Becoming a knowledgeable consumer: types of tests, theory selection, and service delivery models

Occupational therapists have many areas of expertise and tend to specialize in specific age ranges and settings. All therapists share a common knowledge base but add to it by experience and advanced education. A pediatric therapist works with children and is usually employed in Early Intervention (EI), a hospital, a rehabilitation center, a school, or a private clinic or practice. Your state occupational therapy association should be able to provide you with a list of therapists in your area. Don't be afraid to inquire about experience, credentials, and advanced training.

Even among pediatric therapists, you may find different frames of reference for practice. For example, many therapists use Sensory Integration, an OT theory developed by Dr. A. Jean Ayres. Others may emphasize neurodevelopmental therapy, first developed by Dr. Karel Bobath and his wife, Berta, a physiotherapist in England. Some therapists emphasize the Model of Human Occupation or other mental health models. Theories are the tools that underlie intervention: in reality therapists often combine several theories when providing intervention. You should try to match your concerns for your child with the training and expertise of the therapist.

The assessment process may include three levels of testing:

1. Screening to determine the probable need for service; use of less formal tools such as checklists, histories, etc. are acceptable at this level.
   
   
2. Identification (diagnosis) of specific problems (e.g., Dysfunction in Sensory Integration, motor delay, visual-perceptual dysfunction, etc.). This should be done through use of standardized tests. Standardized means that certain procedures have been followed in test development to ensure uniformity in administration, scoring, and interpretation. For the purpose of identification, the child's performance or behavior is compared to that of a normative group; it is then determined that the results (scores) are equal to the normative sample, above those of the sample, or below. Identification depends upon how "like" the child's performance is to the comparison group. Common tests used by OTs for this process are:
   
   
• Peabody Developmental Motor Scales 2nd Ed. (PDMS-2) (Folio & Fewell, 2000);
• Bruininks-Oseretsky Test of Motor Proficiency (BOTP) (Bruininks, 1978);
• Mullen Scales of Early Learning (MSL) (Mullen, 1995);
• Movement Assessment Battery for Children (Movement ABC) (Henderson & Sugden, 1992);
• Sensory Integration Praxis Tests (SIPT) (Ayres, 1991);
• Developmental Test of Visual Perception 2nd Ed. (DTVP-2) (Hammill, Pearson, & Voress, 1993);
  
  
3. Evaluation (measurement) of the current level of concerns or behaviors; it provides a benchmark for gauging change or progress (hopefully the results of intervention). Standardized measures as well as "clinical observations" that are more qualitative and discretionary may be used. An observation of the child in the natural environment (e.g., home or school) may be done. Often the standardized measures use important performance criterions (tasks or skills such as mobility, independent sitting, use of scissors) or outcomes rather than group comparisons (comparing the child's general abilities to those of a matched typical group). This is because the concern is whether or not the child is improving functional or developmental tasks (outcomes), not which group he or she belongs in (identification). Some standardized tests have both norm-referenced and criterion-referenced qualities (e.g., PDMS-2). The School Function Assessment (SFA) (Coster, Deeney, Haltiwanger, & Haley, 1998) is an example of such a measure designed specifically to measure change in performance and behavior in early school grades.

Service Delivery Models

After the evaluation is completed, the team (family, professionals, interested parties) discusses how the OT can BEST meet the needs of the child. Most people are acquainted with the traditional "direct-service" medical model, but as you will see, there are several ways to provide meaningful intervention. The models are not mutually exclusive and may be combined.

Direct: practitioner directly treats the client or a small group of clients.

Monitor: practitioner has treated, but no longer treats the client directly; practitioner oversees (i.e., suggests, interprets) tasks and activities performed or observed by someone else (e.g., the home educator or a teacher).

Consultant: Consultant: practitioner had not and does not treat the specific client directly but oversees tasks and activities performed or observed by someone else (e.g., the home educator or a teacher); practitioner may provide general information or recommendations about conditions, diagnoses, etc.

Transdisciplinary: model developed in early intervention; a single discipline practitioner (e.g., the occupational therapist) serves as the primary service provider with input from other disciplines as needed; goals and strategies are developed across the disciplines.

Inclusion: the practitioner performs treatment within an ecologically valid or natural environment. For a child in school, this is the classroom; for the child in day care, this is the day care center; for the child at home, this is the home.

Case Manager: the practitioner coordinates services; analyzes fiscal benefits; advocates for essential services; advises client, family, or caregiver; monitors use of resources.