Fabian lives in a single-family home with his mother, father, grandparents, and newborn sister.
He enjoys playing outside, watching cartoon TV and movies, baking desserts with his grandma, and
creating his own comic book stories. Fabian said that he “loves Marvel movies” and “wants to be like
Iron Man” when he grows up. Prior to COVID-19, Fabian used to go to weekly piano lessons once a
week. He is currently not participating in in-person piano lessons due to COVID-19 restrictions, but said
that he would like to “learn from his piano teacher through video” if possible. Fabian’s typical day
includes eating breakfast, completing E-learning via Zoom or in-person learning until lunch time,
watching TV, and completing homework in the evening with the help of his parents or grandparents. On
weekends, he spends time with his family, watches TV/movies, reads comic books, plays outdoors, and
does homework for the upcoming Monday.
Fabian’s teacher told his parents that she would like to see him adhere to classroom rules and
expectations, and respect other students ’personal space, especially when engaging in conversations
with others. Fabian’s parents would like him to learn and exhibit safe behaviors at school (i.e., stay 6 ft.
apart from classmates) to lessen the risk of getting ill, and they want him to participate in different
activities at home on weekends. They also said that they would like to enroll him in team sports such as
basketball and/or baseball through their community park district once it is safe to do so. Lastly, Fabian
stated that he “wants to play with his neighbors and friends again” and he “wants to go back to normal
school.”

Occupational therapy theories/models:

List initial occupational theories or models that might guide the occupational therapy process:
• Person-Environment-Occupation (PEO) (Case-Smith & O’Brien, 2015, p. 31):
o Focus on child’s performance and the environmental influences that enable a child’s
engagement and participation in activities
o Health is supported and maintained when clients engage in occupations and activities
that promote desired or needed participation at home, school, and in the community
o PEO suggests that occupational performance is the result of the dynamic, transactive
relationship involving the person, environment, and occupation
o Person: A unique being who participates in various roles that are important to them
o Environment: Cultural, socioeconomic, institutional, physical, and social factors outside
a person that impact their experiences
o Occupation: Any self-directed, functional task or activity that a person engages in
throughout the lifespan

Occupational therapy evaluation:

Describe the methods most likely used to develop occupational profile:

• AOTA’s Updated Occupational Profile Template (AOTA, 2020)
o Summary of a client’s occupational history and experiences, patterns of daily living,
interests, values, needs, and relevant contexts. The Occupational Profile provides insight
to the client’s perspective and background. During the process of gathering this
 information, the client, with the help of the clinician, identifies priorities and targeted
goals that will lead to the client’s engagement in occupations that support participation
in daily life.
• Occupational Therapy Practice Framework: Domain and Process—Fourth Edition (OTPF-4)
(AOTA, 2020b)
o May use with the Occupational Profile. OTPF-4 explains terms related to occupations,
contexts and environments, and client factors that impact how one participates in the
activities they want to do, need to do, and/or are expected to do.
• Gathering information from client, client’s parents, and teacher through interviews helps
establish a therapeutic relationship with clients and their social supports (AOTA, 2020b)

Describe the methods most likely used to complete an analysis of occupational performance, and the
information gathered:
• Observation and analysis of client’s occupational performance and assessment of specific
aspects of the client/their performance. Due to COVID-19 restrictions in the school,
observations may take place primarily in the classroom. Normal observations (i.e., prior to
COVID-19) may take place in the classroom, lunchroom, at recess, in the library, or other similar
settings where the student spends time at school. This method includes synthesizing
information from the occupational profile; completing an occupational or activity analysis; and
using specific assessments to measure the quality of client’s performance/performance deficits,
client factors that influence performance skills, and/or the client’s contexts and their effect on
occupational performance (AOTA, 2020b).
• Chart review in collaboration with social worker and school psychologist
• Refer to the OTPF-4 for definitions and examples of Social Interaction Skills to use during
observation and analysis.

Describe additional assessment tools that may be used in the analysis of occupational performance,
and the information gathered:
• Social Skills Improvement System (SSIS) Rating Scales (Gresham & Elliott, 2008): Provides a
general, multirater standardized assessment of social skills and challenging behaviors of
students from preschool through high school.
• Teacher Report Form (TRF) (Achenbach & Rescorla, 2001): Questionnaire for children age 6-18
years old. Designed to obtain reports of children’s academic performance, adaptive functioning,
and behavioral-emotional problems.
• Evaluation of Social Interaction, 2nd ed. (ESI) (2010) (Fisher & Griswold, 2010): Designed to
measure quality of social interactions with individuals the client usually sees, in natural context
of life tasks that involve social communication.
• Social Profile (2013) (Donohue, 2013): Used to assess behaviors of an individual participating in
a group, or of the group as a whole, to develop intervention for enhancing social skills.
 • Child Occupational Self Assessment (COSA) Version 2.2, 2014 (Kramer et al., 2014): designed to
discover children's and youth's perceptions regarding their own sense of occupational
competence and the importance of daily activities. May use card sort option.
Information about these tools were taken from Case-Smith & O’Brien, 2015, p. 326 and Asher,
2014, pp. 343-344, 359-360.

Describe the hypotheses about the client’s occupational performance strengths and needs
• Fabian has high energy at school and is excited to be around his teacher and peers. He is
experiencing challenges with social interaction skills, specifically looks, places self, regulates,
replies, discloses, takes turns, and matches language. He struggles with understanding and
demonstrating expected social behaviors in the classroom and other school contexts. These
social interaction challenges are affecting his occupations while at school – formal education
participation, community participation, and peer group participation. Per teacher report, Fabian
“keeps getting up during class to talk to his classmates,” and “is having a hard time maintaining
a safe physical distance from his peers.” Additionally, his teacher reported that he frequently
talks without raising his hand or being called on, which disrupts instructional processes in the
classroom. When talking to his classmates, Fabian tends to dominate conversations by talking
about what he does at home on E-learning days, and does not pay attention when other
students are talking to him.

Describe the overall outcomes that would be targeted through OT services:

• Fabian will become aware of social rules in the classroom by listening to his teacher and abiding
by classroom instructions.
• Fabian will become more aware of others’ perspectives by respecting their space and
demonstrating cooperative interaction during activities with peers.
• Fabian will demonstrate improved executive function, specifically self-management skills such
as keeping his hands/feet to himself and reduced interfering behaviors, in the classroom.
(Case-Smith & O’Brien, 2015, p. 322)

Describe how an occupational therapist would contribute to the evaluation process:

• Participate in a domain meeting to determine which screenings/assessments need to be
completed within the domains applicable to OT
• Determine assessment tasks that can be delegated to the OTA
• Define needs to be addressed within OT domain
• Determine client’s goals and priorities in collaboration with the child’s parents and school team
• Analyze and synthesize information for the development of the intervention plan
Interpret information from OTA into the evaluation process (AOTA, 2020a)

Describe how an occupational therapy assistant would contribute to the evaluation process:
• If OTA has previously demonstrated service competency, then implement delegated
assessments
 • Provides verbal and written reports of assessments, analysis of performance, and client
capacities to the occupational therapist (AOTA, 2020a)

Considerations for the evaluation process (that are specific to the practice setting):
• First, there would be a Domain meeting to determine what information is already known about
the student and what additional information is needed. The school team would then determine
what evaluations need to be completed and which team members would complete those
evaluations.
• After the evaluations were completed within a designated time frame, the school team would
conduct an Evaluation and Eligibility Determination meeting to see if Fabian qualifies for special
education.
o If he does, the team would develop an Individualized Education Program (IEP) and
determine all of the services that he would receive
• There would be collaboration with the school/IEP team throughout the process. It is important
to note that parents/guardians are considered part of the team.

Occupational therapy intervention:

In addition to the above-referenced occupational therapy theories and models, list any additional
theories, models, or frames of reference that may guide the occupational therapy intervention process:
• Social Cognitive Theory (Case-Smith & O’Brien, 2015, p. 329): Children learn by observing
others’ behavior. Two phases = acquisition and performance.
1. Acquisition: child observes behavior and others and consequences
2. Performance: child may decide to perform those behaviors
• Self Determination Theory (Case-Smith & O’Brien, 2015, p. 328): Involves satisfaction of needs
for autonomy, competence, and relatedness to promote well-being.
o Autonomy: having a choice, initiative of one's activities
o Competence: sense of mastery
o Relatedness: feeling of closeness and connectedness to others
• Coaching model (Case-Smith & O’Brien, 2015, p. 56): Reciprocal, interactive process between
coach (occupational therapist) and parent/caregiver which includes conversations about child
outcomes and solutions. Coaching encourages clients to make their own decisions, participate
fully, and maintain participation over time.
• Theory of mind (Case-Smith & O’Brien, 2015, p. 324): Defines social dysfunction as the result of
disruptions in processes leading to the capacity to consider other people’s and one’s own mind.
Problem behaviors include getting too close while interacting with others and having difficulty
understanding how to take turns in conversation.
• Social emotional learning (SEL) (CASEL, n.d.): Specifically focusing on Social Awareness, this
includes the capability to feel compassion for others, understand broader social norms for
behavior in various settings, and be aware of family, school, and community resources and
supports.
 • Social play models of intervention (Case-Smith & O’Brien, 2015, p. 36): Supports peer
interaction and positive social behaviors for young children with social skill challenges
o Modeling, cueing, positive affect, and reinforcement

List some likely goals that would be written with the client that are appropriate to the setting*:
1. With no more than 1 adult prompt, Fabian will apply learned strategies to manage impulsive
classroom behaviors (e.g., staying in seat, not calling out, etc.) on four of five recorded
observations by the end of one school year. (Connected to IL SEL standard 1A.1b. Demonstrate
control of impulsive behavior.)
2. With no more than 1 adult prompt, Fabian will demonstrate awareness of hidden social rules by
exhibiting expected social interaction with peers or teachers (e.g., respect personal space, etc.)
within the classroom on four of five recorded observations by the end of one school year.
(Connected to IL SEL standard 2C.1b. Demonstrate appropriate social and classroom behavior.)
3. Fabian will independently initiate expected social interaction with peers (e.g., initiate a verbal
exchange, ask to play, initiate eye contact, etc.) on four of five recorded observations by the end
of one school year. (Connected to IL SEL standard 1B.1a. Identify one’s likes and dislikes, needs
and wants, strengths and challenges.)
*Note that these goals would be team-generated student goals, not OT-specific goals. The OT
practitioner would help address the goals and contribute to measuring progress, but other school
team members would contribute to them also.

Describe at least three interventions that could be used to address each of the above goals:
1. Social scripts (Case-Smith & O’Brien, 2015, p. 331): Allow for children to practice what to do in
social situations that may be awkward or challenging. The therapist works with the child to
identify a script appropriate for that specific situation, and the script is written so the child can
rehearse it. The child may keep a notebook to write scripts to refer to when necessary.
2. Social stories (Case-Smith & O’Brien, 2015, pp. 331-332): This method helps children establish
healthy routines and develop new social skills. Each story addresses a social skill or issue. The
four types of sentences used in social stories include descriptive sentences (explains what
happens and why, who is involved, and provides background), directive sentences (provides
direction to the child and teaches them how to do something or how to respond), perspective
sentences (describes the reactions of others and their feelings), and control or affirmative
sentences (written by the child to help them remember information).
3. Video modeling (Case-Smith & O’Brien, 2015, pp. 330-331): Involves an individual watching a
video demonstration of a specific behavior and then copying the behavior of the model. Video
self-modeling allows children to observe and model from their own behaviors. This may be
effective for improving social communication skills (i.e., social interaction skills such as looks,
regulates, places self), functional skills, and behavioral functioning.
4. Self-management (Case-Smith & O’Brien, 2015, pp. 333-334): May be used to increase social
interactions and decrease off-task behaviors in children. Children are taught to differentiate
between appropriate and inappropriate behaviors (i.e., appropriate physical distancing),
examine and record their own behaviors, and reward themselves for behaving appropriately.
Considerations for the intervention process (that are specific to the practice setting):
• Least restrictive environment (LRE) to greatest extent possible: services should be provided to
the student in the general education setting, including the classroom, as much as possible. The
OT practitioner may work with the student individually or in a small group to initially teach skills
or address goals that may be difficult to address in a classroom setting. However, the OT
practitioner should attempt to transition services back into the classroom to help the student
generalize those skills to the natural environment. The OT practitioner will also collaborate with
other school staff to embed and reinforce learned strategies into the general education setting
to help facilitate carryover.
• Best practice (and legally defensible practice): OT practitioners should ensure that they use
clinical and professional reasoning to determine the best evidence-based interventions to use
with the student.
• Services provided as part of IEP: all services provided should be related to the student’s IEP and
relevant to their role as a student within an educational setting.

Describe how an occupational therapist would contribute to the intervention process:

• The OT has the overall responsibility for the development and implementation of the
intervention plan
• Collaborate with OTA and client to develop the plan
• When delegating various aspects of the OT intervention to the OTA, the OT is responsible for
providing appropriate supervision
• Collaborate with OTA to choose, implement, and make modifications to therapeutic activities
and interventions that are consistent with competency levels, goals, and the practice setting.
• The OT will contribute to the school team’s determination of the need for continuing, modifying,
or discontinuing therapy services (AOTA, 2020a)

Describe how an occupational therapy assistant would contribute to the intervention process:
• The OTA is responsible for being knowledgeable about the evaluation results and providing
input into the intervention plan, based on the client’s needs and priorities
• Collaborate with OT and client to develop the plan
• The OTA is responsible for being knowledgeable about the client’s OT goals
• Collaborate with OT to choose, implement, and make modifications to therapeutic activities and
interventions that are consistent with competency levels, goals, and OT setting
• The OTA exchanges information with the OT about the client’s responses to and
communications during intervention
(AOTA, 2020a)

Describe how/when occupational therapy services might be discontinued for this client:
• OT services would be discontinued when Fabian no longer has adverse needs impacting his
education that would need to be addressed through occupational therapy. This might happen
 after he has met his short- and long-term goals or other services are implemented that would
sufficiently meet his needs. This would happen in collaboration with IEP team.
• OT services may also be discontinued if his parents choose for him to no longer have an IEP.

Additional resources to learn more about OT in this practice setting:

American Occupational Therapy Association [AOTA]. (n.d.). Occupational therapy in school settings [Fact
sheet]. https://www.aota.org/About-Occupational-Therapy/Professionals/CY/school-
settings.aspx

American Occupational Therapy Association [AOTA]. (n.d.). Successful participation at school: Strategies
for all students [Fact sheet]. https://www.aota.org/-
/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Tips-for-Educators-Successful-
Participation-School-Strategies-for-All-Students.pdf

American Occupational Therapy Association [AOTA]. (2017). Guidelines for occupational therapy
services in early intervention and schools. American Journal of Occupational Therapy, 71(Suppl.
2) 7112410010. https://doi.org/10.5014/ajot.2017.716S01

American Occupational Therapy Association [AOTA]. (2021). Improve your documentation and quality of
care with AOTA’s updated occupational profile template. American Journal of Occupational
Therapy, 75, 7502420010. https://doi.org/10.5014/ajot.2021.752001

American Occupational Therapy Association, American Physical Therapy Association, & American
Speech-Language-Hearing Association. (2014). Workload approach: A paradigm shift for positive
impact on student outcomes. http://www.aota.org/-
/media/Corporate/Files/Practice/Children/APTA-ASHA-AOTA-Joint-Doc-Workload-Approach-
Schools-2014.pdf

Hanft, B. & Shepherd, J. (Eds.). (2016). Collaborating for student success (2nd ed.). AOTA Press.

Illinois State Board of Education. (2015). Developing meaningful IEPs and utilizing the new Illinois
learning standards [PowerPoint slides]. https://www.isbe.net/Documents/IEPs-with-NILS-
pres141208.pdf

Illinois State Board of Education. (2019). Recommended practices for occupational and physical therapy
services in Illinois schools. https://www.isbe.net/Documents/occupational_therapy.pdf

Illinois State Board of Education. (2020). Educational rights and responsibilities: Understanding special
education in Illinois. https://www.isbe.net/Documents/Parent-Guide-Special-Ed-Aug20.pdf

Frolek Clark, G., Rioux, J. E., & Chandler, B. E. (Eds.). (2019). Best practices for occupational therapy in
schools (2nd ed.). AOTA Press.

Obermeyer, I. (2018). Executive function for school-age students. SIS Quarterly Practice
Connections, 3(4), 2–5. https://www.aota.org/Publications-News/SISQuarterly/children-youth-
practice-connections/CYSIS-11-18.aspx
References:
Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms & profiles. University
of Vermont, Research Center for Children, Youth, & Families.
American Occupational Therapy Association [AOTA]. (2020). AOTA occupational profile template.
https://www.aota.org/profile
American Occupational Therapy Association [AOTA]. (2020a). Guidelines for supervision, roles, and
responsibilities during the delivery of occupational therapy services. American Journal of
Occupational Therapy, 74(Suppl. 3), 7413410020. https://doi.org/10.5014/ajot.2020.74S3004
American Occupational Therapy Association [AOTA]. (2020b). Occupational therapy practice framework:
Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2),
7412410010. https://doi.org/10.5014/ajot.2020.74S2001
Asher, I. E. (2014). Asher’s occupational therapy assessment tools: An annotated index (4th ed.). AOTA
Press.
Case-Smith, J. & O’Brien, J. C. (Eds.) (2015). Occupational therapy for children and adolescents (7th ed.).
Elsevier/Mosby.
Collaborative for Academic, Social, and Emotional Learning [CASEL]. (n.d.). SEL: What are the core
competence areas and where are they promoted? https://casel.org/sel-framework/
Donohue, M. V. (2013). Social profile: Assessment of social participation in children, adolescents, and
adults. AOTA Press.
Fisher, A. G. & Griswold, L. A. (2010). Evaluation of social interaction (2nd ed.). Three Star Press.
Gresham, F. M. & Elliott, S. N. (2008). Social skills improvement system SISS rating scales (SSIS rating
scales). Pearson.
Kramer, J., ten Velden, M., Kafkes, A., Basu, S., Federico, J. and Kielhofner, G. (2014). Child Occupational
Self Assessment (COSA) Version 2.2. University of Illinois at Chicago.

Case example author: Asia Kim, CHES®, OTS

Case example reviewers: Michelle Ponsolle-Mays, MS, OTR/L & Anne Kiraly-Alvarez, OTD, OTR/L, SCSS
Last review date: March 2021