Insights from Linden Occupational Therapist, Ashwini
Remote Occupational Therapy: What it is & how kids can benefit from it?
What is occupational therapy?
Occupational therapy is a client-centered health profession concerned with promoting health and well-being through occupation, across the lifespan. Occupational therapists achieve this by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement (WFOT 2012). Occupations are activities that are meaningful and purposeful to an individual. For children of school-going age, occupations include play, self-care, writing, reading, social participation, and other school activities. Occupational therapists have a broad education in the medical, social, behavioral, psychological, psychosocial, and occupational sciences, which equips them with the attitudes, skills, and knowledge to work collaboratively with people, individually or in groups. Occupational therapists can operate either as part of learning support teams, or they can support such teams to assist their students. Schools and parents regularly seek out support services to identify and support a child to achieve their full potential. There may be established diagnoses (ASD, ADHD, Dyspraxia, co-occurring neurodevelopmental conditions, Down’s syndrome, etc.) or there may be functional challenges (e.g., anxiety, arm fatigue from inefficient writing patterns, etc.) These difficulties may hinder successful participation in his/her school, home, and community.
What is teletherapy in the context of occupational therapy?
Virtual or online care provided by healthcare professionals to clients is also referred to as telehealth. It has evolved both as an alternative - and an adjunct - to in-person care as healthcare professionals sought new innovative approaches to healthcare delivery. International schools in different countries regularly seek support for their students’ learning outcomes from occupational therapists. The trajectory of occupational therapy is different across the globe, and not all countries have access to a community of occupational therapy practitioners. This resource issue, as well as the COVID-19 pandemic, has led to practitioners adjusting to an online-based method of service delivery. However, this method of service provision was already in place in rural areas in some countries where traveling regularly to remote locations is a challenge.
Occupational therapists successfully utilize teletherapy to evaluate, intervene, research, provide parent education, and to work collaboratively with teachers and schools in designing and implementing students’ therapy plans.
What are the types of teletherapy and who can it help? As occupational therapists, we can use teletherapy in two ways. Real-time sessions which involve face-to-face consultations over virtual platforms (e.g., MS teams, zoom) and asynchronous sessions where pre-recorded data is transferred between the OT and the student/family/teachers. For example, after caregivers film videos of the child’s engagement in an activity or fill out questionnaires, they are sent to healthcare professionals or uploaded to a platform or app. For a student working with an OT where a school visit is not possible, the teacher could send photographs of the student’s everyday environment, capturing the chair arrangement, work baskets, visual schedules, etc. The professional will use this to provide feedback and recommendations on intervention specific to the needs.
Who can benefit from teletherapy?
Although teletherapy is a useful tool, clinical judgment needs to be made regarding who can use virtual therapy. Autism spectrum disorder is one area where virtual evaluations and interventions have been researched in the past few years and found to be effective for both assessment and intervention. Our clinical experiences inform us that various aspects of a student’s life can be supported by online occupational therapy, irrespective of diagnosis. Sometimes all sessions may be entirely online. However, an OT practitioner will always aim to facilitate direct in-person meetings for an initial full evaluation, where possible. Teletherapy is not a recommended approach for diagnostic evaluations that require identification of dyspraxia or other movement-based difficulties. A hybrid approach is often effective and practical with school-aged children. Where direct sessions are not possible, online assessments can be completed with relevant technology, creativity, and collaborative planning between the practitioner and the client’s team, which includes both the student’s family and school team. Some standardized assessments can be completed entirely online.
What are the approaches to online occupational therapy support services for children?
OT ASSESSMENTS: Initial and ongoing assessment is vital to effective goal setting and therapy. An individualized approach is required for a child, and it is important to understand the student as a ‘whole’. A priority for the OT would be to build a rapport with your child and for you to get to know the OT, before an online assessment is attempted. The student’s comfort is of utmost importance. If a previous OT assessment has been completed in-person recently enough, interviews may be sufficient to inform and precede online intervention sessions. If an assessment has not been completed, it is still important to identify the current baseline for your child through some informal/standardized measures. This includes email exchanges, teacher and parent questionnaires, interviews with relevant family/teachers, informal observations (pre-recorded videos sent by the parent), and formal observations of your child engaged in specific tasks. These can also be split across sessions, keeping the student’s ease as a priority. It is important to note that some direct measures of OT assessments such as assessing a student’s muscle tone, range of motion, motor patterns of movement, gait, among others, may not be optimal through video calls, so standardized scoring is not recommended remotely. OT INTERVENTIONS: Teletherapy intervention may involve a combination of recommendations and support in making environmental modifications, individual capacity building, and parent and/or teacher support to support children and their families. This multifaceted approach is particularly useful for children with neurodiverse conditions. For example, skill-building could target specific executive functional skills. A virtual consultation meeting with the teacher in her classroom would feed into environmental modifications such as the need for preferential seating or ways to include a safe space in the classroom for all children. Parent consultations as part of this intervention plan would include contextual strategies to support a child at home (e.g., creating a self-regulation corner at home or organizational strategies for homework). However, for a child with a query of dyspraxia, a different approach may be required. A motor performance assessment may be adapted to observe the child’s performance skills to inform the intervention. Intervention may also include supporting parents of young children and teachers through remote coaching sessions, where joint problem-solving is used to support the child’s participation in school. The approach ultimately depends on the reason why occupational therapy was initially requested. It is important for the practitioner to clearly communicate after a couple of sessions as to what components of assessment have not been possible and ways to address it. What settings are best for teletherapy and what are the concerns with teletherapy? Preparation of an adequate setting within the home environment which has a relatively easier schedule to the school routine might allow for more relaxed participation in teletherapy, and may potentially also have fewer distractions. Some autistic children and adolescents spend a great deal of time using computing devices for recreational purposes. Because they find the technology familiar and comfortable, they could consider these interventions as engaging, and preferable to in-person therapy. While telehealth is known to ensure the observation of parent–child interactions in their natural environment, and can protect children from potentially stressful or overloaded sensory experiences (e.g., travel, crowding, other stressful environmental elements in waiting rooms), it does not allow for identification of challenges that occur outside in the natural environments, at the home or at school. Factors to consider for parents, teachers and OT practitioners are the presence of distractions at home, and to a certain extent the inability of the camera to adequately follow the child on the move. Active parental involvement during teletherapy sessions could be supportive, and it also depends on the presentation and needs of your child. According to literature, most healthcare professionals believe that teletherapy cannot replace face-to-face interaction completely.
Who is the best fit for online OT services?
The use of teletherapy should be tailored according to the client profile. If the child/adolescent has good cognitive, communication, and technological skills, as well as an appropriate level of comfort and cooperation, they may not need the parent's mediation. Although, on the one hand, awareness of being observed may be hard for some children, on the other hand, provision of learning support services at a distance could alleviate children’s anxiety and stress allowing them to remain in a predictable and familiar environment. It is important to note that an online session does not mean that the student has to stay seated. Sessions include movement breaks and a camera that is positioned in a manner which allows for the OT to view the child as he moves in and out of the seat to get that input is encouraged. This is where an adult might be needed to support technology use with younger children. A physical disability (e.g., deafness, blindness, infantile cerebral palsy, etc.) may prevent the ability to participate in virtual interventions. Due to hypersensitivity or hyposensitivity to sensory inputs, visual and auditory stimuli (e.g., excessive brightness, flashing screens, excessive loud sounds, etc.) can be distracting or disturbing. Co-occurring conditions such as photosensitive epilepsy limit the use of flashing screens. It is important for the family to advise the OT on potential difficulties such as migraines or medications that might impact on virtual sessions. There is little doubt that teletherapy is not suited for all and that it cannot be used in all scenarios. However, there is sufficient evidence that teletherapy provides several advantages. For example, it could be used to provide adequate training for families, which has been shown to be one of the most relevant needs of parents of children with ASD. Therefore, virtual sessions for a 4-year old child is possible, with a parent coaching approach. Providing parents with practical and concrete strategies on how to manage everyday life has been found to considerably improve quality of life and alleviate stress on caregivers in these families. Undoubtedly, the use of teletherapy takes more effort from professionals and family members.
What are the factors that support teletherapy?
In order to facilitate successful telehealth, the following factors were important: parent and clinician access to technology/internet, parent/therapist basic computer skills, appropriate physical space for parent/therapist as well as parent’s previous experience in use of recommended occupational therapy strategies. The influence of a pre-existing relationship with clinician and child/parents is a possible enabler of success. Parent/clinician attitudes towards telepractice also influence teletherapy. As with any new medium, teletherapy is not a ‘one size fits all’ approach and brings with it some limitations. There will always be occasions where face to face contact with the children and families we work with is essential. Telepractice is not an option for some families due to technical problems such as poor internet connection, lack of a suitable device or technology skills. Additionally, the clinician may not achieve everything that is required as part of an assessment or intervention via telepractice, and therefore a face-to-face consultation may be necessary to ensure best practice. Telepractice has brought about more efficient and accessible ways of working with our families and we envisage telepractice as part of a blended model of service delivery in the future.
References: Gabellone, A., Marzulli, L., Matera, E., Petruzzelli, M. G., Margari, A., Orazio, V. G., & Margari, L. (2022). Expectations and concerns about the use of telemedicine for autism spectrum disorder: A cross-sectional survey of parents and healthcare professionals. Journal of Clinical Medicine, 11(12), 3294. doi:https://doi.org/10.3390/jcm11123294 Önal, G., Güney, G., Gün, F., & Huri, M. (2021). Telehealth in paediatric occupational therapy: A scoping review. International Journal of Therapy and Rehabilitation, 28(7), 1-16. doi:https://doi.org/10.12968/ijtr.2020.0070 Evaluation & Assessment | AOTA
About the author
Ashwini is a passionate occupational therapist with a strong interest in working with children. She provides a range of individualized assessments and interventions to support children and young people in achieving their goals. Her sessions are conducted both in-person and online, and she uses a hybrid model of coaching-based interventions and consultations to create a strengths-based framework for her clients. Additionally, she offers group sessions for targeted interventions such as the Alert Program, Zones of Regulation, Sensory Modulation, and Handwriting.
Having worked as an occupational therapist since 2005, Ashwini has gained valuable experience working in various settings such as early intervention, specialist autism, and disability settings. In Ireland, she primarily worked as part of multidisciplinary teams in mainstream schools and is experienced in diagnostic assessments as part of an autism specialist service.
Ashwini holds a B.Sc. in Occupational Therapy from India, along with post-graduate diplomas in Evidence-Based Practice in Occupational Therapy from University College Cork, Ireland, and Executive Coaching from Irish Management Institute. She has completed advanced training in Sensory Integration in the UK and is certified by CORU (Ireland) and by the NBCOT (National Board for Certification in Occupational Therapy, USA). Ashwini is a member of the Association of Occupational Therapists, Ireland.