NOTE: The following blog post is VERY LONG and is the first part of a research project I am developing and conducting as part of the graduation requirements to earn my MSOT (Master of Science in Occupational Therapy) degree. If you are interested in attending graduate school for occupational therapy, you will likely be required to complete a similar project. Although specific project requirements vary, this post is an example of the work occupational therapy students do to develop skills in the area of critical thinking, research, interdisciplinary collaboration, and the application of evidence to practice.
Background: As part of a small group conducting research in the area of post-secondary transition planning for students with intellectual disabilities, I am responsible for creating a research question, conducting a literature review, developing a research project, implementing this project, and then documenting the results in written and presentation formats. I am working with a faculty advisor who provides support and guidance as I complete this project over the next year, but the work you see here (and possibly in future posts) is mainly the result of my own efforts. This post is the “literature review” component of my assignment.
STATEMENT OF THE PROBLEM
In the United States, vocational, employment, academic, social, and functional outcomes for young people with disabilities are disappointing, and have even been described as “bleak” in the literature (M. Kardos & White, 2005). For example, in the years 1987-2003, only 1/3 of high school graduates with disabilities pursued post-secondary education compared to 40% of typically developing students. Additionally, the transition to community-based services in which the individual is responsible for requesting services from school-based services in which the school personnel are responsible for providing services can be very difficult for these students and their families, which may contribute to negative post-secondary outcomes (Barnard-Brak, Schmidt, Wei, Hodges, & Robinson, 2013). Quality transition coordination services are crucial in order to improve the lives of high school students with disabilities as they leave the familiar world of school-based services (including occupational therapy services) and enter the world of adult and community-based services.
Further, it is important to address this issue because the Individuals with Disabilities Education Act (IDEA) of 1990 (and 1997, in later years) mandates that students who are receiving special education services receive transition planning as well. States and local education agencies (LEA) are responsible for providing these services, but a thorough review of the literature indicates that there are few federal guidelines regarding the provision, monitoring, and regulation of the mandated transition planning services. For this and other reasons that will be explained later, transition planning in many places across the United States is in a state of disarray, and students are not receiving the education, skills, and training they need to live life to its fullest as capable, successful, independent adults.
Providing transition planning for students with special needs is crucial not only because it is federally mandated, but also because it is important to provide all students with the skills they will need to find meaningful careers, interact successfully with their peers, participate in local communities, and live their lives in a way that is pleasing and accommodates them, regardless of their abilities or disabilities.
As providers who frequently work in school settings with students who are receiving special education services, occupational therapists are well-equipped to help students transition successfully out of school and into the workforce, community, post-secondary education, or other settings. As Kardos and White (2006) wrote, “Occupational therapists have the professional skills and training to expand the scope of school-based practice into the area of transition planning, particularly in conducting evaluations in the areas of daily living skills, work and leisure, and community participation” (p. 174). However, the majority of school-based OTs are not providing these services, for a variety of reasons including lack of training, lack of professional advocacy, and lack of research on effective interventions and practices.
In addition to being an issue of professional knowledge and practice, the lack of occupational therapists involved in transition planning may also be considered an issue of occupational justice, insofar as the students who are receiving inadequate transition services or no services at all are being deprived of their legal right to these services as well as their opportunities for future success in the areas of academics, leisure, social interaction, independent living, and community participation.
Initial Question: What does OT practice in the area of transition look like?
- Who is involved?
- What is the model of practice most commonly used?
- What assessments, tools, strategies, methods, interventions, etc. are used?
As I began researching this issue, my initial questions focused on occupational therapy’s role in the transition planning process and the practical elements of practice as a school-based therapist who was involved in this particular area of practice. My earliest questions were very broad, and I derived these initial questions as I reviewed the (decidedly sparse) literature regarding OT practice in the area of transition planning and found myself wanting to learn more about how a therapist who was interested in this area or who was expected to provide transition services might begin to establish guideliines for practice.
I also developed these questions as a result of the lack of recent evidence and OT-specific literature about what this area of practice looked in in comparison to other areas of pediatric practice, especially because such a large percentage of OTs work in schools. I found it strange that according to the literature and a 2007 NBCOT survey most OTs were not involved in transition planning in schools, although this service is federally mandated and 24% of OTs work in school-based settings where they could contribute or this service might be expected of them, as it is included in the Occupational Therapy Scope of Practice (Mankey, 2011; American Occupational Therapy Association, 2014).
Additionally, I had a desire to learn more about what the best models of practice are in transition planning in order to inform occupational therapy practice for the present and future, as well as improving outcomes for students with special needs who are leaving school.
Final Question: What is the best model of practice and most effective interventions for occupational therapists in schools who are contributing to transition planning for students with disabilities?
The literature search process helped create my final question in several ways. First, the literature revealed that there is not currently a “best practice” model for OT work in transition planning, although there is literature available for best practice in other settings such as acute care. Additionally, it is important to understand what is currently happening in the field (as best as possible considering the limited research examples) in order to make valuable and feasible suggestions about how to move forward. Further, the search process drove me to want to help find out how to “fill the gap” between what OTs are currently doing and what they could or should be doing to provide the most benefits for their clients; there is (arguably) much broader discussion of how transition processes typically go and what the problems are, but not a lot of discussion about what works, recommendations for practice, and examples of successful implementation of solutions to the problems.
Ultimately, the final question was developed because while it is important to understand the perspectives of all people involved in the transition planning process – including school personnel, students, and families – for occupational therapists, more practice-specific guidelines and models may be more useful than case studies or survey about the experience, many of which already exist.
In order to locate articles for this project, I used two main databases. The University Libraries and Google Scholar online databases provided the majority of the articles for my research, but I also searched the American Journal of Occupational Therapy (AJOT) database for more OT-specific articles. The University Libraries and Google Scholar databases were the most useful, simply because of the quantity of results provided and the customizability of the searches performed (limited by year, peer-reviewed status, etc.).
I used the following keywords to conduct my search:
transition disability school; occupational therapy college transition; disability transition team makeup; disability transition team roles; high school transition team; high school transition team disability; high school transition team disability occupational therapy; high school transition team model; occupational therapy high school transition team; occupational therapy high school transition team member; occupational therapy school transition team role; school transition team disability service delivery model; and school transition team service delivery model.
Although the literature review process for this project was likely not exhaustive, I collected examined 61 articles in total. These articles mostly focused on transition planning processes, models, issues, and practices, although a small number of articles described client and family experiences with transition planning. At the end of the search, I used 11-13 articles to inform my final research question.
As a note, I began the search process by only reviewing articles on transition planning practices in the United States, as I felt that these articles would be most appropriate to use for the purpose of recommending practices that met federal guidelines related to IDEA. However, as my research question developed I found that articles about transition planning practices outside of the United States (in the UK, for example) included a great deal of helpful information about effective practices and service delivery models that could inform at least part of my question about best practices for occupational therapists in transition planning.
SUMMARIZING THE RESEARCH
The overall state of evidence regarding transition planning practice as it relates to occupational therapists can be broken down into four main areas of research, which I have outlined below. As I researched, I found that articles tended to fall into one of these main categories or veins of research, although several articles bridged two or more.
The categories include:
- Category 1: Transition Planning Models
- Category 2: Transition Planning Best Practices
- Category 3: Current Occupational Therapy Practice in Transition Planning
- Category 4: Best Practices and Resources for Occupational Therapists in Transition Planning
Some elements of the research question can be answered definitively based on the literature. For example, questions about what models of transition planning exist, what makes transition planning successful, what hinders transition planning, why OTs are not involved in transition planning, and how successful transition planning impacts students have been answered. However, specific questions about occupational therapy practice in transition planning within diverse school environments and the most effective model of transition planning remain unanswered. Further research is needed in both of these areas to determine how OTs can make the best use of their skills and which models of transition are appropriate in various situations.
Based on the articles that were most relevant during the search process, it appears that the disciplines of special education, remedial education, and post-secondary studies are conducting the most research in the area of transition planning for students with disabilities. Other disciplines conducting research in this area include occupational therapy and vocational rehabilitation. There does not appear to be a geographical bias in the evidence base, as the research was conducted in schools, settings, and populations from across the United States (and overseas, in the case of a few articles).
Journals in which these articles were published include the Journal of Postsecondary Education and Disability, Journal of Learning Disabilities, and Remedial and Special Education. Articles related more specifically to occupational therapy were mostly found in the American Journal of Occupational Therapy.
Although it is difficult to tell based on searches of large databases, it appears that the quantity of research in this area has decreased slightly since the mid-2000s, with few articles being written since 2010. However, without a clearer way to examine the literature’s full scope, I am uncertain as to the general trend in this area of research.
Because the majority of the articles I reviewed and used in this literature review contained a summary of the previous and current issues with transition planning in their backgrounds or introduction sections, I will briefly summarize these problems here before discussing how they relate to the research in the four main categories I’ve identified.
Summary of Issues in Transition Planning
Providers across disciplines, including special education, school administration, occupational therapy, and vocational rehabilitation, face many of the same challenges when helping students with disabilities transition to post-secondary settings (Benz, Lindstrom, Unruh, & Waintrup, 2004; Beresford, 2004).
These issues include:
- Lack of information about post-secondary options, supports, and services for students and families
- Imbalance between number of students requiring transition services and staff available or equipped to provide these services (lack of qualified staff)
- Failure to incorporate student values, goals, needs, and interests during transition planning (i.e. neglect of areas of concern such as “friendships, social life, and leisure”)
- Low expectations for students by staff members and often students themselves
- Coordination or provision of services too late in student’s academic career
- Exclusion of students and families from transition planning
- Lack of coordination and communication between transition team members resulting in haphazard or clumsy provision of services
- Lack of funding for dedicated transition planning team members or staff
With these issues in mind, the rest of this section will focus on describing the literature relating to the four categories listed above.
Category 1: Transition Planning Models
Higher Education Transition Model: Three-dimensional model that facilitates planning in multiple areas of student life as they transition into a college setting. This model incorporates student opinions and preferences, and is designed for use with students who will be attending post-secondary institutions. (Schutz, 2002)
- Psychosocial Adjustment: Relationship building and communication skills; includes “self advocacy skill development,” frustration tolerance, navigating social situations and mentoring relationships
- Academic Development: Focus is on school staff who is preparing student for college, with inclusion of student; includes exam preparation, study skills, career exploration, goal setting, and academic and learning support
- College and Community Orientation: Prepare student for transition into college setting by exposing them to various aspects of campus life and activities; includes attendance at college programs, introduction to other students with disabilities on campus, information about various colleges and campus environments, information about support groups, and community offerings such as shopping and restaurant
Transdisciplinary Transition Model (TTM): Series of sequential steps that transition service provider complete to help guide student to positive post-secondary outcomes and assess success? (Schutz, 2002)
- Steps: Assessment à Planning à Training à Placement à Follow-up
- Can apply to students entering the workforce, entering college or other academic program, or pursuing other post-secondary options
Alternative Learning Project: Specific to Pennsylvania, project of the College of Misericordia’s Alternative Learners Project. (Schutz, 2002)
- Goal was to learn effective ways of preparing students for postsecondary education
- Student participants engaged in four year program and 44 activities in multiple categories, including Self-Awareness, Career Awareness, IEP Programming, Parent Activities, and College Search
- Students were expected to develop skills over time, with measurable goals regarding their development of self-awareness,
- Appears to be most appropriate for students with mild to moderate learning disabilities, based on level of self-reflection and awareness expected
Youth Transition Program (YTP): Created in response to need for “comprehensive” transition planning services for youth with disabilities in Oregon. (Benz et al., 2004)
- Collaborative effort between state-run programs (Oregon Department of Education and Vocational Rehabilitation Division), the University of Oregon, and local schools
- Focus on providing services “beyond typical general education, special education, and school-to-work programs” to help achieve post-secondary education and employment goals
- Instruction and support in wide variety of skills – academic success, independent living, managing adult services, job training, and more
- Team members include special education teachers, “transition specialists” as defined by school districts, and local vocational rehabilitation counselors, at a minimum
- Keys to success of program are stable, well-trained staff, administrative support, perception of program as having positive outcomes for students by school and community members, and clear role in school districts
Universal Design for Transition: Recently proposed and still-developing model of transition planning for students with disabilities based on Universal Design for Learning principles. Multi-part model with focus on multiple transition domains, multiple transition assessments, self-determination, and multiple resources and participants.
There was little research available on schools, professionals, or programs that utilized these models successfully (or unsuccessfully), with the exception of the Oregon YTP program, which has a well-documented success rate in schools that maintained a high level of fidelity to the program’s initial guidelines, structure, and organization.
Category 2: Transition Planning Best Practices
Best practices for transition planning were echoed in articles spanning multiple disciplines, time periods, and geographic areas. The major components of successful transition programs are described below (Schutz, 2002; Stewart, Stavness, King, Antle, & Law, 2006).
- Provision of specific transition services by skilled providers
- Development of self-management and self-determination skills
- Development of psychosocial skills and support for relationship-building and social growth
- Collaboration with students and families throughout planning process
- Consideration of how peers fit into post-secondary planning and activities
- Offering of choices to students and families regarding employment, education, independent living and other post-secondary options
- Providing information to students and families and educating them about differences between school- and community-based services as transition occurs
- Adopting a positive, strengths-based approach to planning
- Ongoing evaluation of student challenges, achievements, and outcomes (case management)
- Collaboration with community-based service providers
Additional articles discussed the importance of adopting a team-based approach to transition planning, coordinating efforts among school personnel and community services, such as offices of Vocational Rehabilitation or other adult service providers, and positive outcomes associated with mentoring and direct instruction in self-advocacy for students with disabilities (Barnard-Brak et al., 2013; Mellard & Lancaster, 2003).
The following categories focus literature that focused specifically on occupational therapy practice as it relates to transition planning for students with disabilities.
Category 3: Current/Recent Occupational Therapy Practice in Transition Planning
As discussed in the introduction to this literature review project, occupational therapists can play a key role in the successful transition of students with disabilities to post-secondary options (M. R. Kardos & White, 2006). However, the majority of school-based OTs are not currently involved in transition planning for a variety of reasons, which are listed below.
The majority of the responses in the following list were obtained as a result of surveys distributed to populations of OTs either in specific geographic areas or nationally.
Reasons Why Occupational Therapists Are Not Typically Involved in Transition Planning (Emery, Schneck, & Spencer, 2003; M. Kardos & White, 2005; Mankey, 2011)
- Lack of parent participation in transition planning process
- Traditional focus on early intervention and sensorimotor skill development, rather than student’s post-secondary outcomes
- Lack of interagency planning between therapist and community based services
- Therapist unfamiliarity with standard transition planning model of “real life activities practiced in context” in comparison to traditional school-based service delivery models (i.e. pull-out, group, or embedded classroom interventions for specific skill development)
- Tendency of school-based therapists to view interventions as “remedial, task-oriented, and specialized” instead of “holistic and person-centered”
- Lack of funding in schools
- Lack of understanding of occupational therapy’s unique contributions to transition planning by other professionals
- Other professionals typically handle transition planning role
- Lack of information regarding appropriate assessments for OTs to use in transition planning
- Poor understanding of specifics of transition planning as it relates to occupational therapy services
In essence, it seems that while there are external barriers to occupational therapists’ participation in transition planning for high school students, many of the issues lie within practitioners’ view of and understanding of OT’s potential contributions in this area. The final category of research addresses these issues by providing specific recommendations, resources, and examples of successful practices in transition planning from occupational therapy and special education literature.
Category 4: Best Practices and Resources for Occupational Therapists in Transition Planning
Although the literature on this topic was scarce, the articles available listed helpful resources and guidelines for occupational therapists desiring to develop skills in this area of practice. The following articles provide a starting point for OT practice in transition planning, and provide reliable, evidence-based examples of how OTs can be involved.
Although the article is from 1996, Clark’s survey of over twenty assessments related to transition planning provides a broad view of various assessments that can be used with students with disabilities to begin the transition planning process. The most critical aspect of this article is the author’s focus on evaluators “obtaining present level-of-functioning information for IEP planning that extends beyond high school graduation as a single outcome.” The article includes standardized and non-standardized assessments that OTs can use to obtain a holistic view of the student and his or her current needs and skills in areas such as independent living, cognitive functioning, and employment, as well as assessing future hopes, preferences, and interests (Clark, 1996).
Note: A more modern resource that includes information about assessments related to transition planning is the “Age Appropriate Transition Assessment Toolkit (3rd Edition)”. Although it is not a journal article, it is a free resource from the National Secondary Transition Technical Assistance Center that can be used to structure provision of transition planning services from the assessment stage through the tracking of student outcomes (www.nsttac.org).
Although this article is a case study that focused on occupational therapy’s role in transition planning with one student, the client’s positive outcomes and the author’s profession-specific recommendations are very helpful. (Kardos & White, 2006).
The article titled “Secrets from the Field: Secondary Transition Resources and Tips” is the collective effort of multiple occupational therapists who are specialists in transition planning. It is a compilation of their experiences and includes recommendations for various website, books, resources, and tools therapists can use throughout the transition process, methods for successful collaboration, intervention strategies, and advice about how occupational therapists can become part of transition teams and help promote better outcomes for students with disabilities (Orentlicher et al., 2014).
THE SCIENCE BEHIND THE QUESTION
Due to the diversity of research conducted in this area, with articles ranging in structure from single case study to survey design to critical appraisal to single-group posttest, it is very challenging to succinctly explain the epistemological, theoretical, methodological, and methodological structure of the evidence base.
Methodologically, the majority of the research in this area consists of survey research, literature reviews, and non-experimental design studies. There is not one main theoretical structure of the base, again because of the diverse points of view from which the research is developed. Further, none of the articles I examined stated a specific epistemological standpoint from which the data was analyzed and conclusions were gathered.
The research in the area of transition planning for students with disabilities, especially as it involved occupational therapists, were greatly varied in purpose. Few studies were purely descriptive, without offering any suggestions for successful practices in this area, and all had an explanatory element regarding reasons why transition planning failed, why students with disabilities had poorer outcomes, or how occupational therapists could become involved in this practice area.
Of the articles that were not descriptive or explanatory, most were research studies designed to either test the effectiveness of a specific transition service delivery model, describe the structure and goals of a specific method,
Based on my research, it appears that this wide variety in the type of research being conducted is due in part to the lack of standardization within the area of transition planning. Without any specific federal guidelines to follow beyond the general mandates of IDEA, there is a great deal of room for professionals and practitioners to propose effective transition planning models, examine pre-existing models, or simply begin exploring reasons why practitioners are excluded from this area of practice (in the case of occupational therapy literature). It seems that professionals in the fields of special education and post-secondary education are “further along” in the research, having moved beyond the point of assessing practices to proposing ideas about how to improve services and make them most effective for all involved.
Comparatively, since occupational therapy practice in schools has occurred fairly recently, and the literature base is not quite as developed, it makes sense that there are few articles that go beyond describing the current nature of practice to proposing models of best practice for OTs in transition planning. The fact that most of the articles I found (related specifically to OT) are case studies of occupational therapy services related to transition for students with disabilities or surveys describing the number of therapists and types of services provided supports this conclusion. However, it appears that therapists may be moving beyond the initial descriptive “phase” and embarking on the next leg of the research journey, as the article by Orentlicher et al. (2014) collects the recommendations, suggestions, and experiences of veteran therapists involved in transition planning, for the use of therapist who are new to this area. With virtually none of the 45 articles in journals of special or remedial education even mentioning occupational therapists as potential transition team members, it appears that occupational therapy researchers had to start building their foundation of knowledge from scratch, without the benefit of surveying literature that describes how OTs might have contributed to transition planning in previous years as a starting point.
In conclusion, there is a growing body of literature being created by researchers in multiple disciplines to promote successful transition planning for students with disabilities as they leave school and pursue post-secondary options. In the discipline of special education, there is a great deal of research regarding successful transition practices that helped answer part of my research question, but in spite of this positive finding, my final research question still remains largely unanswered.
Although the literature describes best practices for transition planning in general, as well as offering multiple models of transition planning for professionals to apply in their diverse settings, there continues to be very little information available about the unique role that occupational therapists can play in this area or structures like the MOHO or Person, Environment, Occupation models to help therapists help identify their unique contributions in this area of practice.
These gaps in the research are troubling because they signify a stagnation in the development of research and a focus on answering questions that have already been answered multiple times in the literature. Rather than agreeing that therapists are not appropriately involved in transition planning and conducting research that examines how therapists can provide better services in this area or proposing practice models that can inform present and future school-based practitioners, it appears that researchers are focused on identifying deficits and not building strengths in this area of practice.
In order to help further occupational therapy practice in this area, research should focus less on current occupational therapy practices in the area of transition planning, as this vein of research has led to the same conclusion in multiple geographic regions, schools, and time periods over the years. In order to move beyond these descriptive and explanatory studies, researchers should begin to identify specific strategies, modes of clinical reasoning, or interventions OTs can use (or are using) in transition planning to broaden the knowledge base for therapists in this practice area. Instead of focusing on why OTs are not involved, future research should develop methods for understanding more about how OTs are involved in successful transition planning, and begin developing a client-centered, occupation-based framework for practice in this area. For example, research could focus on describing methods by which therapists can begin to establish relationships with community employers, comparing and contrasting two transition models in a randomized controlled trial, or providing a comprehensive, up-to-date “transition practice toolkit” for therapists that includes the most recent evidence-based intervention options are all ideas for endeavors that would provide practical solutions to the most readily remedied barriers to OT practice in this area.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1). http://dx.doi.org.libproxy.lib.unc.edu/10.5014/ajot.2014.682006
Barnard-Brak, L., Schmidt, M., Wei, T., Hodges, T., & Robinson, E. L. (2013). Providing Postsecondary Transition Services to Youth with Disabilities: Results of a Pilot Program. Journal of Postsecondary Education and Disability, 26(2), 135–144.
Benz, M. R., Lindstrom, L., Unruh, D., & Waintrup, M. (2004). Sustaining Secondary Transition Programs in Local Schools. Remedial and Special Education, 25(1), 39–50. http://doi.org/10.1177/07419325040250010501
Beresford, B. (2004). On the road to nowhere? Young disabled people and transition. Child: Care, Health and Development, 30(6), 581–587. http://doi.org/10.1111/j.1365-2214.2004.00469.x
Clark, G. M. (1996). Transition planning assessment for secondary-level students with learning disabilities. Journal of Learning Disabilities, 29(1), 79–92.
Emery, L. J., Schneck, C. M., & Spencer, J. E. (2003). Occupational therapy in transitioning adolescents to post-secondary activities. American Journal of Occupational Therapy, 57(4), 435–441.
Kardos, M. R., & White, B. P. (2006). Evaluation Options for Secondary Transition Planning. The American Journal of Occupational Therapy, 60(3). Retrieved from http://search.proquest.com.libproxy.lib.unc.edu/docview/754138367?pq-origsite=summon
Kardos, M., & White, B. P. (2005). The Role of the School-Based Occupational Therapist in Secondary Education Transition Planning: A Pilot Survey Study. American Journal of Occupational Therapy, 59(2), 173–180. http://doi.org/10.5014/ajot.59.2.173
Mankey, T. A. (2011). Occupational Therapists’ Beliefs and Involvement with Secondary Transition Planning. Physical & Occupational Therapy in Pediatrics, 31(4), 345–358. http://doi.org/10.3109/01942638.2011.572582
Mellard, D. F., & Lancaster, P. E. (2003). Incorporating Adult Community Services in Students’ Transition Planning. Remedial and Special Education, 24(6), 359–368. http://doi.org/10.1177/07419325030240060701
National Secondary Transition Technical Assistance Center (2013). Age Appropriate Transition Assessment Toolkit Third Edition. University of North Carolina at Charlotte, A. R. Walker, L. J. Kortering, C. H. Fowler, D. Rowe, & L. Bethune.
Orentlicher, M. L., Demchick, B. B., Gibson, R. W., Persch, A. C., Case, D., Jackson-Pena, H., & Schoonover, J. (2014). Secrets From the Field: Secondary Transition Resources and Tips. Early Intervention & School Special Interest Section Quarterly / American Occupational Therapy Association, 21(3), 1–4.
Schutz, P. F. (2002). Transition from Secondary to Postsecondary Education for Students with Disabilities: an Exploration of the Phenomenon. Journal of College Reading & Learning, 33(1), 46–61.
Stewart, D., Stavness, C., King, G., Antle, B., & Law, M. (2006). A Critical Appraisal of Literature Reviews About the Transition to Adulthood for Youth with Disabilities. Physical & Occupational Therapy in Pediatrics, 26(4), 5–24. http://doi.org/10.1080/J006v26n04_02