Push In versus Pull Out in School Occupational Therapy

Introduction

In school occupational therapy, the delivery of services can be approached through two primary models: push-in and pull-out services. These models provide different ways of supporting students in achieving their therapy goals within the school environment. By understanding the characteristics and benefits of each model, occupational therapists can tailor their interventions to meet the specific needs of students effectively.

Many studies and articles in occupational therapy and special education have shown that working together and including students with disabilities in regular school settings is the most effective way to provide them with special education and related services. Despite this evidence, the research also reveals that occupational therapists in schools often use traditional methods for their interventions.¹  These methods involve one-on-one sessions focused on developing skills, which take place outside of regular classroom settings. The reason for this reliance on traditional methods instead of using collaborative and inclusive practices is often explained in the research as therapists facing challenges related to the structure of schools, personal factors, and professional obstacles they encounter in their work.

Inclusive services refer to support provided to a child in their natural environment, which is where they would be if they didn’t have a disability. In inclusive classrooms, children with disabilities have access to the regular education curriculum, spaces, and services alongside their non-disabled peers. In these settings, children with disabilities are placed in general classrooms in the same proportions as their non-disabled peers in the same grade level.

Collaboration is considered an important part of the occupational therapy process, involving shared problem identification, intervention decision-making, and a balanced partnership between therapists, educators, parents, and the children they serve. Inclusive and collaborative practices in schools involve occupational therapy practitioners engaging in general education settings, aligning with classroom routines, supporting teachers in catering to diverse learners, and providing coaching and assistance to develop strategies that address the social and academic needs of individual students with disabilities. These interventions are integrated into the everyday classroom structure through the collaborative efforts of educators and occupational therapists.

What is Push In?

Push-in services involve providing one-to-one support to a child within the general classroom setting. Therapists using the push-in model collaborate with the child during teacher-led activities and focus on tasks that are expected of all students at that time.²  For example, a therapist may schedule therapy services during math instruction to assist a child with aligning numbers on a worksheet, using counting tools, and improving visual perceptual math skills. In push-in services, therapists may also bring pre-planned therapy activities into the general classroom to work alongside the child on tasks unrelated to the ongoing teacher-led instruction. For instance, a therapist might enter the classroom and engage the child in a clothespin activity while other students are involved in small group work, independent reading, or other teacher-led activities. Therapists using the push-in approach may also offer services by consulting with classroom staff, observing a child’s performance, and providing support or instruction to the staff on behalf of the child.

By collaborating closely with classroom teachers and other educational professionals, the occupational therapist aims to integrate therapy seamlessly into the student’s daily academic routine. This model allows the therapist to observe firsthand the challenges that students may face in the classroom environment. Through push-in services, therapists can provide targeted support to individuals, small groups, or the entire class. By incorporating therapy goals into classroom activities and routines, students have the opportunity to generalize their skills in real-life situations. This seems good, so is this the best way to approach school OT?

Pull Out

The pull-out model is a conventional approach where therapists or other providers take a child out of the regular classroom to deliver services in a different space. In this model, services can be provided on a one-to-one basis or in small groups. This model allows for a more intensive and focused approach to address individual students’ specific needs. By working one-on-one or in small groups, the occupational therapist can provide specialized interventions and utilize specific tools or equipment tailored to the students’ requirements. Pull-out services can offer a dedicated environment free from classroom distractions, allowing students to concentrate on targeted therapy activities and build skills more intensively. These activities are tailored to address the specific impairments of individual children, and they typically wouldn’t align with the activities planned by a regular classroom teacher. It would be ineffective to try to incorporate such activities within the classroom setting.

Therefore, therapists find it more practical to implement these strategies in an alternative environment. Traditionally, therapists often prefer the pull-out delivery method when they utilize specialized activities that don’t fit well with the usual classroom routines.² 

Trends

Over the last ten years, there has been a growing movement to promote greater integration of students with IEPs into regular classrooms alongside their non-disabled peers. A similar case has been made for incorporating occupational therapy within the child’s classroom, allowing skills to be acquired in the environment where they will be applied. In terms of practice, occupational therapists traditionally performed pull-out for students in the school setting. There seems to be more of a shift in practice towards push-in for students to minimize the amount of time that the student spends away from their classroom.

Watt and Richards (2016) conducted a survey to study the patterns of school-based therapists to determine whether if more push-in or pull-out was used. Participants included OTs who worked in a large Western metropolitian area. Results found that among the 43 OTs and 2 OTAs, services were provided 39% of the time via pull out and 50% of the time within the education setting. They concluded that occupational therapy practitioners viewed push-in delivery as favorable, but they had their limitations as a primary model for school-based OT in Colorado.³ 

Theory and Real-World Practice

Sources

1. Clough, C. (2019). School-based occupational therapists’ service delivery decision-making: Perspectives on identity and roles. Journal of Occupational Therapy, Schools, & Early Intervention, 12(1), 51-67.↑
2. Benson, J. (2013). School-based occupational therapy practice: Perceptions and realities of current practice and the role of occupation. Journal of Occupational Therapy, Schools & Early Intervention, 6, 165–178. doi:10.1080/194112443.2013.811348↑↑
3. Watt, H., & Richards, L. G. (2016). Factors influencing occupational therapy practitioners’ use of push-in and pull-out service delivery models in the school system. The American Journal of Occupational Therapy, 70(4_Supplement_1), 7011510205p1-7011510205p1.↑