School-Based Occupational Therapy Assessments: Capturing the Student-Environment Interaction to Promote Engagement and Access

Deb Misrahi, OTD, OTR/L

Pauline Kelly, OTD, OTR/L

The school based occupational therapy assessment provides us with a plethora of information and can be used in a variety of ways. One is to determine the need for related services while the other includes assisting the multi-disciplinary-team (M-team) in the decision-making process to determine eligibility for Exceptional Student Education (ESE) services. This assessment follows the format many practitioners use, regardless of practice setting, yet stands out in one particular manner: the intense focus on the relationship between the student and the environment.

During the assessment process, we look at performance skills as recommended by the American Occupational Therapy Association (AOTA) via an analysis of occupational performance, which they consider “…the step in the evaluation process in which the client’s assets and limitations or potential problems are specifically determined through assessment tools designed to analyze, measure, and inquire about factors that support or hinder occupational performance” (American Occupational Therapy Association, 2023) . 

These performance skills are “observable, goal-directed actions and consist of motor skills, process skills, and social interaction skills. Performance skills are evaluated and analyzed by occupational therapists during actual activity performance, with real objects, in a natural context, and often in the presence of others” (AOTA,2023) and most widely recognized portion of the assessment.

Our own Florida Occupational Therapy Practice Act emphasizes the use of “skilled observation or the administration and interpretation of standardized or nonstandardized tests and measurements to identify areas for occupational therapy services.” (FLSenate.gov). Thus, both national and state guiding documents clearly indicate the need for consideration of the environment or context where occupation occurs in the assessment process. 

The assessment should focus on the child’s ability to participate in school related activities, whether they are following a standard or modified curriculum so let’s discuss the meaning of participation. Participation or “involvement in life situations” is a key outcome (WHO, 2007), in classroom and school-based activities. Participation in school includes unstructured activities (e.g friendships, play), organized activities (e.g. sports, clubs, arts), classroom based activities (e.g. group work, study) and engagement in social roles (WHO, 2007).

Meanwhile the learning environment can be considered “... more than just a classroom—it’s a space in which students feel safe and supported in their pursuit of knowledge, as well as inspired by their surroundings” and incorporate the following landscapes: physical, psychological, and emotional (3 Types of Learning Environments, 2021).

Research on pediatric occupational therapy assessment has found a reliance on performance skills assessments that are not always conducted in the natural context, however.  A bottom-up assessment style tends to lead to occupational therapy interventions that are deficit reduction based and not in alignment with the basic tenet of occupational therapy which is to focus on occupation based intervention (Hinkley et al, 2021). Fortunately Hinkley et al (2021) also found that by the very nature of school-based occupational therapy occurring within the student’s natural environment, despite assessment approaches, intervention is more apt to involve occupation based principles.

While assessing fine motor, visual perception, visual motor, and self-help skills are intricate components of a school-based assessment, assessing the learning environment is sometimes not regarded as highly. Consider how we explain the difference between clinic based and school-based services? We all assess the same performance and pattern skills, yet assessing the learning environment is the one area we do not overlap with the community providers. Our ability to view students in the actual context of the services we provide and where the demand is presented is some of the most valuable information we have.

The Florida Department of Education (FLDOE) oversaw the development of the Assessment of Functional Skills tool in collaboration with therapists statewide and specifically note the Learning Environment as an entire section to assess (FLDOE, 2012). Other recommendations when using this tool include the explanation that “therapists provide strategies to facilitate participation within the school environment”, while not limiting our scope to the classroom alone (FLDOE, 2012, p.2). Although somewhat dated, this document provides a functional tool to systematically consider the various aspects of the school environment within the school-based occupational therapy assessment process. For example, the following is an excerpt from the Learning Environment section of the assessment:

This section considers the student’s performance in his/her learning environment, including the classroom, computer and science labs, community-based instruction (CBI) sites, and any other areas for which the primary use to the student is instructional, including the home environment for students who receive hospital/homebound services (FLDOE, 2012, p.6).

Another example comes from the Sample/Template Occupational Therapy Evaluation from the University of North Carolina (UNC) School of Medicine Department of Health Sciences to provide resources to North Carolina school-based occupational therapists: 

III. ENVIRONMENTAL DESCRIPTION:

(Level of impact of the environmental factor on participation and performance:  N=No impact; Min=Minimal impact; S=Significant impact)

Comments:

Using the tools above, a school-based occupational therapist can ensure that their assessments are authentic representations of a student’s strengths and limitations related to their occupational performance in the student role. The following are additional considerations which may assist in capturing this data:

• Performance of several observations within various school contexts: Have you observed the student in all of the areas where occupational performance occurs? Some of these may include the classroom, the cafeteria, the playground or physical education area, the bus area, the library and various “specials” classrooms (art, music, etc). If a student changes classes during the day have you observed them in each of these classrooms? 
• Performance of observations within various temporal contexts: Have you observed the student at various times during the school day? A student’s performance may look very different at the beginning versus the end of the school day. 
• Performance of observations during various activities? Have you observed the effects of the built environment on task completion? For example can you determine if technology is available for the student to complete writing or reading tasks and, if so, can the student access this aspect of the built environment? 

So, consider how you describe the classroom setting in your assessments. Do you employ a top down approach that clearly describes the supports and barriers to occupational performance afforded by the school environment? Or do your school based occupational therapy assessments reflect more of a bottom up approach that focuses on performance skills deficits? Emphasizing the fit between the student, the occupation, and the setting will assist in framing school-based assessments within OT theory and best practices and in our opinion, deserves further exploration to assist practitioners fully develop this section of the school-based assessment.

The School-Based Occupational Therapy Assessment

The school-based occupational therapy assessment provides us with a plethora of information and can be used in a variety of ways. One primary use is to determine the need for related services, while another involves assisting the multidisciplinary team (M-team) in the decision-making process to determine eligibility for Exceptional Student Education (ESE) services. This assessment follows a format many practitioners use, regardless of the practice setting, yet stands out in one particular manner: its intense focus on the relationship between the student and the environment.

During the assessment process, performance skills are evaluated, as recommended by the American Occupational Therapy Association (AOTA), via an analysis of occupational performance. AOTA considers this analysis “...the step in the evaluation process in which the client’s assets and limitations or potential problems are specifically determined through assessment tools designed to analyze, measure, and inquire about factors that support or hinder occupational performance” (AOTA, 2023).

These performance skills are “observable, goal-directed actions and consist of motor skills, process skills, and social interaction skills. Performance skills are evaluated and analyzed by occupational therapists during actual activity performance, with real objects, in a natural context, and often in the presence of others” (AOTA, 2023). This aspect is widely recognized as the central focus of the assessment.

The Florida Occupational Therapy Practice Act emphasizes the use of “skilled observation or the administration and interpretation of standardized or nonstandardized tests and measurements to identify areas for occupational therapy services” (FLSenate.gov). Both national and state guiding documents clearly stress the importance of considering the environment or context in which occupation occurs during the assessment process.

The assessment focuses on the child’s ability to participate in school-related activities, whether they follow a standard or modified curriculum. Let’s explore the meaning of participation. The World Health Organization (WHO, 2007) defines participation as “involvement in life situations.” Participation in school includes unstructured activities (e.g., friendships, play), organized activities (e.g., sports, clubs, arts), classroom-based activities (e.g., group work, study), and engagement in social roles.

Meanwhile, the learning environment encompasses “... more than just a classroom—it’s a space in which students feel safe and supported in their pursuit of knowledge, as well as inspired by their surroundings.” The environment incorporates physical, psychological, and emotional landscapes (3 Types of Learning Environments, 2021).

Research on pediatric occupational therapy assessments has shown reliance on performance skills assessments that are not always conducted in natural contexts. Bottom-up assessment styles often lead to deficit-reduction-focused interventions, which may not align with the fundamental principle of occupational therapy: occupation-based intervention (Hinkley et al., 2021). Fortunately, Hinkley et al. (2021) also found that, by the very nature of school-based occupational therapy occurring within the student’s natural environment, interventions tend to integrate occupation-based principles more effectively.

While assessing fine motor, visual perception, visual motor, and self-help skills are intricate components of school-based assessment, evaluating the learning environment is often undervalued. Consider how we explain the difference between clinic-based and school-based services. Both settings assess the same performance and pattern skills, yet assessing the learning environment is unique to school-based services. Viewing students in the actual context where demands are presented provides some of the most valuable information available.

The Florida Department of Education (FLDOE) developed the Assessment of Functional Skills tool in collaboration with therapists statewide. This tool specifically emphasizes the learning environment as an entire section to assess (FLDOE, 2012). Recommendations include strategies to facilitate participation within the school environment, without limiting the scope to the classroom alone (FLDOE, 2012, p. 2). For example, the following excerpt from the Learning Environment section provides systematic considerations for assessment:

“This section considers the student’s performance in his/her learning environment, including the classroom, computer and science labs, community-based instruction (CBI) sites, and any other areas for which the primary use to the student is instructional, including the home environment for students who receive hospital/homebound services” (FLDOE, 2012, p. 6).

Another useful tool comes from the University of North Carolina (UNC) School of Medicine Department of Health Sciences, which offers a sample/template occupational therapy evaluation to assist North Carolina school-based occupational therapists:

TABLE

Using these tools, school-based occupational therapists can ensure their assessments authentically represent a student’s strengths and limitations related to their occupational performance in the student role. Additional considerations to capture this data effectively include:

• Observing performance across various school contexts: Assess the student in all areas where occupational performance occurs, such as the classroom, cafeteria, playground, physical education area, bus area, library, and specialized classrooms (e.g., art, music).
• Observing performance at different times: Assess the student’s abilities at various times during the day, as their performance may vary significantly between morning and afternoon sessions.
• Assessing activity-specific environmental impacts: Determine how the built environment influences task completion, such as whether technology is available for the student and if the student can access these resources.

Consider how you describe the classroom setting in your assessments. Do you employ a top-down approach that highlights the supports and barriers to occupational performance afforded by the school environment? Or do your school-based occupational therapy assessments reflect more of a bottom-up approach focusing solely on performance skills deficits? Emphasizing the fit between the student, the occupation, and the setting frames school-based assessments within occupational therapy theory and best practices. This alignment, in our opinion, deserves further exploration to assist practitioners in fully developing this section of the school-based assessment.

References-.

American Occupational Therapy Association. (2020). 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

American Occupational, Therapy Association, 2023) Domain and Process: Evaluation & assessment, 

2023). Retrieved from https://www.aota.org/practice/domain-and-process/evaluation-and-assessment. 

American Occupational Therapy Association (2023): EVERYDAY ADVOCACY Policies supporting 

OT's role in shaping contexts and environments Retrieved from https://www.aota.org/advocacy/everyday-advocacy/ots-role-in-shaping-contexts-and-environments.

Assessments of Functional Skills: Occupational Therapy and Physical Therapy. (2012) Florida

Department of Education. Retrieved from https://www.fldoe.org/core/fileparse.php/7690/urlt/0070072-otptguide.pdf

Assessment of the Learning Environment retrieved from 

https://achieve.lausd.net/cms/lib/CA01000043/Centricity/domain/361/positive%20behavior/tier%20iii/t3%20resources/Assessment%20of%20the%20Learning%20Environment%20rev%20October%202016.pdf

Emily Hinkley, Christen Leach, Vanessa D. Jewell & Taylor L. Wienkes (2022) Utility of the occupation-

centered intervention assessment in pediatric occupational therapy practice, Journal of Occupational Therapy, Schools, & Early Intervention, 15:3, 302-313, DOI: 10.1080/19411243.2021.1975603

Fisher, A. G., & Griswold, L. A. (2019). Performance skills: Implementing performance analyses to 

evaluate quality of occupational performance. In B. A. B. Schell & G. Gillen (Eds.), Willard and Spackman’s occupational therapy (13th ed., pp. 335–350). Wolters Kluwer.

Fisher, A. G., & Marterella, A. (2019). Powerful practice: A model for authentic occupational therapy. 

Center for Innovative OT Solutions.

Fraser, Barry (2021). Classroom Learning Environments: Assessing and Investigating the Learning 

Environment DOI: 10.1093/OBO/9780199756810-02 . Retrieved from https://www.oxfordbibliographies.com/display/document/obo-9780199756810/obo-9780199756810-0287.xml87.

Gettinger, M., Schienebeck, C., Seigel, S., & Vollmer, L. (2011). Assessment of classroom environments. 

In M. A. Bray & T. J. Kehle (Eds.), The Oxford handbook of school psychology (pp. 260–283). Oxford University Press.

Occupational Therapy Practice Act. Title XXXII. Florida Senate2012. 

https://www.flsenate.gov/Laws/Statutes/2012/0468.201

Rune J. Simeonsson, Dawn Carlson, Gail S. Huntington, Janey Sturtz McMillen, J. Lytle Brent (2001) 

Students with disabilities: a national survey of participation in school activities, Disability and Rehabilitation, 23:2, 49-63, DOI: 10.1080/096382801750058134

Sasson, I., Yehuda, I. & Miedijensky, S. Innovative learning spaces: class management and universal 

design for learning. Learning Environ Res 25, 725–739 (2022). https://doi.org/10.1007/s10984-021-09393-8

Sarah Y. Skinner, Jennifer Katz & Vicki F. Knight (2022) Meaningful participation in a general education 

classroom of a student with significant disabilities: bridging the fields of occupational therapy and inclusive education, International Journal of Inclusive Education, DOI: 10.1080/13603116.2022.2137589

3 Types of Learning Environments (2021). Retrieved form https://www.wgu.edu/blog/3-types-learning-

environments2111.html#close

University of North Carolina School of Medicine, Department of Health Sciences, North Carolina 

School-based OT Retrieved from https://www.med.unc.edu/healthsciences/ocsci/nc-school-based-ot/documents/evaluation-supports/