Beyond the Therapy Room - Integrated Therapy

Over the years, the staff at the VCU-Autism Center of Excellence have spent a great deal of time talking to and working with hundreds of related services therapists (Occupational Therapists, Speech Language Therapists, Physical Therapists, etc) throughout Virginia. The focus of our conversations have mostly been about how they deliver services to students on the spectrum in the most effective and efficient manner. More specifically, we have been discussing the importance of inclusive practices as it relates to many facets of a student’s education.  We know the research supports that better academic and social outcomes occur when supports are provided in the least restrictive settings 1. That being said, we also know that each child with autism is their own person with unique educational, social, and emotional needs which underscores the significance of individualized planning. When we consider service delivery models, there is no “one size fits all” approach and a continuum of models should always be offered based on needs.  This article highlights the overall benefits of a service delivery model called, “Integrated Therapy” (IT), because of it’s emphasis on least restrictive environment service delivery and emphasis on inclusion. 

What is Integrated Therapy anyway? We are all familiar with the term “push-in” therapy. This is when the therapist works with the student in the classroom either separately from the rest of the class or within the context of the lesson and existing classroom structure. There are different interpretations of how this can be implemented but ultimately the student benefits by having less transition in and out of the class, more opportunities for practice with other adults and classmates, and embedding related services goals into the academic milieu. However, collaboration is important to the success of this model and it is possible data collection will be more difficult.

Integrated therapy incorporates the same therapy approach as “push-in” but adds additional structure to the relationships with teachers and overall process.  In this service delivery model, supports are provided in the classroom, where the student is receiving instruction. Therapy is provided in a less restrictive setting and does not remove the student from the classroom or instruction.  IT also helps students to generalize communication skills beyond the pull-out therapy setting and provides generalized benefits for all students. For example, a SLP has exposure to levels of communication (rate, volume, complexity) in natural environment, where she would not have in a typical therapy room.

A significant shift from the “push in” approach, is how IT emphasizes a close and productive relationship with the classroom teacher(s). In fact, the therapist and the teacher serve as the instructional team. The SLP, OT or other related services provider shares “his/her” lesson plan with the teacher and actually allows the teacher at times to reteach or echo the speech task.  Conversely, the teacher, from time to time, lets go of “his/her” role as the main instructor and allows the therapist to provide some small group or whole group instruction.  This is an example of a transdisciplinary team approach.  The ultimate goal is for the two “experts” to let go of their traditional roles and build that capacity in the other person in order to completely collaborate with instruction.  This “role release” results in greater efficiency and comprehensive service delivery.  In addition, it allows more opportunity for data collection.

Is Integrated Therapy a good match for students with Autism? The answer is Yes! Students with autism have a difficult time generalizing skills from one environment to the next. This is also true for therapy services. Some children with autism may think that new skills learned in the therapy room are specific to those environments and students can be resistant to use new skills in other situations. When a therapist moves into the classroom, the skills are learned in a more inclusive environment with peers who can model skills, teachers who are present to collaborate with the therapist on specific learning tasks and opportune times to “push-in”. This practice allows for more intensive, on-going involvement with the entire educational staff. Teachers often desire the modeling and demonstration that can be witnessed while the therapist is in the classroom. The carry over and transfer of new skills to the whole school environment leads to faster skill development.  This collaborative strategy leads to enhanced learning and functional outcomes for children with autism2. Additionally, having an ongoing view of the student’s functioning in the general school settings allows for more relevant and meaningful instruction.

Integrated Therapy in Action

Speech Language Pathologists

The Alexandria City Public Schools ACE-Autism Team has chosen to build up the knowledge base and practice implementation of Integrated Therapy among their Speech Language Pathologists (SLP’s).  A goal on their VCU ACE Services Improvement Plan is to utilize trained SLP’s as coaches to other SLPs as well as to teachers in order to implement integrated therapy across the division. The SLP’s will not only support each other to ensure fidelity, they are also educating and coaching teachers to increase social communication skills instruction and opportunities with their classroom. Their division wide data collections indicated this was an area of need and as we know social communication deficits are a primary characteristic of Autism. They have a SLP devoted to this goal who is currently implementing the IT approach with her caseload and related teachers. They are creating ways to efficiently plan (i.e. google docs and others) as well as to ensure IEP goals are written in such a way to better reflect the service delivery.

For additional resources and testimonials on push-in and integrated therapy models:

Occupational Therapists

Several Occupational Therapists across the state have begun to implement an integrative therapy model for students with autism. For example, occupational therapists observe in classrooms to assist with students staying on task by providing non-intrusive classroom object or task or navigating the hallway without bumping into others by discussing personal space. The following are other creative ways that were implemented through the collaboration of teachers and occupational therapists through "push-in" services.

Elementary School Middle School High School
Concern Solution Concern Solution Concern Solution
Poor cutting skills Use thicker paper and larger lines to cut on Cannot find anything in locker Make a map of where things go in the locker and provide labels on shelves Gets lost in school when moving from one classroom to another
  • Send student to locations when halls are less crowded
  • Provide visual cues in hall to mark locations
  • Match student with partner for transitions

References:

1. http://occupational-therapy.advanceweb.com/Archives/Article-Archives/The-Push-for-Push-In.aspx, The 'Push-In' Model of School Therapy Building a case for providing therapy services directly in the classroom. Sarah Don, MS, OTR/L, Estee Katzenstein, MS, OTR/L, and Susan Weichbrod, OTR/L.

2. http://www.iidc.indiana.edu/pages/The-21st-Century-Speech-Language-Pathologist-and-Integrated-Services-in-Classrooms, The 21st Century Speech Language Pathologist and Integrated Services in Classrooms. Beverly Vicker, CCC-SLP.