What Are School-Based OT Practitioners’ Perceptions of Meaningful Occupations for Students in Middle School Special Education Programs? ()
1. Introduction
Meaningful occupations are those that hold value to a person and are ideally self-initiated resulting in a sense of autonomy (Fossey, Krupa, & Davidson, 2016; Hammell, 2004). Valued occupation of children is enhanced by purposeful, occupation-based interventions (Cahill & Beisbier, 2020). Occupational therapists recognize barriers that hinder students’ full participation in meaningful occupations and can guide students through engagement in these meaningful occupations (Shea & Giles, 2016). Meaningful activity differs between elementary and middle school students, yet practitioners continue to address foundational rather than occupation-based skills (Seruya & Ellen, 2015). The purpose of this study is to explore occupational therapy practitioners’ perceptions of what meaningful occupation is for middle school students with IEPs.
1.1. Theoretical Underpinnings
The Model of Human Occupation (MOHO) is a client-centered, occupation-focused model where the client is viewed as a unique individual. It asserts that competent interaction within one’s environment is a process of effective role performance (Kielhofner & Burke, 1980). The Person-Environment-Occupation Model (PEOM) places an emphasis on occupation rather than on performance components and posits that optimal occupation performance occurs when there is a “fit” between the person, the occupation, and the environment (Law et al., 1996). Combined, these two models are suitable for determining what a meaningful occupation is for a middle school student.
1.2. Meaningful Occupation and Youth
Therapeutic interventions based on student needs are purposeful and contribute to a sense of autonomy (Cahill & Beisbeir, 2020), but may not necessarily reflect what is meaningful to an adolescent. However, a modicum of insight into adolescent meaningful occupation is gained by a study in which adolescents with Autism Spectrum Disorder (ASD) were interviewed, indicating that physical activity in the form of Physical Education can be meaningful to some students (Arnell, Jerlinder, & Lundqvist, 2018). Further, participation in valued occupations of children is enhanced by activity- and occupation-based interventions (Cahill & Beisbier, 2020).
1.3. The Role of School-Based Occupational Therapy
School-based occupational therapy supports a student’s ability to participate in occupations (i.e. self-help skills, literacy skills, recess) in an educational setting (AOTA, 2016). Occupational therapy interventions can address areas which affect a student’s ability to engage in meaningful occupations whether it be elementary school or up to transitioning out of high school (Mankey, 2011; Rosner, Grasso, Scott-Cole, Villalobos, & Mulcahey, 2020). It is supportive of best practice to ensure that practitioners integrate meaningfulness into interventions.
2. Summary
Although current literature proposes which interventions are suitable for adolescents in middle school (Alley, 2018; Cook, Faulkner, & Howell, 2016), little evidence is available about which occupations are important to middle school students classified with an IEP. A study about meaningful occupation for elementary students did not include middle schoolers (Yokoi, Kurasawa, Utsumi, & Miyai, 2020). Studies conducted outside of the profession lack therapeutic perspective as they attempt to discover meaning in academic success from middle schoolers’ perspectives (Alley, 2018). Further, studies that were conducted from an OT perspective primarily showcase elementary level data or post-secondary transition data, thus leaving a gap at the middle school level (Christner, 2015; Giordanella et al., 2015; Shea & Giles, 2016; Rosner et al., 2020). Other sources, while comprehensive regarding occupation and participation, applies this to youth ages 5 - 21 years in broad terms (hospitals, outpatient, homecare, school) with more emphasis on interventions (Cahill & Beisbier, 2020). The lack of an accurate depiction of meaningful occupation for students with disabilities in middle school leaves a gap in professional knowledge and therefore practice. The question remains as to whether evidence-based practice is being impeded at the middle school level since there is limited scholarship supporting what constitutes meaningful occupation for middle school students with IEPs.
3. Method
3.1. Research Approach
A qualitative, phenomenological approach was employed in this study. The research question was, “What are school-based OT practitioners’ perceptions of meaningful occupations for students in middle school special education programs?” Qualitative methodology was the appropriate choice for in-depth exploration of participants’ perceptions. The method of phenomenology was suitable for this study due to its nature of interactive dialogue and in-depth conversation. Meanings were attached to the data and the outcome of the analysis was a theoretical statement.
3.2. Recruitment
The study population was comprised of occupational therapy practitioners who work with middle school students that are enrolled in special education programs. The geographical location from which the practitioners were recruited was in the northeastern region of the United States. Recruitment postings on social media occupational therapy forums (Facebook, Twitter) were unsuccessful in garnering volunteers. Snowball sampling at a Long Island school-based therapy agency was used as a primary source of recruitment. Thirty requests for volunteers were emailed with permission that included the contact information of the researcher. One follow-up request was sent to those who had not responded within ten days of initially indicating interest. Ten volunteers responded to the request and participated. All ten volunteers digitally signed consent forms prior to being interviewed. To be eligible for inclusion in this study, participants needed to be currently working in middle schools for the last five years in an effort to keep current with trends among adolescents and working with students who have Individualized Educational Plans (IEP). The interview of one participant had to be excluded from the study as the practitioner had only worked in the middle school setting for two years. The remaining nine interviews were included in the study.
3.3. Data Collection Method
Data collection occurred through phone interviews and video conference interviews using the Zoom platform. Interviews were digitally recorded. For those interviews using video conferencing, two live stream capable recording devices such Zoom on a laptop running Windows 10 and an iPad or smartphone were used simultaneously. For phone interviews, a voice record application was used only. Permission from participants was granted for recording interviews. Audio recordings were uploaded to the transcription service Otterai. When using the Zoom platform, the “audio_only.m4a” files portion were uploaded to Otterai and transcribed. Semi-structured, specific interview questions were developed from the literature review. An open-ended question at the end of each interview allowed for contextual feedback and solicited additional information about meaningful activity for adolescents in middle school. Each interview lasted between 20 and 45 minutes.
3.4. Data Analysis Method
The data was verbatim interview transcriptions. The interviews were conducted in October 2020. The responses to the interview questions were transcribed as previously stated. These transcripts were then thematically coded by hand and by using computer qualitative data analysis. Microsoft Word and Microsoft Exel were used for transcription analysis, coding, and text interpretation. Open coding was used to read through the data and create preliminary labels for coding. Axial coding was then used to identify relationships among codes for theme development. Thematic material was identified and organized into comprehensive categories through employing inductive and deductive reasoning. All interview data were read and coded twice to ensure consistency.
3.5. IRB Approval
The recruitment process began upon receiving approval for the study from the Institutional Review Board (IRB) at Quinnipiac University in Hamden, CT. The proposal was submitted on September 28, 2020. The study was given IRB approval (#11130) which was obtained on September 29, 2020 by the Human Experimentation Committee/Institutional Review Board (appendix). Revisions of the IRB after the initial submission were not required and therefore were not submitted.
4. Results
The results from the data analysis are presented according to the themes that emerged. In addition, comments from the practitioners are included to support the thematic clusters about the perceptions of meaningful activity for adolescents in middle school. The interview participants identified what they perceived as meaningful activity for middle-school students with IEPs. For the sake of consistency, interview participants are referred to as “practitioners”. Three major themes emerged from the interview data; a) purposeful activity correlates with meaningful activity; b) there are hindrances to engagement in meaningful activity; c) certain supports need to be in place for classified students to have access to meaningful activity. The repetitive nature of some of the text in the results section allowed for data saturation to be reached. Overlapping themes supported by practitioners’ quotes enabled triangulation of the data.
4.1. Demographic Information
A total of 10 occupational therapy practitioners were interviewed, however the data from only 9 interviews fit the inclusion criteria. In this case, the practitioner had had only two years of experience rather than at least five. All practitioners worked in public middle schools across Long Island in middle class, suburban communities. Years of experience working in this setting ranged from 5 - 25 years.
4.2. Purposeful Activity Correlates with Meaningful Activity
Practitioners reported that when students are given options to choose an activity during a free period, there are some similarities in activity preference between classified students with an IEP and those who are not classified. Clubs, sports, crafts, and video games were frequently identified as extracurricular activities that middle schoolers seek out regardless of IEP classification or not. Practitioners indicated that students are more likely to engage in intervention activities when their feedback about preferred activities is taken into consideration. While the practitioners involved in this study expressed that they do not allow free rein during intervention sessions, they provide their students with activity choices based upon what the students report as preferred activity. One topic that was consistently expressed amongst practitioners was that socialization is important to students (regardless of IEP status) and that when incorporated into intervention activities, it will result in increased engagement during an intervention activity.
“They function as regular teenagers. They enjoy sports [and]…of course the video games, …they enjoy all the same things as general ed kids. [They] are just like your regular teenagers…they care about how they dress and social interaction…” (Interviewee A, personal communication, November 22, 2020).
“…it’s engaging in those extracurricular activities. They sometimes need to be pushed to participate. Some students who are not interested in clubs or sports will often seek out the library.” (Interviewee B, personal communication, October 9, 2020).
“Being part of the group is meaningful to kids that age.” (Interviewee C, personal communication, October 15, 2020).
“They like to socialize. That’s something they definitely do when there are no demands placed on them, no matter what setting they’re in… The more impaired student [wants] to socialize just as much as a typical student.” (Interviewee B, personal communication, October 9, 2020).
“…We need to [be] integrating them a little bit more… they all need to be at the same [lunch] table, interacting the same whether it’s life skills or general [education] kids… It’s the same thing for walking in the hallways.” (Interviewee A, personal communication, November 22, 2020).
4.3. There Are Hindrances to Engagement in Meaningful Activity
Practitioners reported issues that interfere with a classified student’s ability to engage in meaningful activities during the school day. Some of the supports that are in place to assist students throughout the day tend to unintentionally limit them. Hindrances such as a 1:1 aide and having IEP goals that focus primarily on foundational skills hold students back from engaging in activities that are meaningful to them. Motivation to engage in something meaningful begins to ebb. The idea that an IEP mandate of having a 1:1 aide is a hindrance to engagement in socialization surfaced several times throughout the interviews.
“Unfortunately, I think some of them don’t even seek out that socialization as much, as they’re so used to being socialized [and would] rather hang out with an adult.” (Interviewee D, personal communication, October 9, 2020).
“…socialization will be with that aide. They’ll talk to that aide all day. Some of them won’t speak to other students as much. That’s what I’ve seen.” (Interviewee A, personal communication, November 22, 2020).
Goals that address foundational skills rather than occupation-based skills were identified as obstacles to engagement in meaningful activity during intervention sessions. Practitioners indicated that goals addressing foundational skills (handwriting, scissor skills, dressing, fine motor, visual motor, and perceptual skills) are more suitable for elementary students yet continue to be used for middle school students. This limits practitioners in choosing more occupation-based activities which would be meaningful to each individual student whether it is increased participation in social activities with peers or the ability to become an independent problem-solver.
“How much longer do I work on their name? By middle school you really should have those skills… I feel like my kids [have] plateaued at letter formation... [that’s] what hinders them by the time they get to middle school.” (Interviewee D, personal communication, October 9, 2020).
“The feedback I get from kids about handwriting goals, is that it’s boring.” (Interviewee E, personal communication, October 9, 2020).
The use of pre-fabricated goals from goal banks of IEP generating programs was also identified as a limiting factor in fostering meaningful experiences during intervention sessions. Most practitioners interviewed reported that they feel pressured to pick goals from goal banks rather than create their own custom goals. For those who are able to create custom goals, input from the student resulted in a more meaningful intervention experience.
“I would probably create a goal focusing around something functional… That’s something that they would be more willing to participate in than a handwriting goal.” (Interviewee E, personal communication, October 9, 2020).
“I still use the numbers on the goal bank… I feel like I need to have that number.” (Interviewee F, personal communication, October 13, 2020).
“I [include] them and I will tell them, ‘Okay this is your goal and this is where we have to be by the end of the year.’ I really want that buy-in for them to be intrinsically motivated to work.” (Interviewee D, personal communication, October 9, 2020).
4.4. Certain Supports Need to Be in Place for Classified Students to Have Access to Meaningful Activity
Practitioners identified supports that facilitate student involvement in daily school life. This involvement appears to lead to increased socialization with peers or engagement in sports or clubs. In some instances, practitioners reported that some of the hindrances, as mentioned above (1:1 aide, in particular), were also supportive in accessing meaningful activities within the school environment (as is their intended purpose). A well-trained aide is aware of when to intervene and when to withdraw. Other supports that were mentioned were allowing students to use a buddy system when attending clubs or group events to facilitate socialization or collaborating with teachers and family to identify student preferences and needs outside of the intervention session.
“Depending on the aide, you could have a very supportive aide who knows when to back off and give the students free rein to explore friendships and interactions. And socialization is obviously meaningful to a student at that age.” (Interviewee B, personal communication, October 9, 2020).
“A student that has lots of support will be able to engage in more activities than those who do not have the same level of support… Parents need to be involved to help their children engage in more extracurricular activities.” (Interviewee G, personal communication, October 9, 2020).
“If…they’re in a club, it may help to have a friend with them. Sometimes assistive technology is a support that needs to be in place for them to communicate and express their needs and wants.” (Interviewee B, personal communication, October 9, 2020).
5. Discussion
5.1. Interpretation of Results
This study aimed to develop a deeper understanding into what activities middle school students with IEPs find meaningful. Practitioners’ perceptions provided insight into the daily school lives of their students beyond the confines of an intervention session. Overall, the findings revealed practitioners believed that students with IEPs frequently seek out the same activities as their non-classified peers. Further, there may be barriers in place that unintentionally impede access to such activities. OTPs are well-equipped to help their students develop the skills needed in order to access those meaningful activities.
When asked about socialization and its degree of importance to students in this age group, practitioners consistently revealed that socializing is equally important to students with a disability classification as it is to those without. The most striking difference between the two groups of students is that students that are classified hold back in social situations for a variety of reasons. Such reasons range from being shy to not having had the opportunity to practice age-appropriate socialization with peers due to interaction with only adults throughout the school day. Practitioners often made a point in saying that students in special education are just as aware of the latest trends in fashion, social media, and fads as students in general education and express a desire to involve themselves in that social network. They have as much desire to participate in clubs, sports, and extra-curricular activities as students in general education but often have not fully developed the necessary social or physical skills needed to participate. Behaviors associated with depression were identified as a barrier for some students that feeds into a cycle of wanting to participate in an activity but holding back and slipping into the role of observer rather than participant.
As stated in the results section, some of the IEP supports that are put into place to help a student throughout the day can often have the reverse effect. Sometimes, there is too much support from teachers and staff thus limiting the student in terms of opportunities for socialization and independence. Access to some activities may be impeded if the student may not participate without an aide due to concerns with IEP compliance. In addition, practitioners feel restricted by goals which are more suitable for students in elementary school. Practitioners that participated in this research noted that students have less motivation to engage during intervention sessions when elementary school goals limit working on more appropriate age and grade level meaningful tasks.
5.2. Relationship to Prior Literature
A comprehensive list of Practice Guidelines (Cahill & Beisbier, 2020) developed through a systematic review of current literature categorizes specific interventions according to evidence that these interventions improve outcomes. While this is expansive and in-depth, the range of practice areas for youth ages 5 - 21 addressed is broad and not necessarily focused on middle school students. Furthermore, there is little discussion to support that such interventions hold value to adolescents. Research from outside of the OT profession studied what motivates general education middle schoolers academically (Alley, 2018). As previously mentioned, one study specifically examined Autism Spectrum Disorder (ASD) in this age group to determine what improves motivation and participation in physical activity (Arnell et al., 2018). This supports that middle school students with IEPs are not only aware of the trends and interest of their peers but they want to engage in similar activities-making them meaningful and thus may increase motivation. The practitioners that participated in this study presented clear barriers to achieving this meaningful participation that give rise to implications for practice.
5.3. Implications for Practice
Based upon the data from the literature and practice documents, it appears as though there should be increased collaboration between practitioners and school personnel (teachers, paraprofessional teachers, administrators). This would allow IEP goals to be adapted in the transition year to the middle school. Involving family members should also be considered as they play a vital role on the IEP team. Their support could be the determining factor for participation in extracurricular activities such as clubs or sports. When considering extracurricular activities, it is worth noting that practitioners are well-positioned to work with the advisors/coaches to learn what barriers may be interfering with a student’s ability to participate. Intervention sessions could address these barriers.
Drawing again from the interview data, practitioners stated that students should have some input into their goals once in middle school. Depending on the functional level of the student, practitioners should consider including their students in the goal planning process thus empowering them to take a more active role prior to age 14. Most practitioners that participated in this study indicated that they integrate students’ preferred activities during intervention sessions and it is worthy to note that including students in this process provides an incentive to work.
5.4. Limitations
A limitation of this study was sample size. A total of 10 interviews were conducted but one had to be eliminated simply because of the inclusion criteria. However, the information expressed during this eliminated interview was comparably insightful to the responses given by those who met the inclusion criteria resulting in the elimination of potentially useful information. Another limitation was that during the period when interviews were being conducted, COVID-19 restrictions didn’t allow for in-person interviews which may have contributed to a small number of participants.
5.5. Recommendations for Further Research
The findings of this research broaden the understanding as to what is meaningful to adolescents in middle school with IEPs. Further research is needed to determine if special education programs should begin to address occupation-based skills in the grades leading up to middle school. This could potentially reduce the amount of time students need to acclimate to the demands of middle school making it more likely for them to meaningfully engage with their new environment. Additionally, future studies should examine what role OTPs could play in advocating for the students on their caseloads in terms of inclusiveness within the school setting. Lastly, more research is needed in determining how behaviors associated with depression in this population affect the likelihood of engagement in meaningful activity in all aspects of student life.