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- 1. P A T R I C I A T E R R E R - P E R E Z , M S C O T C O N S U L T A N T A N D C L I N I C A L S P E C I A L I S T O C C U P A T I O N A L T H E R A P I S T M E D I C O - L E G A L O T SEND Tribunals: OT perspective and Best Practice
- 2. Plan for this session The assessment Report Writing for Tribunals: my experience The Evidence The Hearing Case Studies/ Examples / Discussion / Questions Top Tips for Managing Tribunal Work
- 3. Tribunal Assessments Instructions and Preparation Expectations of parents/ school staff Clinic Vs Real Setting Standardised Assessments Vs Functional Assessments Use of Images Views of the child/young person, parents and school staff
- 4. Report Writing: what I’ve learned so far… 1. Review Bundle Documents, specially the other OT’s report. 1. Follow a TEMPLATE (work in progress): credentials, instructions, statement of truth, evidence, description of assessments, what your team can offer the student (provision), etc. will be very similar in every report. Follow EHCP sections. 1. Don’t dwell on the PAST!: keep background info relevant and brief. Include only relevant diagnosis and current difficulties. 1. Investigation of the FACTS/ FINDINGS: What happened on the day in logical order + additional information from assessments carried out and parents’ / professionals’ / students’ views. Likely to go in NEEDS section of EHCP. 2. EXPERT OPINION (clinical reasoning): link needs to OUTCOMES and PROVISION. Keep things in the right sections.
- 5. Report Writing (cont.) 6. Avoid jargon, commenting on ‘what’ placement or non-OT subjects (obvious!). You can comment on environment instead. 7. Number / label every section (for future reference) and all pages. 8. Use IMAGES wisely 9. Quantify everything: amount of OT sessions and time in each, and whether they are Direct or Indirect. 10. Use Appendixes: for assessments used, for the evidence you are quoting or additional images
- 6. KEY LEARNING POINT IF IT’S NOT WRITTEN UP IN YOUR REPORT, IT CANNOT BE DISCUSSED IN THE TRIBUNAL!!
- 7. OT Provision Set Relevant / Functional Outcomes QUANTIFY EVERYTHING Direct time with student Indirect time (additional activities): parents, teachers /TA, training, meetings, programme/report writing, etc.
- 8. Evidence 1. To explain best practice in school-based OT interventions 2. To clarify some long-standing Myths: Weekly OT sessions ‘Out of class’ sessions LSAs delivering interventions Impairment-based interventions
- 9. How to justify occupation-based practice
- 10. Impairment-based interventions Research evidence: isolated motor/sensory/perceptual tasks do not improve function or participation in activities (Novak et al. 2019). Child Development is not linear and sequential. There are NO pre-requisites to be met, before attempting a higher level task. Practicing A will not result in B (time is wasted!). What we practice is what we get better at. Motivating and functional activities for the student will result in better outcomes (child-centred). Use strengths and interests to increase engagement and participation. Practice in the real context (NOT in a clinic or quiet room)
- 12. Checking our Expectations Fine motor skills activities Practice: A Good writing, colouring, drawing, cutting and use of classroom tools Results: B
- 13. Is this true in real life? Going to the gym Practice: A Great skills at Playing Tennis Result: B
- 14. Contemporary views: a different pyramid!
- 15. Where to find the EVIDENCE RCOT and WFOT– Factsheets and Practice Briefs/ Guidelines (i.e. school-based interventions, SI, etc) Research articles and systematic reviews (i.e. to justify amount of OT or relevant interventions for certain conditions) – high levels of evidence (Novak et al. 2019/2020) By omission: lack of evidence or inconclusive Government guidelines (NICE) and Charities (Kings’ Fund)
- 16. The Hearing • Working with the Solicitor / Family: help to clarify OT issues • Be clear about your ‘WHYs’ (i.e. amount / type of therapy recommended) • Concise language (no jargon) • Use examples from your assessment • Talk about evidence + professional expertise • Try and reach a compromise wherever possible
- 17. Case Example: Leah Girl, 9 y.o., Specific Learning Difficulties, some anxiety, sensory processing differences, Irlen Syndrome Attended Mainstream school, pulled out by parents and enrolled in private specialist provision. Parents requesting weekly OT, PT and SLT sessions and special school provision. Very mild level of need found on assessment. Two previous OT reports found she required weekly OT sessions, plus special school provision.
- 18. Case Example: Amir Male Student, 17 y.o. with ASD, Mild Learning Difficulties Transfer from residential special school to local college, where he gets one-to-one support (IT Studies). Poor independence skills and IADLs (travelling, simple snack making, home maintenance, etc.) Adequate literacy level but writing / recording work difficulties Some anxiety around new places, new people and community activities
- 19. Best Practice TIPS 1. Explain the impact of OT in Plain Language 2. Collaborate with Tribunals officers / family to reach an agreement 3. Be very Specific about OT interventions (quantity and type) 4. OT services CAN be delivered by non-OT people (training, modeling and knowledge translation) 5. Embed OT interventions within school routines and collaborate with other professionals / parents/ school team to propose integrated services 6. Refer to current evidence (not just ‘expert opinion’)
- 20. More Resources Model report from Legal Firm OT Provision Wording Evidence Wording (Appendix) EHCP template from RCOT OT report examples (from NHS and Private services)
- 21. Any questions? Thank you! Contact details: Patricia Terrer-Perez, MScOT Clinical Specialist Occupational Therapist Email: admin@medicolegalot.com Webpage: www.medicolegalot.com Linkedin: www.linkedin.com/in/patricia-terrer-perez SlideShare: https://bit.ly/2OA2w0e
- 22. References Anaby D, Avery L, Gorter JW, Levin MF, Teplicky R, Turner L, Cormier I, Hanes J. (2019). Improving body functions through participation in community activities among young people with physical disabilities. Developmental Medicine & Child Neurology, 62 (5). Ashburner, J.K., Rodger, S.A., Ziviani, J.M., and Hinder, E.A. 2014. Optimizing participation of children with autism spectrum disorder experiencing sensory challenges: a clinical reasoning framework. Canadian Journal of Occupational Therapy, 81, 29-38. Dancza K, Missiuna C and Pollock N (2017). Occupation-centred Practice: when the classroom is your client. S Rodger and A Kennedy-Behr (2017). Occupation-centred practice with children: a practical guide for occupational therapists. Wiley Blackwell, West Sussex, UK. Hinder E and Ashburner J (2017). Occupation-centred intervention in the school setting. In: S Rodger and A Kennedy-Behr (2017). Occupation- centred practice with children: a practical guide for occupational therapists. Wiley Blackwell, West Sussex, UK. Hoy M M P, Egan M Y, Feder K P. (2011) A Systematic Review of Interventions to Improve Handwriting. Canadian Journal of Occupational Therapy, 2011 (78: 13). Novak, I; Honan I (2019). Effectiveness of paediatric occupational therapy for children with disabilities, a systematic review. Australian Occupational Therapy Journal. Vol. 66 (3). S Rodger and A Kennedy-Behr (2017). Occupation-centred practice with children: a practical guide for occupational therapists. Wiley Blackwell, West Sussex, UK. RCOT: Informed View. Sensory Integration and Sensory-based interventions. Royal College of Occupational Therapists. February 2021. RCOT Evidence Spotlight: Sensory integration and sensory-based interventions – children & young people. Royal College of Occupational Therapists, February 2021. The Council for Disabled Children (2019). Sensory Differences and Approaches to Intervention. https://councilfordisabledchildren.org.uk/help- resources/resources/sensory-differences-and-approaches-intervention World Federation of Occupational Therapists: Position Statement. Occupational Therapy Services in School-based Practice for Children and Youth. 2016. Zivianni J, Jenkins J. Effect of Pencil Grip on Handwriting Speed and Legibility. 2006. Educational Review, Vol. 38.
Editor's Notes
- About me: experience so far. 22 years working as an OT, in the NHS and Social care, mainly with children and young people. Clinical Specialist Band 8A at Royal Free London NHS Trust. Now Lecturer at Brunel University as well part time. Started my own OT private practice 4 years’ ago, mainly doing specialist work for Tribunal officers and at times offering OT services to schools as well. Different perspective to offer, than other private practices and professionals, and you may see why in the rest of my talk. As a private OT, I’ve been mainly working for Croydon Local Authority as an external contractor, but also Brent, Barnet, Lewisham. At times I am representing both parents and local authority, but mainly Local Authority work. Now about you – years of practice, areas of expertise, have you ever been asked to do Tribunal Ax or Report? Have you ever been to a hearing?
- Read all the Bundle Documents First, especially the other OT’s report. Take your TIME.
- Give it your best go, don’t bother to do things half-heartedly. If you have the other party’s OT report: try and match their content. If they comment on something they feel is vital (i.e. SI needs), you MUST comment on it too. I use templates as needed, but ensure that each report is individualised and fully reflects the needs of each student. 2. Work on developing a good template for your team. It will save you lots of TIME in the long term. There are certain things that do NOT change. Careful with NAME changes. More on Wording later. Even with a template and a lot of experience, the average time that it takes is around 5-6 hours. 3. Only comment on other people’s reports if relevant to your reasoning. Summarise Diagnosis. If you’re unsure, leave out diagnosis. If SPD mentioned, just say ‘reported sensory processing difficulties’, not ‘disorder’. 4. Describe what happened in the day with honesty – if the student was having a bad day, just say so. Describe presentation of the students, who was there and their views as well. VIEWS of the student also very important. 5. This is the trickiest part and easier to pull apart by the other party if not well-reasoned. EHCP sections: presenting problems need to be organised into relevant sections, outcomes sought and interventions. Keep things in the right sections: Cognition and Learning, Social-emotional, Physical / Sensory and Self-care. Section E: Outcomes; and Section F: OT provision, has to be linked to the assessment results clearly. You have to be specific with interventions and outcomes, BUT this is NOT a therapy plan/ goals. Things can be narrowed down by the intervening therapist later on. Example: OTs often place ‘Handwriting issues’ in the Cognition and Learning – this is only ok if related to attention problems or content of the writing, but not with regards to the physical process of writing (sensory and physical section).
- 6. Technical terms should be explained first time they appear. Don’t comment on Non-OT subjects, such as the student’s communication skills or literacy level. Some areas might overlap, i.e. visual supports to help transitions and prevent behavioural outbursts. Do not comment on WHAT PLACEMENT will be best, but on the characteristics of that placement/ environment required. 8. IMAGES: posture, pen grip, workstation, observations from books, samples of work done in the session, bathroom, lunch hall, etc. I’ve been able to demonstrate the other party’s comments on a student’s posture were irrelevant, as I took a picture of the student’s regular posture in class. 9. Amount of Therapy: consider the needs of the child and rate of progress. High level of need does not always equate to higher number of sessions (i.e. in the case of a PMLD student or someone that may have had a lot of OT sessions already). See more in evidence section. 10. Better to keep the report focused on EHCP sections, and additional information in Appendixes. Still CAN be discussed in Tribunal if in Appendix.
- You can submit late evidence if needed, up to a limit, as the other party has to see it as well before the Tribunal. You can also explain, discuss and justify what is in your report, but not add new evidence at the Hearing time.
- Exercise : Look at examples of OT wording and determine which are examples of best practice.
- No evidence to say that weekly OT sessions / out of class/ impairment focused or SI-focused have better outcomes, no study confirming this in any area. Frequent OT sessions do have an impact (.i.e. handwriting interventions in Hoy’s systematic review – 3-5 times weekly groups have good outcomes). Consistency / embedding of interventions in daily routines is key to obtain better outcomes in the long term. Training of staff, modelling, knowledge translation is often more effective than an OT turning up every week and taking over from other professionals working with the child daily. Out of class interventions do not generalise gains in class
- Practice in context: demands of the task are related to the context where it takes place. Example: not the same changing clothes at home, where there is a set up of bed, wardrobe, drawers, quiet and warm space, parent supporting, etc. to changing clothes in a gym or school changing room, with increased noise levels, distractions, peers, gym kit bag, pegs, benches, no supporting adults, etc. Besides, what is practiced in one context might not be generalised to others (specially for students with ASD or LD). Hence why interventions or practice in ‘clinics’ or ‘quiet rooms in schools’ may not generalise to the real context (i.e. classroom, lunch room, playground, etc).
- Many versions of this model (which is near 20 years old) have been shared by OTs and other health/educational professionals. The premise is to make people aware of all the systems involved in learning and how complex an activity can be for an individual with impairments in one or more underlying areas. The downfall is the pyramid shape. People have since interpreted this model as a sequential route to higher cognitive functions. Example: if you wish to participate in academic learning, you have to work first on individual capacities, such as your body scheme, visual perception, motor planning, eye-hand coordination, etc. You need good foundations to expect to achieve at a higher academic level.
- Fine motor skills activities often found in schools: putting pegs on boards, lacing cards, mazes, threading beads, screwing plastic screws, theraputty exercises, sheets with patterns to copy, tongs and tweezers, etc. Some of these activities are absolutely fine, when inserted into a real context (i.e. playing Jenga, making a card for mum’s day, colouring a picture related to a class topic, etc). At times they are also found in nursery or reception classrooms, as part of wider play activities on offer. However, in isolation and for older students, they can be an added-on to the child’s day, stigmatising and time-consuming, making them feel different to their peers. Practicing skills like this during nursery and reception classes, as part of whole class activities is fine. But not beyond these ages. The reasoning behind these kinds of tasks goes like this: if they spend some time practicing their fine motor skills with these tasks, they will get better at higher level tasks, such as drawing, colouring, writing, and manipulating materials in the classroom.
- However, is this true in real life? Let’s have a look at some examples: Practicing going to the gym several times a week will not result in great skill at tennis. Practicing tennis skills in the court several times a week, with a good coach/trainer, and graded activities, will result in great skill at tennis Practicing moving fingers in isolation vs. practicing playing the piano, reading music, getting fingers used to different songs, chord patterns, etc. Also, practicing once a week, is not likely to have great results in the long term. Practicing little and often will have better results.
- Bottom-up approaches have been favoured for a long time (they still are!), where health professionals are considered ‘experts’ who provide advice to be followed. The hypothesis at the time was related to improving or changing body structures or functions, so that this would have an impact on the activities and general participation of the individual in their chosen tasks. Research demonstrated that Bottom up approaches are very time-consuming, and have very limited effectiveness in achieving participation in functional tasks, roles and situations. The opposite, in fact, seems to be true. Facilitating participation in relevant and meaningful activities improves the individual’s body functions and structures in the long term, and even in cases where this is not possible (long term conditions), it still promotes better participation and inclusion. In schools, most of the students with EHCPs will have long-term conditions, where changes in body functions and structures are very limited. And we’re not thinking here about just physical ability, but also attention, memory and other cognitive/executive functions. We have to try a different way! Top-down approaches will be more effective, less stigmatizing, more motivating and faster to achieve gains and enable participation in tasks.
- Lack of evidence of ‘weekly OT’ making a difference. However, good evidence on 3-5 times/week interventions, delivered by other professionals (i.e. Hoy et al. Systematic review 2011). NICE guidelines, more generic than OT ones, but still all advocate for integrated, client-centred care: topics that may be relevant Spasticity for under 19 y.o., Cerebral Palsy, Autism. King’s Fund – helping patients to self-manage long term condition and patient activation. Novak, 2019. Systematic review on OT- CYPF interventions
- Carried out AMPS, Sensory profile with school staff, REAL with parents, classroom observations. Described functional needs and set Outcomes related to arousal levels and recording of work (OT provision and equipment)
- Private OT report recommending weekly OT sessions and working on handwriting, IADLs, some sensory behaviours. In his previous residential college, he was independent with some IADLs (i.e. laundry, meals, microwave use, etc) but lost these skills since back home. Carried out college observations, travel training and home AMPS / parent interview. Tried technology and DASH assessment. Recommended 6 OT sessions to set up OT interventions / modeling and one follow up then close. Referred to local LD team for further support at home with IADLs and accessing community resources.
- 2. Not ‘Weekly OT’ sessions 4. Aim for self-management or supported management of long term conditions, rather than a quick fix by a professional.