Push-In Therapy: How To Make It Work, As Told by LLA Therapists

There seems to be this buzz around the notion of push-in therapy as of late. [Push-in therapy is also sometimes referred to as co-treating or co-teaching] I get the sense that districts, therapists, and teachers want to make it work, but it seems best laid plans sometimes fall flat for one reason or another. Why? Ultimately, I feel push-in therapy depends greatly on the types of students and the educational environment. But, that is just one opinion. I wanted to learn more about push-in services, so I decided to get together with some of my therapy friends at LLA for a focus group about push-in therapy. I shared our discussion below with the hope that you can find takeaways as a district, teacher, admin, or therapist about how to make push-in therapy work for your unique situation.

What is your greatest success with push-in therapy?

Physical Therapy

As often as I can I like to push in. In the preschool setting I can almost always spend at least ½ my session in the classroom because it is more play based. Working on ½ kneel –stand, squat-stands to put puzzles together, stack blocks picking them up off the floor, reaching out of base of support for toys from friends, reaching for their snack in various planes, transfers in/out of wheelchair to carpet time, jumping coordination with songs in circle time makes it so easy in preschool, and even kindergarten.
 

Occupational Therapy:

– My greatest success has been demonstrating strategies or techniques to teachers or aides that they then carryover and implement during classroom times.
– It is time-saving when you are working a larger caseload. It also allows you to provide intervention and awareness to students who may need a little extra support, but not necessarily full-blown therapy.
– It gives us the opportunity to support students in their natural environment, where the skills are most needed. Also, it gives the teacher another person to help struggling students complete activities in the classroom that they may otherwise not be able to without direct teacher intervention. Plus, it helps us catch things or provide tier 1 intervention to kids who we otherwise wouldn’t see.
– When teachers and paraprofessionals are empowered to utilize the strategies in the classroom when I am not there. It is so rewarding when a teacher pulls me into the classroom to watch the student because they are improving so much!
 

Speech Therapy:

I find the most success with teachers who really buy-in. If you are adding value to their lesson, that seems to be really empowering for the teacher to take it to the next level. Plus, I learn a ton from teachers– they are the smartest people I know. So, I find myself using a lot of their tools in my sessions as well.
 
 

What are your greatest barriers with push-in therapy?

Physical Therapy

Large gross motor goals aren’t always appropriate in the classroom, i.e., ball handling, skipping, or stairs.
 

Occupational Therapy:

– The environment and peers. The student must demonstrate good attention to task because they are in an environment with other students, and many visual and auditory distractions that may impact the quality of their work. Some of the students I work with feel embarrassed if their peers are observing them needing extra help with their work during class instruction.
– Scheduling, classroom distractions during sessions, as well as planning interventions. With your caseload duties and a teacher’s duties, it can be difficult to find time to connect to plan together.
– The misunderstanding of what therapists are there to do. Personally, I think teachers might believe we are evaluating their abilities, which is not at all the purpose. We need to build better relationships and trust to help teachers be more open to this model. Also, some teachers believe it is distracting, but I would argue after a few times, we can blend seamlessly into the classroom routines.
– The amount of school buildings I service, as well as amount of teachers I interact with within those buildings. It is hard to align schedules with everyone.
 

Speech Therapy:

Attention to task is a huge one. Sometimes it just takes everything for that child to even be sitting in the classroom amongst his or her peers. Add another adult, plus additional demands on that child that may be just a touch outside of their routine, and you can have a mess on your hands. Picking and choosing your spots for push-in, carefully, makes all the difference in the world.
 
 

What is the ideal environment for push-in therapy?

Physical Therapy:

A team of professionals that want to provide a team approach with a variety of interventions that maximize a student’s potential. Having teachers and staff who work with you to let you know optimal times to be with their students in their classroom. And I love when Occupational Therapy can work with PT to assist with transitions, upper extremity weight bearing and visual motor attention to and activity. Even Speech increases during gross motor activity and we will hear things they don’t. Fellow students who understand that their peer may need more help and they assist and motivate but aren’t distracted by that child’s needs. And the environment has equipment that supports the child whatever that might be: bench, mats, mobility devices, sensory tools.
 

Occupational Therapy:

– When the student is completing a specific occupation that matches their goals written on their IEP. For example, kids who have goals set to complete functional living skills (i.e. opening containers, using two hands, cleaning), then a lunchroom environment or cooking class is an ideal environment.
– During writing centers or ELA, Math and Art as they encompass the most fine motor, visual motor and perceptual skills.
– I think push-in services are much easier at the preschool – kindergarten age level when students are working more fluidly, learning many of the foundational skills. They are also less cognizant of another adult being there helping them. It can be done in any setting if done well, but it can get tricky in more formal lecture environments.
 

Speech Therapy:

Definitely a language-rich environment. A math class is not an ideal environment for push-In therapy. Reading difficulty and speech and language difficulty tend to go hand-in-hand. Reading intervention specialists are already doing great stuff. So, adding the SLP touch with some prompting techniques, graphic organizers, or drilling a particular piece of language in a specific way seems to be the best environment for push-in.

What class subjects have you had the most success pushing-in with?

Physical Therapy:

I love to work with kids during recess or during their physical education classes if my schedule allows! I find that with their peers around you can get everyone doing an activity, and they don’t even realize they are working. They move further, faster, and complete more reps when peers are pushing them and encouraging them or distracting them.    

Occupational Therapy

– In the multiple disabilities classroom the students’ schedules are flexible, and the teachers are more likely to work with me for carryover when I am not there because the class size is small.  In these classes I have worked with students during lunch, math, cooking class, and during their functional life skills class.   – Obviously as OTs we do a lot with fine motor skills. We have been able to work in general preschool and kindergarten classes for writing, and really any activity they do as it is often hands on. As the student gets older we have pushed into language arts, computer, typing, life skills, math, art, music. You name it; we have likely been there if we have a student struggling.   – One in which teachers or aides are working with students in small groups or assisting with individual work. The OT could lead a small group (2-3 students) in a classroom activity such as writing or a fine motor center. Providing push-in services during whole-class instruction periods can be challenging as it may be distracting to other students and draw further attention to the student who is receiving intervention.    

Speech Therapy:

– At the middle school level, where I spend most of my time, the best opportunities are in small group settings with reading intervention specialists. If a school has Read-180, that is a great class to push-in to.   – At the preschool, early elementary level, you can push-in to centers, hold a center, or engage in free play to work on language concepts and social skills.    

What is your favorite activity for push in therapy?

Physical Therapy

Getting kiddos out of their power wheelchairs and assisting them to run the bases in a kickball game is so motivational! I love helping those who are moderate to maximum assist to move, feel free to move in their environment, and do things they don’t typically get to do with the aides and teachers who may not feel as comfortable dancing, running, or walking with a more challenging and dependent body.    

Occupational Therapy:

– I have really enjoyed providing push-in services and leading small fine motor centers in intensive preschool classes. The teachers and aides are always intrigued as to what new activity I have created for the week, and are then inspired to try similar activities on their own, which is very beneficial to the students.   – At the middle school I am at the students run weekly café for teachers to purchase warm beverages. The café takes a lot of preparation. The students must set-up each cart with money, cups, tea, cocoa, coffee, water, sugar, and more. One of my students has a functional living goal and using two hands during tasks. For his therapy, we fill up the pitchers of coffee and water and fill up the hot cocoa bottles. Another one of my students required adaptations in order to be able to pour and serve the drinks due to ataxic movements in both arms. I worked with the team, and provided them with a set-up so that the student is now able to make drinks independently. The opportunities are endless to push-in therapy during the café!   – Currently, one of the therapy assistants works with a speech therapist in the district to do a monthly group within one of the resource rooms. The group provides a multi-disciplinary approach to support students building social skills with visual motor skills built into the activities.  I have also done push in with kindergarten classrooms where we run a visual motor/fine motor “station” for the teacher linked to a daily lesson.    

Speech Therapy:

– Splitting classrooms into teams to engage for cooperative learning. With their class material we do games for identifying the main idea, defining unknown vocabulary with context clues, or just general vocabulary acquisition: synonyms/antonyms, idioms, categories, etc.   – I know of a district that is doing a push-in therapy group lead by an SLP and a school counselor for social skills. Talk about two incredible professions putting their heads together to share resources. That sounds awesome and I would like to start something like that.  

What is a resource that you often share with teachers to make push-in therapy more effective?

Physical Therapy:

I am not sure I have one? I need one especially for some teachers that are more reluctant to allow the push-in model. I’d welcome any out there! Ultimately, I think we have to just keep planting the seed of how we can work together.    

Occupational Therapy:

I would say at this time, I educate teachers and administrators in verbal discussions, nothing in formal writing at this time.    

Speech Therapy:

I really enjoy using IXL.com with teachers. That is a great website that breaks down class subjects by grade and content standards. We pull the website up on the smartboard and the kids love engaging with it. Whether it be main idea, inferencing, or vocab, it is always a great 10 minute activity  to supplement what we are working on in the classroom.  

It is no secret that both teachers and therapists can be reluctant to do push-in therapy services. How do you think we can get folks on board?

Physical Therapy:

Preschool teachers and kindergarten classrooms are the most accommodating, and understandably. Once students get to 1st grade the demands are huge. That is when you begin to see a big difference between those we service, and their peers. As a result, the time they are able to spend in regular-ed classes decreases considerably. In those circumstances, there is usually a read aloud time where I can still get my more involved kiddos out of their adaptive seating, and sit on the floor behind them with their peers.  Some teachers think it’s a distraction, others embrace it. We just have to keep demonstrating moments when we can help maximize our kids’ chances to be in positions like their peers, and try not to take things personally. We also have to look at the big picture to make sure we aren’t adding unnecessary noise to the class.    

Occupational Therapy

– It is all about relationships and education. The teachers need to be able to trust us. Ultimately, they are responsible for what goes on in their classrooms, and they need to understand how we can support them. Relationship building takes time, but we have to keep opening that door and show them the benefits. We need to always be looking for those opportunities and jump in when we can until we build confidence around the push-in model. ​   – I have found the best way for teachers to get on board is to educate them and show them ideas in person. It is important to be able to show the interventions work or why they are successful to utilize within the classroom. ​    

Speech Therapy:

As a therapist, I think it can sometimes be a confidence thing. Teachers are so talented at engaging an entire classroom. I give them all the credit in the world. This shift to push-in therapy is relatively new, and historically as therapists we have been programmed to provide these super intensive 1:1, or small group sessions. So, to get in front of an entire class and another educational professional really takes some guts. For a therapist starting out I recommend only doing push-in services with areas you are the most confident with until your other skills develop further. Ask yourself the following questions: what is it as a therapist that you really do well? And, what do you understand the most in your discipline? It is likely you will have the most confidence in this area, and that confidence yields passion. Kids and teachers feed off of passion. With that confidence and that passion you will have so much more success getting your students and teachers to buy-in. That will allow you to really hone your craft with push-in therapy to allow you to achieve more success in other areas.