School mental health interventions

A child with an anxiety disorder may present with excessive worry, poor information processing, low motivation, poor attention span, poor sleep hygiene, social isolation, and low self-esteem at home, school, and in the community. Occupational therapy practitioners provide multiple levels of intervention, including promotion and prevention.

This section includes considerations that you can use when working with students who have symptoms of, and/or are at-risk for anxiety.

• Advocate for school-wide efforts to reduce stress and sensory overload throughout the day for:
  • social-emotional learning approaches,
  • school-wide bullying prevention,
  • after-school leisure activities, and
  • stress-management activities.
• Teach school personnel how to create supportive relationships with children for
  • healthy discipline
  • positive behavioral supports, and
  • effective emotion management.
• Promote environments that support regulation (e.g., brain breaks throughout the day, attending to sensory qualities of the classroom).
• Help teachers incorporate relaxation techniques (e.g., stretching, balance postures, breathing exercises) into existing course structures and routines.
• Foster supportive environments that develop personal passions and promote the play and leisure interests of children.
• Plan inclusive recess experiences (e.g., activity zones, organized group sports) to support social participation, attention, perseverance, cooperation, and conflict resolution.
• Educate school staff and parents on the use of student-specific relaxation kits (e.g., comfort items, fidgets).
• Model emotional regulation strategies and coping skills to children.
• Promote occupation- and activity-based teaching methods for positive relational skills and problem-solving during existing school and after-school programs (e.g., group sports, recess games, classroom jobs).
• Establish predictable routines and habits with children and school staff that promote mental well-being (e.g., classroom routines, organizational skills).

Students

• Use Cognitive Behavioral Therapy (CBT) and Social and Emotional Learning (SEL) to help students recognize and manage their emotions, thoughts, and behaviors.
  • Use self-awareness techniques to teach children emotional regulation strategies.
  • Teach children mindfulness strategies to reduce stress and cope with overwhelming emotions.
• Allow children to gain control by offering choice within activities and contexts.
• Help children build self-esteem by providing frequent praise and positive reinforcement as well as frequent direct instruction and modeling.
• Engage children in activities that promote optimal levels of arousal and relaxation (e.g., stretching, balanced postures, breathing exercises).
• Collaborate with families to address sleep hygiene and sleep routines.
• Use social stories to help children know what to do in stressful situations.
• Offer occupation- and activity-based social skills programs (e.g., play, leisure, life skills) for children at-risk for social isolation (e.g., computer and video games).
• Provide opportunities for creative expression (e.g., art, creative writing, music).
• Check-in on students through self-report measures (e.g., those that address well-being, self-efficacy, or self-regulation skills).
• Promote friendships and positive peer interactions.

School team (including teachers, administrators, related services providers, student, and family)

• Collaborate with the teacher to provide modifications on assignments to
  • break them down into smaller steps,
  • allow flexible deadlines for harder assignments, and
  • reduce homework load.
• Create opportunities for stress reduction in the classroom in collaboration with the teacher to
  • allow breaks for symptom management,
  • develop cues or signals between child and teacher for when a child wants to speak during class, and
  • ask the teacher for the child to be partnered with a friend during more challenging learning activities.
• Educate teachers, caregivers, and children on arousal states (e.g., alertness levels and how to regulate them, the progression of emotion, emotional connection to thoughts and behaviors).

AOTA resources

• Occupational therapy practice guidelines for children and youth ages 5-21 years
• Addressing mental health needs of elementary school children through university-community collaboration
• Group discussions: helping kids plan their transition to middle school

Additional resources

• Mental-health benefits of a mindfulness-based prevention program on elementary school children
• Effectiveness of a mindfulness-based social-emotional learning program
• Research review: the effects of mindfulness-based interventions on cognition and mental health in children and adolescents
• Intervention strategies for anxiety in children
• Mental health

Sources

Mei-Ling, L., Nasser, A., Molina, C., Smith, E., & Millar, K. (2020). Mental-health benefits of a mindfulness-based prevention program on elementary schoolchildren. American Journal of Occupational Therapy, 74, 7411515385. https://doi.org/10.5014/ajot.2020.74S1-PO4128

Moreno-Gómez, A.-J., & Cejudo, J. (2019). Effectiveness of a mindfulness-based social–emotional learning program on psychosocial adjustment and neuropsychological maturity in kindergarten children. Mindfulness, 10, 111–121. https://doi.org/10.1007/s12671-018-0956-6

Dunning. D., Griffiths, K., Kuyken, W., Crane, C., Foulkes, L., Parker, J., & Dalgleish, T. (2019). Research review: The effects of mindfulness-based interventions on cognition and mental health in children and adolescents—a meta-analysis of randomized controlled trials. Journal of Child Psychology and Psychiatry, 60, 244–258. https://doi.org/10.1111/jcpp.12980

Contributing author

Rebekah Highlander, MSOT
Saint Louis University

Why should occupational therapy practitioners integrate services during lunch and recess?

Non-academic times of the school day (e.g., lunch, recess) can be significant contributors to student mental health. Research evidence demonstrates that when students enjoy lunch and recess, have good friends, and perceive school personnel as supportive and caring, they feel more connected to school, which enhances classroom engagement, academic performance, and school completion rates (Bazyk et al., 2018; World Health Organization & the United Nations Educational, Scientific and Cultural Organization, 2021).

In addition to promoting positive mental health, lunch periods and recess play are also important times for promoting students’ physical health, social interaction, and skill development (Bazyk et al., 2018). Emotionally, students need time to relax, take a break from classroom work, and socialize with peers so they can return to class prepared to learn.

Well-thought-out lunch and recess periods can foster context-specific skill development such as how to engage in meaningful conversations, demonstrate appropriate mealtime manners, eat healthy foods, be a good friend, and engage in active play.

Because lunch and recess are times when students with disabilities and/or mental health challenges are included with their non-disabled peers, these times also provide an opportunity to shape important values such as respect for differences (e.g., cultural, functional, physical) and the importance of including everyone (Heyne et al., 2012). Finally, occupational therapy services provided in natural settings during daily routines, such as lunch and recess, are more likely to be applied consistently leading to the development of new skills and values (Cahill & Bazyk, 2019).

Multi-tiered system

With the growing movement to a multi-tiered system of support, including universal, school-wide mental health promotion (Tier 1), targeted prevention (Tier 2) and intensive intervention (Tier 3), it is important for occupational therapy practitioners (OTPs) to envision, articulate, and advocate for expanding services at each of these levels throughout the school day, including lunch and recess (Bazyk, 2011; Hoover & Bostic, 2021).

Promoting participation and health during lunch and recess reflects occupational therapy’s scope of practice, specifically in the areas of eating/mealtimes, social participation, play, and health management (AOTA, 2020). As such, OTPs can be instrumental in contributing to school-wide health promotion and prevention efforts during lunch and recess by offering the following:

• Advocate for occupational therapy’s contributions to creating positive lunch and recess experiences with principals, cafeteria supervisors, teachers, and school wellness leaders. OTPs’ ability to analyze the relationship between the person, environment, occupation provides a distinct lens for understanding issues affecting successful participation and enjoyment.
  • For example, loud noise in the cafeteria can increase anxiety in students who are hypersensitive to sound, limiting their ability to fully participate and successfully engage in the social aspect of lunch. For students with social and emotional limitations, knowing how to initiate play during recess may be challenging, leading to isolation or boredom.
• Integrate. Find ways to integrate services during lunch and recess. Start by observing how students participate and enjoy lunch and recess. Follow up by providing services for students with disabilities who have functional and/or social challenges during these times.
• Evaluate. Complete an environmental analysis of cafeteria and recess sessions and share findings with the principal. Use Every Moment Counts’ Refreshing Recess Environmental Analysis and Comfortable Cafeteria Environmental Analysis to evaluate the social-emotional, physical, and sensory aspects of the environment. Use these findings to address challenges and modify social, physical, and sensory aspects of the environment.
• Implement. Implement Every Moment Counts’ OT-developed Comfortable Cafeteria and Refreshing Recess programs at the universal, whole school level or at a targeted, small group level. Discuss implementation with key stakeholders (e.g., principal, teachers, cafeteria and recess supervisors) ahead of time by sharing the Refreshing Recess and Comfortable Cafeteria Information Briefs.
  • These 6-week, one day per week programs focus on building capacity of cafeteria and recess supervisors to be effective in their jobs and on fostering prosocial skills and health in students with and without disabilities and mental health challenges (Bazyk et al., 2014a; Bazyk et al., 2014b). An OTP provides a combination of education, short activities, and coaching during implementation.
  • These programs specifically foster: friendship promotion, positive behavior and good manners, healthy eating, active play, meaningful conversations, teamwork, and inclusion of students with disabilities and mental health challenges.

Tier 1, universal strategies

Consider integrating OT services during recess and lunch to foster participation and health (mental and physical) in all students. Specific OT services might include the following actions:

• Implement the Comfortable Cafeteria and/or Refreshing Recess for one recess or lunch period. Consider co-facilitating the program with a teacher, counselor, speech-language pathologist, social worker, or physical therapist.
• Provide an orientation session for recess and cafeteria supervisors at the beginning of each school year giving them specific strategies for: active supervision, promoting positive prosocial behaviors (e.g., being a good friend, including others, using good manners), facilitating active play, and transitioning students to and from lunch and recess.
• Advocate for 20 full minutes of sit-down time for lunch and an additional 20 minutes for recess play.
• Provide recess supervisors with ideas for weekly play activities and model implementation (Playworks).
• Advocate for walking clubs during recess.
• Ensure inclusive and safe play materials for the playground.
• Assist cafeteria supervisors in implementing effective strategies for noise control and gaining students’ attention.
• Offer weekly conversation starters for lunch periods based on developmental age (Family Dinner Project).
• Collaborate with the school dietician or nutritionist to offer monthly food tastings and strategies for encouraging healthy eating (Home Grown Taste Test Guide).

Tier 2 and 3, targeted prevention strategies

Consider implementing small lunch and recess groups for students at risk of or experiencing participation challenges due to social-emotional or physical limitations.

• Implement the Comfortable Cafeteria and/or Refreshing Recess programs with a small group (~6-10) of students with disabilities and/or mental health challenges and neurotypical peers. Small, occupation-based groups offer opportunities to implement more specific intervention strategies for addressing social-emotional skills, self-regulation, friendship, and play.
  • Select 1-3 students who have social participation and/or functional goals to participate in a lunch bunch or recess group.
  • Ask the teachers of students at that grade level to suggest other students who might benefit from participating in the small group during lunch or recess.
• Collaborate with physical education teachers, speech-language pathologists, and/or physical therapists to provide accommodations (e.g., adapt the activity or environment) to foster inclusion and successful participation for students with disabilities during lunch and recess.
• For students experiencing self-regulation and sensory processing challenges that impact successful participation during lunch and/or recess, provide problem solving and specific adaptations to promote enjoyable participation. This might include, for example, teaching deep breathing for a student who struggles with transitions or the use of noise-cancelling headphones for a student with auditory hypersensitivity.
• Provide individualized consultation and modeling for students with significant physical and/or behavioral challenges who struggle with successful participation during lunch and/or recess. This might involve, for example, modeling safe ways to play on equipment for students with multiple disabilities with high intensity needs.

AOTA resources

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2). https://doi.org/10.5014/ajot.2020.74S2001

Bazyk, S. (2011). Mental health promotion, prevention, and intervention with children and youth: A guiding framework for occupational therapy. AOTA Press.

Bazyk, S., Demirjian, L., Horvath, F., & Doxsey, L. (2018). The Comfortable Cafeteria program for promoting student participation and enjoyment: An outcome study. American Journal of Occupational Therapy, 72(3). 7203205050p1-7203205050p9. https://doi.org/10.5014/ajot.2018.025379

Sources

Every Moment Counts website. www.everymomentcounts.org

Playworks website. http://www.playworks.org/playbook/games

The Family Dinner Project: Conversation Starters. https://thefamilydinnerproject.org/conversation/

Wisconsin Department of Public Instruction. (2015). Home Grown Taste Test Guide. https://dpi.wi.gov/sites/default/files/imce/team-nutrition/pdf/homegrown-taste-test-guide.pdf

References

Bazyk, S., Demirjian, L., & Horvath, F. (2014a). Comfortable Cafeteria Program. Every Moment Counts. https://everymomentcounts.org/comfortable-cafeteria/

Bazyk, S., Mohler, R., & Kerns, S. (2014b). Refreshing Recess Program. Every Moment Counts. https://everymomentcounts.org/refreshing-recess/

Cahill, S., & Bazyk, S. (2019). School-based occupational therapy. In J. C. O’Brien & H. Kuhaneck (Eds.). Case-Smith’s occupational therapy for children & adolescents (8^th ed., pp. 627-685). Mosby.

Heyne, L., Wilkins, V., & Anderson, L. (2012). Social inclusion in the lunchroom and on the playground at school. Social Advocacy and Systems Change Journal, 3, 54–68.

Hoover, S. H. & Bostic, J. (2021). Schools as a vital component of the child and adolescent mental health system. Psychiatric Services, 72(1), 37-48. https://doi.org/10.1176/appi.ps.201900575

World Health Organization & the United Nations Educational, Scientific and Cultural Organization. (2021, June 22). Making every school a health-promoting school: Global standards and indicators for health-promoting schools and systems [Guidance (normative)]. https://www.who.int/publications/i/item/9789240025073

 Contributing author

Susan Bazyk, PhD, OTR/L, FAOTA
Director, Every Moment Counts and Professor Emerita, Cleveland State University

Occupational therapy practitioners work as part of an interprofessional team to structure environments, teach cognitive strategies, and support children’s social and emotional skill development to promote self-regulation, and feelings of competence, well-being, and resilience through participation in everyday activities and occupations. This decision guide includes considerations that occupational therapy practitioners can use when working with children who have or may have experienced trauma.

• Raise awareness about the occurrence and impact of childhood trauma.
• Create a culture of nonviolence through promoting positive behaviors.
• Foster children’s interests in healthy and safe play and leisure occupations.
• Teach children positive coping skills, relational skills, and problem-solving skills.
• Model and teach staff and adults who serve survivors of trauma principles of emotional regu­lation and co-regulation.
• Model and teach children emotional regulation skills.

• Recognize signs and symptoms of trauma.
• Collaborate with clients to identify goals and interventions designed to empower them.
• Use self-awareness techniques to teach children emotional regulation strategies.
• Teach children mindfulness strategies to reduce stress and to cope with overwhelming emo­tions.
• Provide interventions focused on self-regulation and sensory modulation, as well as self-efficacy.
• Educate parents and teachers about healthy discipline including the use of positive behavioral supports and ways to effectively deal with crises.
• Create predictable routines.
• Allow children to gain control by offering choice within activities and contexts.
• Provide frequent praise and positive reinforcement.
• Provide frequent direct instruction and modeling to create opportunities for ongoing competence and success.

AOTA resources

• From the SIS Quarterly Practice Connections — Understanding Children who have Experienced Early Adversity: Implications for Practitioners Practicing Sensory Integration
• Book — Trauma, Occupation, and Participation: Foundations and Population Considerations in Occupational Therapy
• Podcast episode – Trauma, Occupation, and Participation: Foundations and Population Considerations in Occupational Therapy

Additional resources

• The National Child Traumatic Stress Network
• The Adverse Childhood Experience Study
• What is Child Abuse and Neglect? Recognizing Signs and Symptoms

The incidence of depression among school-age children and adolescents has risen exponentially in recent years. According to a 2022 surveillance of youth mental health conducted by the Centers for Disease Control and Prevention, data analyzed between 2013-2019 revealed 20.9% of youth ages 12-17 have experienced a major depressive episode and 36.7% of high school students reported persistent feelings of sadness and hopelessness.

The prevalence of a depression diagnosis among youth ages 3-17 was reported at 4.4%. A diagnosis of childhood depression was found to have a 73.8% co-occurrence with at least one other mental health disorder. One in four youth ages 12-17 are reported to have received mental health services throughout 2019 (Bitsko et al., 2019).

Depression is characterized by symptoms of depressed mood, loss of interest or pleasure in activities, possible weight loss or gain, fatigue or loss of energy, feelings of worthlessness or unwarranted guilt, lowered ability to think or concentrate, and possible suicidal ideation (APA, 2022). Predictors of depression among youth include heredity, childhood trauma, family environment, poor self-esteem, and poor sleep quality (Fiorelli et al., 2019; Ho et al., 2022).

Impacts of depression on occupational performance can include

• limited or loss of interest or enjoyment in leisure activities,
• limited or loss of interest in social participation including peer interactions and family engagement,
• impaired or ineffective health management such as dietary needs and physical activity,
• difficulty attending and completing educational tasks in school,
• disinterest in self-care and hygiene routines,
• impaired rest and sleep, and
• disinterest in play activities.

Occupational therapy practitioners (OTPs) have a unique skill set to address occupational performance deficits because of childhood depression. Many of the occupational deficits involved in depression can be addressed in the school environment as part of a collaborative team using a tiered approach addressing promotion, prevention, and intervention.

The multi-tiered approach reaches school populations on a universal level where all students benefit, a targeted level where some students with identified needs benefit, and an intense level where few students with exceptional needs benefit (Miles, et al., 2010). A multi-tiered approach to childhood depression in schools aligns with the OTPs commitment to facilitate health and wellness at the individual, group, and population level (AOTA, 2020).

Additionally, OTPs can contribute to various school-wide teams and initiatives that directly and indirectly address school-wide incidence of childhood depression such positive behavioral intervention and supports (PBIS); social-emotional learning (SEL); bullying, suicide, and mental health awareness and prevention programming; and student assistance programs (SAP) or care teams.

Occupational therapy practitioners can promote mental wellness by:

• Advocating for occupational therapy’s role as part of a comprehensive school mental health team.
• Educating administration, faculty, and staff on the unique skill set OTPs possess to address mental health, especially depression, using an occupation-based lens.
• Promoting mental health literacy and stigma reduction in school to create a safe place for students to seek support.
• Establishing school-wide programs and policies for early screening, detection, and intervention of depression.
• Maintaining healthy environments free of bullying, stigma, and social exclusion.
• Encouraging self-advocacy of students to express needs, seek support, and support other students who struggle with depression.

• Provide an in-service to administration, faculty, and staff regarding occupational therapy’s role in youth mental health with examples of contributions, programming, and initiatives.
• Create and advise youth clubs and organizations to address bullying prevention, social inclusion, and mental health stigma reduction.
• Develop and contribute to an early screening, detection, and intervention team to complete school-wide depression screens and referrals for services.
• Collaborate and create community partnership for referrals to mental health supports, social supports, and family resources outside of school.
• Embed social-emotional learning strategies into classroom activities such as self-esteem, resilience training, and social inclusion concepts by assisting teachers with activity planning and implementation.
• Promote mental health resources throughout school buildings through email, posters, flyers, announcements, and social media through student-led initiatives supported by OTPs.
• Partner with local universities by hosting OT and OTA students to implement tiered strategies that address mental health prevention and awareness.
• Contribute to school-to-community outreach efforts by educating families and support persons on risk factors and preventative factors of depression.
• Provide intensive interventions to students with a depression diagnosis by identifying and addressing symptomatology and occupational deficits accordingly.
• Identify and make appropriate referrals for students with risk factors and symptoms that may indicate depression.

AOTA resources

• School Mental Health Community of Practice
• American Occupational Therapy Association. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410035. https://doi.org/10.5014/ajot.2017.716S03
• Bazyk, S. (2011). Mental health promotion, prevention, and intervention with children and youth e-book. AOTA Press.

Sources

• 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 Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, Revised TR, Fifth Edition. American Psychiatric Publishing.
• 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 Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, Revised TR, Fifth Edition. American Psychiatric Publishing.
• Bitsko, R., Claussen, A., Lichstein, J. (2022). Mental health surveillance among children: United States, 2013-2019. Morbidity and Mortality Weekly Report 71(Suppl. 2). 1-42. http://dx.doi.org/10.15585/mmwr.su7102a1
• Fiorelli, C., Gentile, S., Grimaldi Capitello, T., Barni, D., & Buonomo, I. (2019). Predicting adolescent depression: The interrelated roles of self-esteem and interpersonal stressors. Frontiers in Psychology, 10(565). 1-6. doi:10.3389/fpsyg.2019.00565
• Ho, T., Shah, R., Mishra, J., May, A., & Tapert, S. (2022). Multi-level predictors of depression symptoms in the Adolescent Brain Cognitive Development (ABCD) study. Journal of Child Psychology and Psychiatry 63(12). 1523–1533. https://doi.org/10.1111/jcpp.13608
• Miles, J., Espiritu, R.C., Horen, N., Sebian, J., Waetzig, E. (2010). A public health approach to children's mental health: A conceptual framework. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health.

Contributing author

Miranda Virone, OTD, MS, OTR/L
Slippery Rock University

In the United States, foster care provides temporary out-of-home (OOH) care for children who cannot live with their families. Of these placements, 16% are due to abuse, and 84% as a result of neglect, parental/child substance abuse, disability, child behavior problems, parent death or incarceration, caretaker inability to cope, and relinquishment or inadequate housing (Casey Family Programs, 2019).

Children in foster care may present with needs in all areas of occupation. Occupational therapy practitioners provide multiple levels of intervention at individual, system, and policy levels. This section provides considerations that occupational therapy practitioners can use when working with clients at the individual level who are currently or have previously been placed in foster care.

These services may occur within various environments, including the foster home, home environment, pre- and post-reunification, daycare, school, welfare agency, or other natural environments for the individual. Practices may vary widely from state to state and type of OOH placement.

Occupational therapy can assist former foster youth in improved occupation, participation, and health in adulthood by fulfilling gaps in current programming and providing individualized performance-based assessment (Armstrong-Heimsoth et al, 2020). Former system youth express the need for person-centered services that include social skill development, increased participation in meaningful activities, decision-making opportunities, and peer group programming (Armstrong-Heimsoth et al, 2020).

Foundational principles for occupational therapy practitioners include SAMHSA (2014) principles of Trauma-Informed practice. These include safety, trustworthiness, peer support, collaboration, empowerment (voice and choice), cultural, historical, gender, and disability (co-existing condition).

These principles serve as a guide for occupational practitioners to apply occupation-based practice through a trauma lens. Regardless of the setting, SAMHSA principles provide the lens through which OT practice is applied, including the overlay of any additional Trauma-Informed Models of Practice.

ADL

• Focus on bathing, personal hygiene, culturally appropriate hygiene for transracial foster families.
• Teach healthy body boundaries (safe touch vs. unsafe touch).
• Establish a healthy feeding routine.
• Address coping stress with maladaptive behaviors around mealtime or food.

Rest/Sleep

• Develop regulation and co-regulation skills.
• Establish a healthy sleep routine to avoid lack of participation due to frequent sleeping as an avoidance behavior due to stress, falling asleep or night terrors could impact rest and sleep.

Education

• Consider accommodations needed in school to promote occupation and avoid re-traumatization.
• Help children transition to new schools and establish relationships with new teachers and peers.

Play

• Foster developmental skills for play (social, physical, cognitive).
• Promote awareness of possible inconsistent school experience and unidentified learning challenges.
• Facilitate play with caregivers and those who directly interact with the child (i.e., foster family, biological and/or first family, educators, support staff, etc.).
• Strengthen awareness of caregiver’s play skills when interactions with infants and toddlers.

Health management

• Teach basic safety knowledge, such as
  • emergency contact,
  • identifying safe adults,
  • voicing needs,
  • regulation (physical and emotional), and
  • OOH placement awareness of and minimization of trauma triggers.

Social participation

• Promote the development of play and social skills, social-emotional learning.
• Promote awareness of self, self-management, social awareness, responsible decision making, relationship skills.

Client factors to consider

• Foster developmental milestones including:
  • mental function,
  • higher-level cognition,
  • attention,
  • sequencing complex movement physical development,
  • attachment,
  • sensory processing and interoception needs,
  • medical needs,
  • values (consider how first family values and beliefs are carried over in OOH care), and
  • self-identity and knowing “my story” (life book, scrapbooks, etc.)

** Please note that children with experiences of early adversity will frequently demonstrate needs expected to be mastered at a younger age, i.e., their biological age may not match their maturational and developmental age. While occupational considerations are organized generically by age expectation, the provider team understands that benchmarks are mastered in a developmental sequence. For example, a child who is 17 may lack necessary skills such as judgment, problem-solving, impulse control, and perspective-taking needed for healthy social relationships.**

ADL

• Strengthen increased independence with self-care routines including,
  • planning (including weather and context-appropriate clothing),
  • sequencing ADLs, and
  • helping the child explore and create appropriate sexual boundaries for self and others.

IADL

• Explore age-appropriate chores.
• Develop a sense of self through agency over personal spaces, pet care, community mobility, financial management (saving vs. spending), and simple meal preparation.

Rest/Sleep

• Develop sleep hygiene, regulation, and co-regulation skills necessary for the preparation of rest and sleep.

Education

• Consider social and academic accommodation needs and education regarding puberty and body changes.
• Consider social-emotional learning (awareness of self, self-management, social awareness, responsible decision making, relationship skills).
• Assist in school community efforts to promote mental health— bullying prevention, substance use prevention.

Health management

• Promote social-emotional health management.
• Assist with communicating safety needs and symptom/condition management at a developmentally appropriate level.

Play

• Address the foundation of play skills that may have been missed earlier in development.
• Support skills to build team and cooperative play.

Leisure

• Introduce healthy leisure activities or clubs with an emphasis on identifying areas of preferred leisure, internet, and phone safety during leisure such as gaming, sports, theater, band, and extra-curricular activities.

Social participation

• Promote peer group participation and social skills including social media and safety.
• Promote opportunities for team and group activities and community activities.

Client factor considerations

• Consider physical and mental health needs and development.
• Consider cognitive development including,
  • executive functioning,
  • sensory processing and interoception needs,
  • spirituality, values (considering first family values/beliefs as well as supporting child developed values),
  • body image, self-concept, and
  • self-esteem.

** Please note that children with experiences of early adversity will frequently demonstrate needs expected to be mastered at a younger age, i.e., their biological age may not match their maturational and developmental age. While occupational considerations are organized generically by age expectation, the provider team understands that benchmarks are mastered in a developmental sequence. For example, a child who is 17 may lack necessary skills such as judgment, problem-solving, impulse control, and perspective-taking needed for healthy social relationships.**

ADL

• Sequence and take ownership of morning ADL routines.
• Create safe sex practices and education regarding sexually transmitted diseases and sexual identity needs.

IADL

• Develop transition planning for life after foster care such as:
  • child-rearing,
  • driving and community mobility,
  • financial management (banking, budgeting, financial decision making),
  • meal preparation and planning, and
  • vehicle maintenance and responsibilities.
• Create a plan for decision-making opportunities and self-advocacy skills related to the legal system and life skills.

Rest

• Develop sleep hygiene, self-regulation skills, mindfulness, identifying meaningful restful activity.

Education

• Consider social as well as academic needs.
• Identify any specific training/education needed for post-high school planning.
• Promote high school completion.
• Assist in school community efforts to promote mental health—bullying prevention, substance use prevention.

Health management

• Advocate for physical and mental health needs, communication with the healthcare system, medication management.

Work

• Foster employment interests and pursuits.
• Encourage employment seeking and acquisition, job performance, and maintenance.
• Explore volunteer opportunities and participation.

Leisure

• Introduce leisure activities such as sports, theater and/or band, extracurricular, and volunteer activities.
• Cultivate time management for restoration activities.

Social participation

• Promote peer group participation and intimate partner relationships.
• Develop social and safety skills for social media and the internet.

Client factor considerations

• Consider physical and mental health needs and development.
• Consider cognitive development including,
  • executive functioning,
  • sensory processing and interoception needs,
  • spirituality, values (considering first family values/beliefs as well as supporting child developed values),
  • body image, self-concept, and
  • self-esteem.

** Please note that children with experiences of early adversity will frequently demonstrate needs expected to be mastered at a younger age, i.e., their biological age may not match their maturational and developmental age. While occupational considerations are organized generically by age expectation, the provider team understands that benchmarks are mastered in a developmental sequence. For example, a child who is 17 may lack necessary skills such as judgment, problem-solving, impulse control, and perspective-taking needed for healthy social relationships.**

AOTA resources

Ashcraft, R., Lynch, A., & Tekell, L. (2019). Chapter 31: Best Practices in Supporting Students who have Experienced Trauma; In G. Frolek Clark, B.E. Chandler, Rioux, J. (Eds.) Best Practices for Occupational Therapy in Schools. (2nd ed., pp. 243-252) American Occupational Therapy Association Press. ISBN 13: 9781569004111

Lynch, A., Ashcraft, R., & March Tekell, L. (2017). Understanding Children Who Have Experienced Early Adversity: Implications for Practitioners Practicing Sensory Integration. SIS Quarterly Practice Connections, 2(3), 5–7

Lynch, A., Ashcraft, R., Tekell, L. (Eds.). (in press). Trauma, occupation, and participation: Foundations and population considerations in occupational therapy. AOTA Press.

Additional resources

• Adverse Childhood Experiences
• Child Welfare Information Gateway
• Collaborative for Academic, Social and Emotional Learning
• Resources for Youth In Transition
• Zero to Three

Sources

Armstong-Heimsoth, A., Hahn-Floyd, M., Williamson, H., Lockmiller, C. (2020). Toward a Defined Role for Occupational Therapy in Foster Care Transitioning Program. The Open Journal of Occupational Therapy, 8(4), 1-8. https://doi.org/10.15453/2168-6408.1726

Armstrong-Heimsoth, A. (2020). Former foster system youth: Perspectives on transitional supports and programs. Journal of Behavioral Health Services & Research, 1–18. https://doi.org/10.1007/s11414-020-09693-6

Casey Family Programs. (2019). State-by-state data

Lynch, A. K., Ashcraft, R., Mahler, K., Whiting, C. C., Schroeder, K., & Weber, M. (2020): Using a public health model as a foundation for trauma-informed care for occupational therapists in school settings. Journal of Occupational Therapy, Schools, & Early Intervention. https://doi.org/10.1080/19411243.2020.1732263

SAMHSA’s Trauma and Justice Strategic Initiative. (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

Whiting, C. C. (2018). Trauma and the role of the school-based occupational therapist. Journal of Occupational Therapy, Schools, & Early Intervention, 11(3), 291-301

Contributing authors:

Amy Armstrong-Heimsoth, OTD, OTR/L, Northern Arizona University
Rachel Ashcraft, MS, OTR/L, TBRI® Practitioner, Cicero Therapies; Foster the Future Alabama
Arezou Salamat, OTD, OTR/L, Loma Linda University
Lisa Tekell, OTD, OTR/L, Independent Practitioner

Grief is defined as a strong, overwhelming sense of sadness and anguish that is experienced by someone who has been impacted by a loss, death, physical trauma, or emotional trauma (Mayo Clinic, 2019). Trauma from grief can lead to deficits in social emotional skills, stress management, coping strategies, daily routines, problems with attachment, emotional regulation, self-concept, and overall identity. Children also experience increased rates of medical problems, mental health problems, and educational difficulties when identified as having grief (Steenbakkers, et al., 2019).

The grief process in children differs from adults due to communication and cognitive skill development throughout the typical developmental progression. A child’s grief is individualized and can manifest in physical and emotional symptoms, and it depends on their developmental age.

Functional performance in school, social participation, leisure/play, and pleasure involvement is often indicative of how a child is faring in the grieving process (Dyregrov, Salloum, & Kristensen, 2015). Children who struggle with grief and loss can show signs of depression, loss of appetite, prolonged fear of being left alone, emotional immaturity, withdrawal from friends and loved ones, decrease in performance in school, and refusal to participate in academic or extracurricular activities (American Academy of Child & Adolescent Psychiatry, 2019). Grief can also manifest as physical symptoms such as abdominal pain, headaches, or nausea that can impact daily functioning (AOTA, 2014).

Impacts of grief on occupational performance can include:

• limited or changes in social interaction including peer, family, and other social engagements and relationships,
• limited or loss of interest/enjoyment in leisure and/or play activities,
• difficulty or changes in work and/or school engagement including inattention and loss of interest,
• impaired or ineffective health management such as dietary needs, physical activity, or seeking help, and
• changes in self-care, grooming, hygiene, rest and sleep habits and routines.

Occupational Therapy Practitioners (OTPs) can help children recognize and understand that grief may be a part of you but does not need to consume your life. Given all the possible situations that can produce grief in children, it is likely that OTPs will routinely interact with children who are grieving.

OTPs must advocate for increased awareness of the impacts of grief on quality of life, occupational performance, and overall health and wellness. School-based practitioners can provide a multi-tiered approach to addressing an individual, group, or population.

OTPs can foster mental wellness for groups and populations in the following ways:

• Provide in-services for educators, parents/caregivers, and the local community on the impacts of grief on children and youth.
• Create activity/play groups for children who are grieving in your school or community.
• Develop a mental health team for your school district.
• Help normalize the grieving process and its related impacts with education and action within your school and community.
• Embed social-emotional learning and activities into all classroom settings.

For individual students, OTPs can promote mental wellness in the following ways:

• Provide individualized intervention plans that include ongoing reassessment targeting occupational deficit areas.
• Identify and make appropriate referrals for students with risk factors and symptoms that may indicate depression, anxiety, PTSD, or other mental health conditions.
• Provide access to and introduce play and leisure activities.
• Educate and engage the child in positive coping strategies (journaling, painting, exercise, scrapbooking, yoga, mindfulness, etc.).
• Create a safe space for the child to engage with you regarding their grief by using an OTP’s skill in therapeutic use of self to express their emotions.
• Provide developmentally appropriate resources (local support groups, suicide prevention resources, useful coping strategies that you collaboratively develop, local therapy or counseling as appropriate, etc.).
• Modify or adapt assignments and learning environments conducive to overall health and wellness.
• Use a strengths-based approach to help the child understand their own positive and individual attributes.

AOTA resources

• School Mental Health and Pediatric Trauma Communities of Practice
• American Occupational Therapy Association. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410035. https://doi. org/10.5014/ajot.2017.716S03

Additional resources

• Patten, K. K. (2022). Eleanor Clarke Slagle Lecture—Finding our strengths: recognizing professional bias and interrogating systems. American Journal of Occupational Therapy, 76, 7606150010. https://doi.org/10.5014/ajot.2022.076603
• Toolkit to Support Military-Connected Students – School Resources to Support Military-Connected Students (psu.edu)
• Maryland State Education Association (MSEA) Trauma Toolkit for Educators (nea.org)
• Helping Children Cope After a Traumatic Event (childmind.org)

Sources

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

Bazyk, S. (2011). Enduring challenges and situational stressors during the school years: Risk reduction and competence enhancement. In S. Bazyk (ed.), Mental health promotion, prevention and intervention for children and youth: A guiding framework for occupational therapy (pp.119–139), Bethesda, MD: AOTA Press.

Dyregrov, A., Salloum, A., Kristensen, P., & Dyregrov K. (2015). Grief and traumatic grief in children in the context of mass trauma. Current Psychiatry Reports, 17(48), 1-8. Doi:10.1007/s11920-015-0577-x

Patten, K. K. (2022). Eleanor Clarke Slagle Lecture—Finding our strengths: recognizing professional bias and interrogating systems. American Journal of Occupational Therapy, 76, 7606150010. https://doi.org/10.5014/ajot.2022.076603

Schonfeld, D., & Quackenbush, M. (2009). After a loved one dies: How children grieve and how parents and other adults can support them. AfteraLovedOneDiesHowChildrenGrievepdf.pdf (ct.gov)

Steenbakkers, A., van der Steen, S., & Grietens, H. (2019). How do youth in foster care view the impact of traumatic experiences? Children & Youth Services Review, 103, 42–50. https://doi.org/10.1016/j.childyouth.2019.05.026

Contributing author

Jennifer Dessoye, EdD, OTD, OTR/L, CLA
King's College

Occupational therapy practitioners (OTPs) promote inclusion by providing services within the Multi-tiered System of Support (MTSS) and integrating their services into the natural settings of school and community. Integrated service delivery involves providing occupational therapy in students’ natural environments (e.g., school bus, classroom, playground, cafeteria, recreational settings), emphasizing non-intrusive methods, and supporting common goals (Bazyk et al., 2009; Clark et al., 2019). 

Integrated occupational therapy services enhance student learning.

• Practicing meaningful occupations in natural settings is most effective for learning new skills and is supported by theories of motor control and motor learning indicate that (O’Brien & Lewin, 2008; Novak & Honan, 2019).
• Providing occupational therapy in natural environments (e.g., classroom, playground, cafeteria, community settings) is less disruptive to learning compared to pull-out models (Cahill & Bazyk, 2020; Gallagher et al., 2018; Tracy-Bronson et al., 2019).
• Integrating occupational therapy service delivery is associated with better academic results for all students in the classroom, not just those receiving direct services (Tracy-Bronson et al., 2019).
• Reviewing this helpful resource to learn about integrating your occupational therapy services in school-based settings to promote mental health.

Integrated occupational therapy services improve the abilities of everyone on the school-based team.

• OTPs learn about the curriculum, teacher preferences, and the unique culture of the classroom (Cahill & Bazyk, 2020).
• Teachers, paraeducators, and other service providers have opportunities to learn how to embed occupational therapy intervention strategies when services are provided in the natural context. Students with disabilities benefit from teachers’ increased ability to implement therapy strategies throughout the day (Silverman, 2011; Tracy-Bronson et al., 2019).

The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973

• U.S. Civil Rights Laws that prohibit discrimination based on disability.
• These laws focus on accessibility and mandate reasonable accommodations and modifications to ensure students’ participation in school and community.
• People with disabilities must have equal access to all facilities and services.
• Within the school setting Section 504 guarantees accommodations to all students to promote equal access to their education (Ex. environmental, cognitive, social emotional supports or adaptations).

The Individuals with Disabilities Education Act (IDEA) 

• A U.S. law which funds services to support students who have been identified as needing special education services; it supports access to the curriculum and participation in school and community.
• The law mandates that students with disabilities are provided a free and appropriate education (FAPE) in the least restrictive environment (LRE).
• The IEP Team, consisting of the parents, school administrators, general ed and special ed teachers, and related service providers should meet to agree on what related services, modifications, or accommodations would be most effective for the student to access the highest level of academic and social benefit.

The Every Student Succeeds Act 2015 (ESSA)

• U.S. federal legislation that provides explicit support for OTPs to contribute to health promotion, including both mental and physical health (Subcommittee of the ESSA OT Advocacy Network, 2022; Laverdure et al., 2023).
• Included in Under ESSA, occupational therapists are listed as Specialized Instructional Support Personnel (SISP).
• ESSA includes a focus on Multi-tiered Systems of Support (MTSS) giving OTPs a role in all 3 Tiers: universal, at risk, and intensive.

• ESSA expands OTPs role in mental and physical health promotion and prevention to include all students.

Promotion and prevention activities may include:

• Create positive environments for learning (e.g., collaborate with teachers to use a variety of teaching methods, create sensory friendly environment that supports learning)
• Facilitate health-promoting occupations in the classroom (e.g., sensory processing for self-regulation, stress-reduction activities)
• Facilitate health-promoting occupations in the cafeteria, on the playground, and after school leisure (e.g., being a good friend, enjoying active play, teamwork, engaging in hobbies and interests)

Examples of service delivery models that OTPs might use to promote inclusion and follow the law when providing school-based therapy: (Bazyk & Cahill, 2020):

• Whole class interventions
• Small group interventions
• Co-teaching in general education and resource classrooms
  • Review this resource to learn more about co-teaching: Service Delivery Models and Co-teaching
• Small lunch and recess groups for students with disabilities and their peers.
• Pulling students out of class for individual therapy sessions is the most restrictive environment and should only be done when necessary, and rarely done on a regular basis.

OTPs must advocate for their entire scope of practice: Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), Social Participation, Play, Leisure, Sleep and Rest, Health Management, Work, and Education (Bazyk, 2022).

Elevator Pitches: Occupational therapy practitioners serving in schools may find resistance when supporting a student's inclusion. Use these examples of quick pitches to open the door for discussion.

Potential chat with a classroom teacher to initiate a conversation about inclusion.

“I am impressed by how tough your job is! Here you are teaching a lesson plan, managing 20 2nd graders, and on top of all that you are working to meet the individual needs of each of your students. And you make it look so easy. You know that I have been working with [Student name] on emotional regulation and they seem to be improving. I do not want to disrupt your class in any way and am wondering how we can best support [student name] in your class? One idea is partnering with you. While you are teaching a writing lesson, I can work with [student name]. I want you to know that I am here not only to support [Student name], but also to support you and all your students. ”

Potential chat with a teacher or administrator to initiate a conversation about the laws.

“Occupational therapy supports and helps children fulfill their role as a student across all school settings. The law allows occupational therapy practitioners (OTPs) to address physical and mental health. Therefore, we can easily provide services across all settings for all students in the general population.

For those students with individual education plans (IEPs), we know that another law mandates that students are serviced in the least restrictive environment alongside their non-disabled peers to the maximum extent possible. This promotes peer interactions and participation within the general education setting and across all school spaces.

We are here to support teachers in helping students learn and participate throughout the school day everywhere in the school, therefore it only seems logical to be right there, alongside the teacher! This support can be accomplished through several styles of co-teaching.”

Potential chat with a teacher or administrator to initiate a conversation about mental health.

“We provide educationally relevant skilled services in many areas, in addition to academic skills and functional performance, we have the knowledge and skilled training to support each student’s social, emotional, physical, and mental health. We help students with coping and self-regulation skills, social participation, appropriate interactions with others, executive functioning, and relaxation strategies to reduce anxiety.”

OTPs can advocate for the inclusion of students with disabilities in all educational and community settings to promote physical and mental health. In addition, inclusion enhances understanding and acceptance of disabilities to non-disabled peers.

The Individuals with Disabilities Act (IDEA) mandates Individual Education Plan (IEP) teams to include students with disabilities in the general education setting, except when their disability prevents them from learning in that setting. Even with the law in place, a 2019 study revealed persistent separation and segregation of students with disabilities from general education settings (Kurth et al., 2019).

Occupational therapy practitioners can advocate for inclusion in the following ways:

• Share best practices using evidence and the law.
• Express how occupational therapy role in schools is a support service to create an inclusive education experience.
• Learn more about myths related to occupational therapy practitioners working to promote mental health.

American Occupational Therapy Association. (2023). Debunking eight SISP myths. https://www.aota.org/advocacy/everyday-advocacy/debunking-eight-sisp-myths

Bazyk, S. (2022). Occupational therapy: Promoting participation in occupation. https://s3.us-east-2.amazonaws.com/s3.everymomentcounts.com/wp-content/uploads/2022/05/03200324/FINAL_OT-Scope_Diagram_4-7-22.pdf

Bazyk, S., Demirjian, L., Horvath, F., & Doxsey, L. (2018). Comfortable Cafeteria. Every Moment Counts. https://everymomentcounts.org/comfortable-cafeteria/

Bonnard, M., Hui, C., Manganaro, M., & Anaby, D. (2022). Toward participation-focused school-based occupational therapy: current profile and possible directions. Journal of Occupational Therapy, Schools, & Early Intervention, 0(0), 1–18. https://doi.org/10.1080/19411243.2022.2156427

Cahill, S. & Bazyk, S. (2020). School-based occupational therapy. In J. C. O’Brien & H. Kuhaneck (Eds.), Case-Smith’s occupational therapy for children and adolescents (8th ed., p. chapter 24). Mosby.

Clark, G. F., Fioux, J. E., & Chandler, B. E. (Eds.). (2019). Best Practices for Occupational Therapy in Schools (2nd ed.). AOTA Press.

Gallagher, A. L., Tancredi, H., & Graham, L. J. (2018). Advancing the human rights of children with communication needs in school. International Journal of Speech-Language Pathology, 20(1), 128–132. https://doi.org/10.1080/17549507.2018.1395478

Kurth, J. A., Ruppar, A. L., Toews, S. G., McCabe, K. M., McQueston, J. A., & Johnston, R. (2019). Considerations in placement decisions for students with extensive support needs: An analysis of LRE statements. Research and Practice for Persons with Severe Disabilities, 44(1), 3–19.

Laverdure, P., VanCamp, A. B., LeCompte, B., April 2023, V. 28 • I. 4 •, & Pp. 15–19. (2023, April 1). Empowering ESSA’s value in schools | AOTA. https://www.aota.org/publications/ot-practice/ot-practice-issues/2023/empowering-essas-value-in-schools

Novak, I., & Honan, I. (2019). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Australian Occupational Therapy Journal, 66(3), 258–273. https://doi.org/10.1111/1440-1630.12573

O’Brien, J., & Lewin, J. E. (2008). Part 1: Translating motor control and motor learning theory into occupational therapy practice for children and youth. OT Practice, 13, CE1–CE8.

Silverman, F. (2011). Promoting inclusion with occupational therapy: A coteaching model. Journal of Occupational Therapy, Schools, & Early Intervention, 4(2), 100–107. https://doi.org/10.1080/19411243.2011.595308

Sisti, M. K., & Robledo, J. A. (2021). Interdisciplinary collaboration practices between education specialists and related service providers. Journal of Special Education Apprenticeship, 10(1). https://eric.ed.gov/?id=EJ1302874

Subcommittee of the ESSA OT Advocacy Network. (2022). Occupational therapy’s role as SISPs under ESSA. https://www.tota.org/assets/FINAL_OT%20ESSA%20Admin_4-25-22.pdf

The IRIS Center. (2023). Creating an inclusive school environment: A model for school leaders. https://iris.peabody.vanderbilt.edu/module/inc/#content

Tracy-Bronson, C. P., Causton, J. N., & MacLeod, K. M. (2019). Everybody has the right to be here: Perspectives of related service therapists. International Journal of Whole Schooling, 15(1), 132–174.

Contributing authors

Carol Siefert Conway MS, OTR/L
Ingrid M. Kanics, OTR/L, FAOTA, CPSI
Shannon Marder, OTR/L
Rebecca Mohler, MS, OTR/L

Strengths-based approaches have become an important part of clinical practice across several professions including occupational therapy. While there is a lack of consensus on the definition of strengths-based practice, Murthi et al., (2023) have identified the following essential elements:

• presuming competence
• partnering with clients as collaborators
• creating supportive environments.

In this collaborative approach, practitioners partner with clients to identify, honor, and use the client’s strengths to facilitate their desired occupational life. The client’s strengths and talents, rather than perceived deficits, are at the heart of the interaction (Dunn et al., 2013; Patten, 2022). In school-based contexts, there are many opportunities to adopt and promote strengths-based practices with children, youth, caregivers, and across interprofessional teams.

School-based occupational therapy practitioners (OTPs) facilitate children’s and youths’ access to and participation in their educational program. This includes not only academic and functional activities, but also participation in unstructured or semi-structured activities such as recess, mealtimes, and end-of-day routines, as well as extracurricular programs.

These activities provide OTPs with multiple opportunities to promote children’s positive mental and emotional wellbeing at individual, group, and population levels, using strengths-based practices. Positive mental health is associated with improved overall functioning, quality of life, and enhanced outcomes (Harrison et al., 2022; Lewis et al., 2021).

Depending on state regulations, OTPs may provide services within a tiered approach that offers universal supports to all students (Tier 1), focused approaches to small groups of students with similar needs (Tier 2), or intensive supports to individual students (Tier 3).

School-based OTPs can facilitate positive mental health and wellness at individual, group, and population levels (AOTA, 2020). Key elements of practice include:

• Evaluating and modifying physical and social environments to foster a positive school climate, in collaboration with the school team.
• Using activity analysis to create “just right” challenges that build mastery experiences, autonomy, role competence, and sense of self for children and youth.
• Implementing evidence-based practices to teach self-regulation, coping skills, and mental health literacy.
• Building self-determination and occupational justice through the provision of meaningful choices and access to participation in inclusive occupations.
• Using the child’s strengths and interests to build resilience and facilitate positive mental health.

Strategies include:

• Build an occupational profile that explores strengths, interests, and passions first, rather than focusing on deficits.
• Collaborate with children and youth to develop an authentic and individualized evaluation and intervention process that reflects both the client’s strengths and occupational participation challenges; don’t roll out a battery of standardized assessment tools because “it’s the way we do it here.”
• Collaborate with clients (including children, youth, educational team, caregivers) to identify their meaningful therapy outcomes.
• Presume competence in your clients and co-workers.
• Consider using the “F-words in childhood disability” (functioning, fun, family, friends, fitness, and future) to frame and convey the child’s strengths (Rosenbaum & Gorter, 2012; Soper et al., 2021). This strengths-based approach celebrates the uniqueness of each child and uses their strengths to facilitate participation and self-determination.

• Advocate for social, attitudinal, and physical environments that provide opportunities for clients to use their strengths and have them recognized.
• Ensure that documentation fully reflects the client’s strengths and how they are being used to facilitate enhanced occupational performance and participation; the client’s strengths are central to the therapy process and not an “add-on” (Braun et al., 2017; Dunn & Koenig, 2013).
• In collaboration with other school team members, provide Tier 1 services that foster prosocial behaviors and build resilience.
• Collaborate with school teams to co-create environments with a range of supports; shift language away from “high/low functioning” individuals to “high/low” support environments (Patten, 2022).
• Identify opportunities to provide universal (Tier 1) support that acknowledge strengths and foster neurodiversity to positively impact school climate. Examples include:
  • Anti-bullying initiatives
  • Friendship circles
  • Positive behavior supports
  • Resilience building
  • Social-emotional learning
• Provide in-service opportunities that educate and equip team members to adopt strengths-based practices during daily routines and activities (e.g., recess, cafeteria) (Every Moment Counts, n.d.).
• Ask caregivers to identify not only their child’s strengths, but also their own; this can provide contextual information that can strengthen relationships between home and school.
• Partner with OT/OTA academic programs to build capacity for developing Tier 1 services that promote positive mental health such as building coping skills and developing self-regulation and stress management skills (Lin et al., 2020).

AOTA resources

• School Mental Health Community of Practice
• Mental Health Special Interest Section (MHSIS)
• American Occupational Therapy Association. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410035. https://doi.org/10.5014/ajot.2017.716S03
• Bazyk, S. (2011). Mental health promotion, prevention, and intervention with children and youth e-book. AOTA Press.
• Visit Interprofessional Collaborative Practices in Multi-tiered Systems of Support in Schools.

Additional resources

• Collaborative for Academic, Social, and Emotional Learning (CASEL). https://casel.org/
• Every Moment Counts (promoting mental health throughout the day). https://everymomentcounts.org/
• Department for Health and Social Care & Social Care Institute for Excellence. (2019). Strengths-based approach: Practice framework and practice handbook.

Sources

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

Braun, M. J., Dunn, W., & Tomchek, S. D. (2017). A pilot study on professional documentation: Do we write from a strengths perspective? American Journal of Speech-Language Pathology, 26(3), 972–981.

Dunn, W. (2017). Strengths-based approaches: What if even the ‘bad’ things are good things? British Journal of Occupational Therapy, 80(7), 395–396

Dunn, W., Koenig, K. P., Cox, J., Sabata, D., Pope, E., Foster, L., & Blackwell, A. L. (2013). Harnessing strengths: Daring to celebrate everyone’s unique contributions, part II. Developmental Disabilities Special Interest Section Quarterly, 36(2), 1–3

Harrison, L., Sharma, N., Irfan, O., Zaman, M., Vaivada, T., & Bhutta, Z. A. (2022). Mental health and positive development prevention interventions: Overview of systematic reviews. Pediatrics, 149, S1–S39

Lin, M-L., Fierro, C., Medrano, C., Arroyos, D., & Medrano, G, (2020). Addressing mental health needs of elementary school children through university–community collaboration. SIS Quarterly Practice Connections, 5(3), 20–22

Lewis, K. M., Holloway, S. D., Bavarian, N., Silverthorn, N., DuBois, D. L., Flay, B. R., & Siebert, C. F. (2021). Effects of positive action in elementary school on student behavioral and social-emotional outcomes. Elementary School Journal, 121(4)

Murthi, K., Chen, Y.-L., Shore, S., & Patten, K. (2023). Strengths-based practice to enhance mental health for autistic people: A scoping review. American Journal of Occupational Therapy, 77(2), 1–12.

Njeze, C., Bird-Naytowhow, K., Pearl, T., & Hatala, A. R. (2020). Intersectionality of resilience: A strengths-based case study approach with indigenous youth in an urban Canadian context. Qualitative Health Research, 30(13), 2001–2018.

Patten, K. K. (2022). Eleanor Clarke Slagle Lecture—Finding our strengths: recognizing professional bias and interrogating systems. American Journal of Occupational Therapy, 76, 7606150010. https://doi.org/10.5014/ajot.2022.076603

Rosenbaum P, Gorter JW. The ‘F-words’ in childhood disability: I swear this is how we should think! Child Care Health Dev. 2012;38(4):457–463.

Soper, A. K., Cross, A., Rosenbaum, P., & Gorter, J. W. (2021). Knowledge translation strategies to support service providers’ implementation of the “F-words in Childhood Disability.” Disability & Rehabilitation, 43(22), 3168–3174.

Contributing authors

Pam Stephenson, OTD, OTR/L, BCP, FAOTA
Mary Baldwin University

Sarah Greene, OTD, OTR/L
Independent Practitioner

Methods used to physically manage a student's behavior or involuntarily confine their movement are dangerous and may cause trauma. Many schools have stopped using restraint and seclusion and have adopted crisis prevention and response methods to address the needs of students experiencing emotional and behavioral distress.

Consistent crisis prevention and response interventions can be incorporated into multi-tiered systems of support (MTSS) at the school, classroom, small group, and individual levels. Occupational therapy practitioners collaborate with educators and other school personnel to provide multiple levels of intervention that address crisis response and prevention.

This section describes proactive evidence-based strategies within the scope of occupational therapy practice and can be used when working with students who are experiencing emotional and behavioral distress.

Multidisciplinary school team

• Train interdisciplinary staff on restraint reduction interventions, including how to identify, implement, and evaluate outcomes related to short- and long-term goals for restraint reduction.
• Educate families and school personnel on signs and symptoms of emotional and behavioral distress and who to notify.
• Use evidence-based and culturally responsive strategies to address emotional and behavioral health concerns and create a supportive school climate.
• Educate staff on trauma-informed care and trauma-responsive approaches to avoid retraumatization.
• Incorporate movement and mindfulness (e.g., breathing, quiet reflection) breaks throughout the school day.

Students

• Provide education to students and school personnel on effective, non-violent communication.
• Coach student leaders to identify, address, and report mistreatment (e.g., bullying, putdowns, exclusion) of other students.
• Teach students social skills, rules, expected behaviors, and self-regulation skills.
• Promote positive relationships among students in the classroom, cafeteria, and playground.
• Teach students to become aware of their early triggers and provide safe spaces for breaks and the use of effective calming strategies.

School team (including teachers, administrators, related service providers, student, and family)

• Consult with educators and other school personnel to integrate movement (e.g., yoga), mindfulness breaks, and trauma-informed strategies into daily routines.
• Consult with teachers, families, and other school personnel to develop an individualized plan to support the student and facilitate de-escalation and promote overall health and wellness.

Students

• Perform comprehensive assessments of the client’s strengths, facilitators, and barriers to occupational performance.
• Document assessment results for students with difficulties processing sensory information. Provide sensory equipment as needed.
• Modify and adapt classroom environments (e.g., reduce distractions and triggers) and other contextual features to support students’ emotional and behavioral wellness.
• Provide opportunities for students to engage in preferred creative arts activities (e.g., drumming, blogging) that allow for individual expression.
• Use play-based approaches to support behavior regulation and social-emotional development.
• Teach students to self-monitor and request breaks and coping strategies as needed.
• Teach students how to effectively communicate and build positive relationships with adults and peers.
• Encourage students with individualized education plans (IEPs) to attend and participate in their meetings.

AOTA resources

• Mental/Behavior Health and Well-being Decision Guide - pdf
• Choosing Wisely Guide to Sensory-specific and Related Assessments
• Occupational Therapy Practice Guidelines for Children and Youth 5-21
• Addressing Acute Stress and Trauma—Decision Guide for COVID-19
• Societal Statement on Stress, Trauma, and Post-Traumatic Stress Disorder

Additional resources

These websites provide information and resources for occupational therapy practitioners engaging in crisis prevention and response.

• PBIS World
• STAR Institute
• FAB Strategies
• National Alliance of Specialized Instructional Support Personnel (NASISP)
• The National Center for Pyramid Model Innovations

Sources

Fraser, K., MacKenzie, D., & Versnel, J. (2017). Complex trauma in children and youth: A scoping review of sensory-based interventions. Occupational Therapy in Mental Health, 33(3), 199–216

Grasley-Boy, N. M., Reichow, B., van Dijk, W., & Gage, N. A. (2020, May 4). Systematic review of Tier 1 PBIS implementation in alternative education settings. Behavioral Disorders. https://doi.org/0198742920915648

Pat-Horenczyk, R., & Yochman, A. (2020). Sensory modulation in children exposed to continuous traumatic stress. American Journal of Occupational Therapy, 74(4_Supplement_1), 7411505189p1. https://doi.org/7411505189p1

Contributing authors

John Pagano, PhD, OTR/L
Faculty, Department of Occupational Therapy
Quinnipiac University

Susan Cahill, PhD, OTR/L, FAOTA
Director of Evidence Based Practice
AOTA