Bridging Education and Health Outcomes through UDL

In this paper, the authors make a case for the importance of interdisciplinary collaboration between occupational therapists, teachers, students and parents to support the variable needs of children in inclusive classrooms. They describe how the scope of practice of occupational therapists is ideally suited to support the application of UDL principles in all school learning environments. The three principles of UDL are, “provide multiple means of engagement, provide multiple means of representation and provide multiple means of action and expression” (CAST, 2020). The authors discuss the findings of a three-month pilot project where an occupational therapist worked with teachers and students in their classrooms to collectively identify and remove barriers to learning. The pilot project took place from April to June 2019, in a mid-sized Ontario district school board where all students are educated together in inclusive classrooms. Benefits resulting from the collaboration were categorized in the following themes: building relationships, shared learning, student participation, capacity building and support for the classroom. The need to support interdisciplinary collaboration with time to build relationships was identified by participants as an important next step. Additionally, and equally important is the need for increased knowledge about each professional’s scope of practice and potential contributions to common goals of increasing student participation in the classroom. The pilot project was conceptualized based on the premise that the principles of UDL provide common language, values and beliefs to build the bridge between educators and occupational therapists working together in inclusive classrooms to improve student participation.

The Challenge Addressed

The publicly funded district school board where this project took place serves a population of approximately 12 000 students in Ontario, Canada. The model of inclusion adopted within the district promotes the education of students in their most enabling environment. Special education services are integrated into the classroom with specialized program supports provided, only when necessary, through withdrawal. Approximately 21 % of students receive special education services each year (EQAO, 2019). The principles of UDL are promoted as the core pedagogical stance for teachers. Over the past five years, professional learning in-services have focused on deepening UDL practice in all classrooms from Kindergarten to adult education. Educators are learning to ask different questions when students are not engaged or are struggling to participate effectively in the learning environment. The impulse to investigate the capacities of the child solely from a ‘disability perspective’ is slowly shifting to investigating barriers in the environment and tasks assigned. Referrals to school health support services for occupational therapy assessments continue to be one of the most frequent options explored after diagnostic testing. Students may stay on a waitlist for occupational therapy assessment for two years or more before seeing a therapist. The school health support service delivery model for occupational therapy within the region provides for pull out therapy/assessment. Educators only have access to other educators within the school environment when problem-solving limiting the ability to consider challenges and opportunities from multiple professional perspectives.

School-Based Rehabilitation: Research and Practice

The research is clear that healthy students are better prepared to learn, and education is a key determinant of health (Ontario Ministry of Education, 2019). Education and health are inextricably interdependent however service approaches are traditionally siloed. Education professionals (e.g., teachers, principals, education assistants, consultants) and school support health care professionals (e.g., therapists, nurses, social workers) collectively work to enable all children to thrive physically, emotionally, academically, socially and spiritually (Deloitte, 2010).

Occupational therapists (OT) are particularly well suited to collaborate with educators to maximize student participation in all aspects of life based on their scope of practice (Ball, 2019; Hutton et al., 2016; Missiuna et al., 2015). OTs focus of enabling engagement in daily occupation (self-care, productivity and leisure/play) in order to promote physical and mental health and well-being (CAOT, 2012; WFOT 2012). Enabling participation in childhood occupations (things children do /(activities, want to do, or are required to do) leads towards optimizing outcomes for children with diverse needs and their families (Imms & Green, 2020). For a child, schoolwork is understood as productivity and school is also a place that offers opportunities to engage socially with peers and build relationships (Batorowicz & Smith, 2020; Imms et al., 2020). OTs are trained in the areas of child development, assessment and methods to enable functioning and participation through environmental modifications, activity adaptation, and technology support (see e.g., Case-Smith & O’Brian, 2015). The OT approach emphasizes understanding the child in context (e.g., classroom) and illustrates how the performance of child depends on the interaction of child's unique characteristics (physical, cognitive, affective, spiritual) with the environmental factors (e.g., people, space, resources) and specific occupation/activity (Townsend & Polatajko, 2012). For children of all abilities, occupational therapists can help to problem-solve strategies to include them in the curriculum as learners and to facilitate genuine interaction with peers and educators (Imms et al., 2020).

In North America, opportunities for OTs, teachers, students, parents and other educators to work together on common outcomes has historically been constrained by interdisciplinary service delivery models which are not aligned with a tiered intervention or universally designed approaches (Anaby et al., Deloitte Report, 2010; Villeneuve, 2009).

Occupational therapists and teachers as well as other school-based educators (Principals, Early Childhood Educators, Educational Assistants) have encountered each other in schools in the province of Ontario for over 20 years. This interdisciplinary collaboration has been shaped by what is described as a consultative service delivery model in school health support services (Deloitte, 2010).

Consultative therapy is defined as a model where therapists share knowledge, resources and expertise to enable others to make changes in their roles, programs and environments to improve participation for a child (Deloitte, 2010). Within this model, students referred for occupational therapy assessment/services receive one to one support within the school but rarely in the classroom environment. Opportunities for teachers and therapists to truly collaborate on goals and strategies to meaningfully increase student participation, implement plans with fidelity and achieve children’s and families’ goals are hampered by a lack of time to meet and a lack of understanding of each other’s roles (Deloitte Report, 2010; Hernandez, 2013; Wintle, et al., 2017). A common consequence of this service delivery model is the poor generalization of skills by students (Ball, 2018; Missiuna et al., 2015). Additionally, tiered intervention approaches and collaboration between teachers and occupational therapists at the universal or targeted levels in the classroom are not prioritized.

Recommendations from a 2010 provincial review of school health support services (SHSS), The Deloitte Report, included the need to explore alternative models of service delivery to improve access to therapy and reduce wait times (Deloitte, 2010). A leading practice identified in the report was the incorporation of therapy visits within classrooms to enable knowledge transfer between health professionals/therapists and educators (Deloitte, 2010). Ten years have passed since the publication of the Deloitte Report on SHSS yet the consultative model, with students most often removed from the classroom for therapy visits, continues.

The research literature supports employing evidence-based tiered intervention models as a mechanism to improve outcomes for children and increase collaboration between therapists and educators. Tiered intervention models or multilevel models have been proven effective at the universal, targeted and intensive levels for evidence-based programs and service delivery in schools involving therapists and educators (Anaby et al., 2018). Anaby et al. reported that no single model was comprehensive enough to meet the needs of all children, however, a series of common principles were evident across the 22 empirical evaluative studies and future model development could be informed by these principles (Anaby et al., 2018, p. 24). Universal design was one of six macrolevel principles identified within the study to be considered in future school-based service model development to provide prevention and intervention supports for students concerning physical, behaviour, social and emotional needs (Anaby et al., 2018).

In-Class Collaboration Pilot Project

The purpose of the pilot project was to explore in-class interprofessional collaboration as a means to support educators’ goals related to the integration of the principles of UDL. The participants included one OT, eight classroom teachers, and three administrators across three elementary schools. See Table 1 for details.

Table 1

Teacher Participant Information

Note. *Previous Experience response options: None – No experience; Minimal – Rare/infrequent, indirect; Moderate – Some involvement, depending on class; Extensive – Frequent involvement, every school year)

Pilot Project Design

Communication about the pilot project was sent to all schools in February to recruit interest of teachers. Schools where multiple teachers were interested were prioritized for participation in the pilot. Geographical distribution of schools across the district was considered resulting in the selection of three schools from three different cities. Participation in the pilot project was voluntary. All teachers provided verbal consent to work with the OT in the classroom. All teacher participants and principals of the three schools selected completed a pre-pilot survey sent to them by email. Survey questions explored the frequency and nature of the teacher participant’s previous experience working with an OT in the school environment. Letters were sent home to all families of students in the classrooms informing them of the pilot project. The OT then met with each teacher participant at the school to discuss the aim of the pilot, to learn about the teacher’s learning goal related to the collaboration and to collect information about the classroom environment. A schedule of weekly 70 to 90-minute visits was arranged where the OT would join the teacher in the classroom. The OT maintained a journal of observational notes, photos, artifacts to document the pilot project progression. At the conclusion of the three months, meetings were held with the OT and each of the teachers to debrief. Teacher participants and principals also completed an anonymous online post-pilot survey with open-ended questions which collected data on outcomes experienced, challenges encountered and suggestions for future OT/teacher collaborative initiatives. Findings of benefits were developed from debrief meeting notes, post pilot survey responses and OT journal entries. Figure 1 depicts the timeline and progression of activities of the pilot project.

Figure 1

Timeline and Progression of In-Class Collaboration Pilot Project

Pre-Pilot Survey Data—Teachers and Principals

Eight teachers and three principals from the participating elementary schools completed online surveys about their knowledge, expectations, and experiences related to working with an OT. Prior to the OT-teacher partnership, most participants (6/8) agreed or strongly agreed with the statement, “Learning with other professions is likely to improve my ability to address the needs of my classroom”. Of the eight teacher participants, seven had previously worked with an OT in a school setting. Multiple questions pertained to teachers’ previous experiences with OT support in the school setting. Regarding the type of involvement, responses indicated that previous experience was indirect (OT with student) (6/7), consultative (5/7), educational (in-service and/or training) (1/7), and two teachers stated that they had worked collaboratively with an OT (multiple responses accepted). The three main barriers to implementing OT recommendations in the classroom, as identified by teachers in the pre-survey (multiple answers accepted), were lack of time (7/7), lack of training (5/7), and inconsistency between different environments (5/7). Alternative options of barriers included recommendations too difficult to understand (1/7), student not interested (1/7), or communication breakdown (0/7). When teachers were asked about the positive outcomes of working with an OT, there was a variety of answers (multiple answers accepted) including improved student outcomes (3/7), building knowledge (3/7), increased awareness of relevant resources (3/7), someone to talk about OT related concerns (3/7), increased understanding of their students (2/7), and the most popular answer was recommendation for necessary tools and equipment (6/7). Teachers were asked to indicate what best described what they would primarily like to gain from collaborating with an OT as part of the project. Responses showed interest in increasing their knowledge around factors that may impact student performance (e.g. fine motor skills, sensory processing) (4/8), modifying the environment to enhance student participation (2/8), receiving support for universal design for learning (1/8), and more awareness and access to relevant resources (1/8).

Benefits of In-Class Collaboration of Teachers and Occupational Therapist

The in-class collaboration pilot project revealed benefits for educators, OT, schools, and students. The following benefits were identified: building relationships, student participation, shared learning, capacity building, and support for the classroom. Each theme is illustrated in the description and examples below.

Building Relationships

Building collaborative interdisciplinary relationships was the foundation of the pilot project. The OT entered an established community (classroom) in April which made building rapport with the teacher, the school, other staff, and students essential to the collaboration.

Occupational Therapist (OT)–Teacher Relationship

Relationships between the OT and teachers grew through visits to the classroom, routine follow-up, active listening, and approaching the partnership with openness and curiosity. Evidence of effective relationship building was demonstrated through an increase in communication in the form of questions, feedback, and ideas being exchanged as the project progressed. The OT’s comfort and confidence in the classroom increased with the growth of the relationship with the teacher. Similar sentiments were shared by teachers, e.g. teacher (T1) stated “[The OT] was receptive to my feedback and concerns and made me feel comfortable, which is key in a process like this. I look forward to working with her in the fall.”

School Community—Occupational Therapist

Building relationships in the school beyond the pilot project teachers was another benefit identified. Regular involvement at three schools allowed the OT to begin to build relationships with administrators, support staff, special education teachers, custodians, and fellow OTs working in SHSS. Benefits of building additional relationships included stronger connection to the school community, more people to learn from, spreading awareness of the new OT role, and building potential for future collaborative opportunities. An example of additional collaboration occurred during the process of locating, moving, and adjusting classroom furniture. Custodial staff worked alongside teacher (T3) and OT during this process later followed-up with the OT to inquire how the changes were received by students to assess if additional adjustments were needed. Spending time in the staff room proved to be a helpful strategy to build familiarity between OT and school staff. An example of a staff room interaction is an educational assistant asked the OT, “What fun activity do you have planned today?” (in reference to the Alert Program) and proceeded to report that they had observed a student effectively use language from the program to express themselves. Being embedded in the school board and present in schools provided valuable opportunities to build relationships and collect informal feedback. In the post pilot survey, principal from school B expressed “Our staff really appreciated this collaboration and enjoyed speaking specifically about their students' needs. I hope that more schools have this opportunity."

Student Participation

Student participation refers to student involvement in problem solving and incorporation of student voice when developing new strategies in the classroom. This occurred on two levels, problem-solving on an individual level and improving a collective situation on a class-wide level.

Individual Problem Solving

In a Grade 3/4 class, the teacher (T6) shared with the OT that several of the students seemed to have difficulty attending to tasks and felt that this may be an area where OT input could be helpful. The OT began to collect information through observation and interactions with teacher and students. It was evident from the student narratives, that they too were aware of their distractibility at times. As a next step, the OT provided a short lesson about sustained attention and filtering out extra information, followed by a short experiment to illustrate the impact of distractions on written work, and then finally a survey. The students were asked to identify what distracts them and what helps them focus. Their answers showed their ability to self-reflect, provided insight into their experiences and offer practical solutions to address the distractions. A summary of their answers was presented back to them (in an anonymous format) by the OT on a subsequent visit. The summary highlighted the many similarities and the shared experiences among classmates (i.e. “friends talking”). One student stated upon reviewing the compiled class list of distractions, “that all sounds like me” referring to the relatability of each point. The solutions suggested were also summarized and shared which facilitated a discussion among the class about what strategies could be implemented in the classroom. Examples included portable study carrels, timers, schedule breaks, noise cancelling earmuffs, suggested script for asking a classmate to stop talking, a do not disturb sign on desk, and access to independent workspaces. The teacher (T6) was supportive of trialing new, student-identified strategies. The discussion resulted in a choice board being created that reflected the most popular strategies as indicated by the combination of the survey information and class discussion. The choice board was a visual for the class, with strategies to be used on an individual, self-directed basis. The choice board was a visual reminder of their options and more importantly it represented their ideas, problem solving abilities, and the importance of their voice in making change in their classroom.

Collective Problem Solving for the Classroom

On a class wide level, students in a Grade 2/3 class were involved in the process of modifying their classroom from the brainstorming process to physically reorganizing their class. Collecting information from the learner’s perspective was a natural starting point. In a group discussion, students were invited to share their ideas of what they would want to see in their classroom. Every student was given an opportunity to share and all ideas were recorded for further consideration. Their ideas highlighted interest in an alternative classroom configuration and variety in seating options. The teacher’s (T3) input indicated the need for improved organization to support students’ independent access to task materials. The resulting “wish list” was reviewed by the teacher and OT to plan next steps based on what realistically could be accomplished given space and resources. Stools, cushions, bins, and caddies were ordered to begin modifying the classroom space based on student feedback. Once new materials were obtained, a date was scheduled to reorganize the classroom as a class activity. The teacher created unique jobs for the students based on individual strengths which effectively engaged the whole class. Examples of changes made included materials moved to more logical locations, decluttering by removing or storing infrequently used items, reorganizing desks to create new workspaces, labelling bins for small tools, and colour coding bins and shelves to support student’s ability to navigate shelved items. Students worked with their peers and provided input throughout the process. The active participation of the students allowed the reorganization to be completed in a timely manner and the students had an awareness and an appreciation for the environmental changes. The importance of their involvement was highlighted by a student comment following the classroom reorganization. The student inquired if the OT was making further changes to a particular area in the room and when reassured that the OT was not changing the current configuration, the student appeared relieved and replied “Good, because it took us a lot of work to get it like that”.

Shared Learning

Shared Learning as a benefit refers to combining the expertise of two disciplines resulting in an exchange of information and a mutual learning process between teacher and OT.

Sharing Expertise

In a grade 2/3 classroom, the teacher (T3) indicated interest in increasing the variety of seating in the classroom to provide more choice and flexibility and to accommodate the needs of the students. The teacher cited students fidgeting and rocking in their seats as further indication of the need to explore alternatives in addition to implementing a routine that limited periods of sitting. This goal provided an opportunity for the OT to provide information on basic ergonomics, its impact on academic performance, and recommendations for children’s seating. This information was shared through a short lesson followed by a hands-on activity during which students audited their seating. The results of the students’ evaluation of their seating revealed the need for height adjustments to several desks and chairs which prompted the teacher and OT to begin to make changes to the classroom. Together, teacher (T3) and OT searched storage areas in the school for spare chairs and desks. Where possible, ill-fitting chairs and tables were swapped and/or adjusted with assistance from the custodian. Throughout the process the teacher provided insight into the functional needs of the classroom, social dynamics and student preferences. The teacher’s input combined with the OT’s knowledge of positioning helped to inform implementation of changes. The result was seating and workspaces of variable sizes and heights, more reflective of the range of student heights. The OT followed up with the class one-week following the changes at which time the teacher indicated preference to maintain the latest adjustments.

Learning Together

In-class collaboration provided an opportunity for OT and teacher to learn together. An example of this was the experience of co-facilitating an evidence-based program called the Alert Program. Based on the teacher’s learning goal of creating a sensory inclusive classroom to support engagement, the Alert Program was co-facilitated in the classroom. Co-facilitation provided a way to build awareness of sensory-based regulation strategies and create a common language between teacher (T4) and OT. The OT took the lead in planning sessions and providing resource material while the teacher co-facilitated in-class sessions. Together, teacher (T4) and OT observed student participation and debriefed each session to help inform the format of the next session. The feedback shared by the teacher, based on familiarity with the students and expertise in leading classroom activities, supported the OT’s learning. Additionally, the teacher commented on the value of co-leading and explained that the experience allowed them to learn about the material and, at the same time, provided an opportunity to observe and learn more about their students.

Capacity Building

Capacity building refers to enhancing the knowledge, skills, and competencies of the OT and educators as a result of the partnership.

Building Capacity of the Occupational Therapist

Through regular involvement with multiple classrooms, the OT developed a better understanding of the educational context. This included learning of the daily demands of students and educators, challenges and strengths within a classroom, and the relationship between the learning environment and student participation. Administrators were key in providing valuable information about the school community, priorities for the school and trends in student performance. Valuable learning for the OT also occurred through observing educators as they led students through learning activities and transitions, communicated expectations, and supported student problem-solving. Educators modelled strategies that the OT could adopt to improve their effectiveness working in the classroom setting. Learning from the educators during the pilot project made the OT feel more equipped to enter classrooms and work alongside educators.

Building Capacity of the Educator

To support capacity building of educators, the OT provided resources, modelled instructional strategies, and shared information through informal conversation. In a Grade 1 classroom, the teacher (T1) expressed interest in building “strong writers” among their students which provided an opportunity to build capacity around handwriting instructional strategies and fine motor development. The OT modelled handwriting lessons based on an evidence-based program in which all students participated. Modelling lessons allowed the OT to observe student performance and share observations with the teacher. The OT followed-up by providing a summary of the lesson, rationale for the format and content (i.e. related to development of fine motor skills), and recommendations for follow-up activities to reinforce learning. Modelling handwriting instruction in the classroom provided an opportunity for the teacher to learn along with their students and did not require additional time outside of the classroom to review the lesson. The teacher (T1) expressed interest in continued support from the OT and stated in their post-survey “I am excited to try a new program to help develop writing skills.”

Support for Classroom

Support for the classroom refers to the OT’s ability to be present in the classroom to provide support on a universal level. During this pilot project, class-wide support came in various forms including resource sharing and environmental modifications.

Resources

Resource sharing included the creation and/or provision of resources and reference material related to the teachers’ learning objectives to support application of new strategies in the classroom. Several resources were accessible through a shared electronic file created by the OT to exchange and store relevant information with each teacher. Resources on topics such as handwriting instruction, sensory processing, classroom design, self-regulation, and executive function were shared as appropriate. Creation of new resources specific to the collaboration in the classroom, such a choice board, a social story, and presentation visuals were created to support implementation. For example, a presentation that included visuals, interactive components, and a social story was created for a Kindergarten classroom as part of the introduction to their new relaxation space, the “Chill Zone”. The Chill Zone refers to a comfortable space with minimal distractions created through OT and teacher collaboration (T7). The visual resource was presented to communicate expectations of use to the class and to gather input regarding possible additions to their new space.

Environmental Modifications

Many teachers had expressed interest in modifying the learning environment and cited lack of time, resources, or knowledge as barriers to making changes. The main goal for modifying the classrooms was consistently to support student engagement by offering more choice and flexibility, but the specifics varied between classrooms (i.e. a larger common area, seating options, more group work areas, a new centre, a designated quiet space, increase independence in accessing task materials, addition of individual work spaces, and improved organization). In a Grade 1 classroom, the teacher (T1) and OT reorganized the classroom after swapping out a large area rug for individual mats. The result was more space in the centre of the classroom for group activities, a small reading area, and the ability to use floor space creatively with individual and portable mats. Upon seeing their new classroom layout, the students were enthusiastic about the changes with a student noting excitedly “We have a corner!”. Based on student response and teacher preference, the teacher (T1) planned to continue with this layout in the new school year and in the post pilot survey stated, “I am excited to try a new classroom configuration that will hopefully include more UDL and flexible seating for learners of various styles.”

Limitations and Challenges

The main limitation of this pilot project was the short length of time (3 months). There was only one OT involved, because of the available resources. Time was a common challenge identified by most teachers. Finding time to connect with the OT outside of class as well as coordinating schedules during a busy time of the school year was difficult. The short length of time of this in-class collaboration limited the ability for the OT and educators to monitor and modify newly implemented strategies in the classroom over a longer period to help understand if the initially observed benefits were maintained. The collaboration between teachers and the OT focused on goals and challenges within the classroom, at the universal or tier one level of intervention. Parents were not involved directly, however partnering with parents is an important future direction. Challenges to collaboration discovered during the project were the complexity of the classroom environments, difficulty of setting a learning goal related to removing barriers, and educator’s limited understanding of the occupational therapy profession.

Lessons Learned and Future Directions

The in-class collaboration pilot project was a novel approach to interdisciplinary planning and problem-solving involving teachers and an OT. The benefits of building relationships, student participation, shared learning, capacity building and support for the classroom warrant further exploration. Positive, productive interdisciplinary collaboration has been initiated and will have time and opportunity to develop in the future between the occupational therapist and teachers. The pilot project experience as communicated by the teachers and OT reinforced the findings reported in the research literature that dedicated time is essential to build relationship (Missiuni & Hecimovich,2015; Villeneuve & Shulha, 2012). The need for greater educator understanding of the work of occupational therapists and OT appreciation of the complex dynamics of the classroom environment are also consistent with findings in the research literature on OT, teacher collaboration (Ball, 2018; Wilson & Hall, 2018; Wintle et. Al, 2017). Including parents/guardians in the conversation about barriers students experience in the classroom is an important future consideration. The opportunity to build professional familiarity and relationships conducive to increasing collaboration between educators and occupational therapists was identified as an important future direction within the district school board. Preservice placements of OT students within the district are now taking place for the first time expanding the foundation for relationship building between future health professionals and educators. Dialogue is also taking place with faculty between the School of Rehabilitation Therapy and the Faculty of Education about opportunities to integrate pre-service learning for students. The common language, values and beliefs underpinning the principles of UDL and the shared priority of maximizing participation for children in inclusive classrooms connect the two professions of occupational therapy and education. Working collaboratively in schools, teachers and occupational therapists may effectively bridge education and health outcomes.

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