A Case Review: Reframing School-Based Practices Using a Critical Perspective

Abstract

It is well established in the literature that school-based practice is fraught with challenges such as acquisition of appropriate and sufficient resources, communication barriers among professionals, parental burden, and redundancies and gaps in services. The purpose of this perspective paper is to reframe potentially problematic school-based practices using a critical social science perspective, suggesting a vision and strategies for therapists working in school-based practice contexts. We illustrate our approach with a case example. To reframe school-based practices, we begin with Jill’s case, exploring it through a critical lens to identify potential issues and opportunities for change. We then trace these findings to our larger dataset from an ongoing program of research, to ensure relevance to the broader context of school-based practice. Reframing of three school-based practice issues are discussed, from: a) advocacy by proxy to collaborative dialogue, b) governing texts to guiding texts, and c) playing the “right” part to having a voice. Although this is a perspective paper based on a case exemplar, we posit how we may reframe and rethink school-based practices in pediatric rehabilitation. We suggest that only with a genuine shift in our professional values will we see the enactment of collaborative practice in school-based settings.

School-based practice is fraught with challenges such as acquisition of appropriate and sufficient resources, communication barriers among professionals, parental burden, and redundancies and gaps in services (Andrews, Mahoney, & The Canadian Paediatric Society, 2012; Bussing, Zima, Perwien, Belin, & Widawski, 1998; Deloitte and Touch LLP, 2010; McConnellogue, 2011; Mu & Royeen, 2004; Mukherjee, Lightfoot, & Sloper, 2000; Ng, Fernandez, Buckrell, & Gregory, 2010; Villeneuve & Shulha, 2012; Villeneuve, 2009).

The purpose of this perspective paper is to reframe school-based practice using a critical social science perspective to suggest a renewed vision and practical strategies for pediatric therapists working in the school-based practice context. This paper is relevant to occupational therapists, physical therapists, speech-language pathologists, audiologists, pediatricians, and others who interface with or work within schools. Practice models differ internationally, nationally, and provincially. The research that informed this critical perspective took place in a Canadian context, within a specific region in the province of Ontario. In the region of study, need for school-based services is determined through several different mechanisms depending on the need, and with some variability across the province and with ongoing change to systems and processes (Deloitte and Touche LLP, 2010). For students with speech or occupational therapy concerns, community care access centers may become involved and therapists/clinicians from these centers may have some opportunity to provide direct support and attend meetings at school. For students with language or learning concerns, speech-language pathologists and psychologists employed by school boards typically provide or oversee in-school assessment. For students with medical needs that require school support, nursing support may be provided within the school. For students with health needs that influence their experience at school (e.g. vision, hearing), written documentation from the health care professional is typically required in order to acquire support at school and this may include formal identification of a need, placement in a program, acquisition of technology, and development of an individual education plan. Finally, on occasion, some parents may seek private pay services such as a private practice psychologist in the community, in which case communication with the school typically occurs through written correspondence. We refer readers to Figure 1 to orient themselves to a standard format of a school meeting (to discuss an individual education plan: IEP) in the geographic region of our study. In this situated model of practice, clinical professionals such as community-based occupational therapists, physical therapists, and physicians, may not be able to attend school meetings because there are not always funding or scheduling systems to allow them to attend. At these meetings, there are often school-based health professionals in attendance (e.g. employed by the school board), but only the occasionally would there be a clinically-based professional in attendance. Therefore, clinical professionals are often represented by the documents they have generated in regard to the child’s needs.

FIGURE 1.

The IEP Meeting: Standard Protocol.

We have previously contextualized school-based practice challenges in relation to socio-cultural barriers (Ng et al., 2013a). One potential barrier, document-based communication, was identified as an area requiring further study (Cameron & Lart, 2003; Doyle, 2008; Ng et al., 2013a; Sloper, 2004). Given these concerns, we posit that current service-delivery practices may be sub-optimal to support children and families within the health-special education interface. In this paper, we will focus on document-based communication and its social and cultural influences within school-based practice. We will use a critical social science approach to inform a shift in perspective.

Critical social science perspectives allow us to “reframe” or “rethink” current practices by seeing everyday, taken-for-granted practices anew through deconstruction of social and institutional influences, illumination of power relationships, and initiation of social action (Crotty, 2007; Eakin, Roberston, Poland, Coburn, & Edwards, 1996; Simon, 1992). A critical perspective on school-based practice offers an opportunity to challenge current practices by rethinking how and why professionals engage with one another, engage with families, what expectations they develop of one another in these interactions, and how and why they adopt particular practices as acceptable. Further, a critical perspective implores us to question whether the responses to these what, how and why questions suggest a need or opportunity to change our practices, toward ever-improved ethical practice and social justice. We have identified the following aspects of school-based practice as opportunities for change: how clinicians interface with school personnel to advocate for support of children’s needs; what policies are in effect and how people work with these policies; and how families are involved in the processes of enabling appropriate support for their children.

We present this critical perspective through a case example, within the context of a larger dataset from an institutional ethnography investigating integrated systems and team working for children with disabilities in the health-special education context (Ng et al., 2013a), approved by institutional research ethics boards. We begin by describing the case (centering on a child, Jill) that exemplifies the challenges that pediatric therapists face at the clinic-school interface. This case was derived from a program of research shared by the authors (Ng & Lingard, 2014; Ng et al., 2013a; Ng et al., 2013b; Ng, Schryer, & Lingard, 2011), with identifying details modified to protect the child’s, family’s, and professionals’ privacy. To analyze the case, we reviewed the following documents: observational field notes from an individual education plan (IEP) meeting for Jill, her clinical and educational reports (occupational therapy reports, medical/nursing reports, school behavior and safety plans, audiology report), interview transcripts with Jill’s mother and special education teacher, relevant news media from the time period that we observed the IEP meeting (e.g. Wall Street Journal article on rethinking mental illness in children (Wang, 2012), the DSM-IV criteria for Jill’s diagnoses (Association, 2000), Community Care Access Center School Health Support Services policies (CCAC, 2006) and IEP guidelines (Ontario Ministry of Education, 2004)). Following the presentation of the case, we will propose three school-based practice issues that emerged from the data. For each of the issues, we will apply a critical social science perspective to reframe assumptions, analyze underlying structural barriers, socio-cultural influences, and identify opportunities for change (Crotty, 2007; Eakin et al., 1996; Simon, 1992).

Reframing the case through a critical perspective also required us to engage in critical reflexivity during the analysis process (Alvesson & Sköldberg, 2009). Critical reflexivity involves aspects of reflection, in addition to the act of questioning values, morals, and judgments in the context of one’s place/time in society, history, and culture (Bourdieu & Wacquant, 1992; Phelan, 2011; Sandywell, 1996; Taylor & White, 2000). We, the authors, have experience practicing in school settings. One of us practiced as an occupational therapist (SP) employed by the health sector and the other as an educational audiologist (SN) employed by the education sector. During all phases of the research, both authors engaged in regular critically reflexive (Bourdieu & Wacquant, 1992; Phelan, 2011; Sandywell, 1996) dialogue sessions about their practice experiences. This approach involved heightening sensitivity to preconceived professional and personal assumptions in school-based practice and to hidden influences shaping practice from both an insider and outsider lens.

PRESENTATION OF THE CASE

We now present the case of Jill (pseudonym), a 9-year old child attending grade 4 at her local public school. She has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), Anxiety Disorder, Sensory Processing Disorder (SPD), and urinary incontinence. Sensory Processing Disorder (SPD) is not an official diagnosis listed in the DSM-IV or newly released DSM-V. However, it is common for therapists to receive referrals for students with this label indicated on their health record.

Jill has been “acting up” at school, which served as the impetus for a string of communications between her parents and school-based professionals, and her parents and clinic-based professionals. We have chosen Jill as an exemplary case based on identification of the most prevalent concerns across the larger dataset, concerns that, through a critical perspective, merit reframing: a) clinicians’ advocacy was occurring through proxies; b) texts (policies, protocols, and guiding documents) were playing a strong role in shaping practice, often unbeknownst to clinicians; and c) parents were frequently attempting to learn and then enact the “right amount/type” of advocacy and involvement in order to be considered, by professionals, as “appropriately” concerned with their children’s educational support as it related to their children’s health needs.

Our introduction to Jill occurred when our research team was invited to observe a school meeting. The meeting was initiated as a result of clinical documents that had arrived at the school. At the meeting, sitting around the table with Jill’s mother, were professionals from the school: classroom teacher, educational assistant, special education resource teacher, itinerant behaviour teacher, and the school principal. In the middle of the table were documents from clinicians who were not present at the meeting (nor are they typically present): occupational therapist, nurse practitioner, pediatrician, and psychiatrist. The intent of the meeting was to develop and discuss a potential IEP (See Figure 1 for the standard IEP meeting protocol). Jill’s case was identified as an example of a common occurrence across the larger data set, as follows (Figure 2).

FIGURE 2.

The IEP Meeting: Process for Jill.

Jill’s mother, Frances, brought clinical documents to the meeting to help focus the conversation on whether Jill was receiving appropriate supports. Frances expressed frustration on this occasion, and also in her one-on-one interview, about the communication lapses and lack of clarity in her daughter’s school-based health supports. Everyone at the meeting assured Frances of their desire to help, and explained their current and planned strategies for doing so. Nevertheless, frustration was evident, which was not easily understood or resolved.

Frances’ frustrations included the need to shuttle documents around for her child, as expressed during her one-to-one interview:

Interviewer: Once you get this written document from the OT (occupational therapist), for example, you’re then able to do what with it?

Frances: Take it wherever I need it to go. I make triplicate copies. I have one in a folder just for myself all the time. I can give them to the school but it’s up to me to send them to the school. It’s up to me. … I’m the [expletive] pony express here […] I suck it all up, everything that is said, everything that is written [.…] Take it to wherever I need it to go.

She was also troubled that a label for her daughter’s challenges was required, but acknowledged that it was necessary in order to access supports. “I’m kind of torn as a parent because I also don’t want the label there and yet you can’t get any help without it there, nothing.” She wished there was a way for everyone to communicate, and felt the need to do her best to play the part of a “good” parent who helps the various health and education professionals work together, signing all necessary consent forms and making sure she develops a voice at the table as an involved, but not overly demanding, mother. In response to being asked to describe the work she does for her child, Frances described the complexity of managing her child’s care between two parallel systems:

Forms and keeping track of things and scheduling appointments and then managing that stuff in-between life stuff. For example, her occupational therapist will recommend a whole host of things…Here are some occupational therapy, for example, exercises and stuff like that. So I have to manage that. I’m an occupational therapist in our own home trying to do those things. And then she goes to school, so I try and get the school to do them. Well, that doesn’t fit into the school day. So then, I have to really advocate very loudly for the OT to meet with the school and give her the exercises. And then the teachers don’t want to implement them, so I have to argue about that.

Supporting Data

We were able to frame Jill’s specific case in the context of common processes from our dataset of health professional practice in the school-based context (Ng et al., 2013a). Specifically, the supplementary data were used to corroborate, expand, and deepen our understanding of the three school-based practice issues we explore in Jill’s case example. The data sources consisted of 37 participants, 27 of whom were interviewed, 15 observed, with 5 of these participants both interviewed and observed. The data collected included interviews with parents for children for whom an IEP was being discussed, interviews with a variety of health and education professionals, observations of school meetings, and documents provided by parents and professionals. Examples of these documents included documents similar to Jill’s documents described above: practitioner reports, school meeting minutes, assessment forms, and safety plans. In addition, we reviewed relevant policy documents, protocol documents, and news media that were pertinent to each participant’s experiences. These documents included IEP guidelines, DSM-IV diagnostic criteria, and local community health provision policies. These data had been analyzed for overarching work processes, with advocacy identified as a key theme. Health professionals were advocating by proxy, with parents and documents serving as the proxies. Health professionals were doing this in order to spotlight invisible disabilities and needs, and by navigating a largely unknown terrain of school-based practice (Ng et al., 2013b). Jill’s case was analyzed while tracing back to this larger dataset.

ANALYSIS: REFRAMING SCHOOL-BASED PRACTICE

Reframing Process

We next describe the process of analyzing Jill’s case through a critical social science approach. To reframe school-based practice, we began analysis with Jill’s case, identifying barriers and mediating strategies used in her school-based care and support. We then traced these findings to our larger dataset to ensure relevance to the broader context of school-based practice. Analysis proceeded iteratively in three main steps informed by established critical social science approaches (Campbell & Gregor, 2002; Smith, 2006). Are these your steps? If so provide rationale. If developed by someone else reference and relate to critical perspective

Step 1: Practice-level Analysis

We reviewed Jill’s local documents (e.g. clinical assessments, IEP meeting minutes, and clinical notes to schools). In this process, we (SP and SN) read the local documents individually, and then reconvened to discuss and expand analysis. We were able to identify problems, opportunities, and tensions in these documents.

Step 2: Policy-level Analysis

We looked at IEP, DSM-IV, and local community health provision policy documents for high-level coordination / hidden influences on practice (e.g. constraints on practices, expectations, and normative messages), tensions across policy documents, and synergies between the policy documents.

Step 3: Bridging Analysis

The last step was to integrate the local and the high-level analyses to illuminate how school-based practices may be influenced by social and political forces. This analytic step aims to identify opportunities to improve policies to better support, represent, and recognize local efforts. For example, we identified a lack of congruence between the designation of “sensory processing disorder” (SPD) by the occupational therapist and the absence of SPD as a disorder in the DSM.

FINDINGS: SCHOOL-BASED PRACTICE REFRAMED

Through our analysis, three school-based practice issues were identified and reframed using a critical social theory perspective. We direct readers to Table 1, for a summary of these issues and their reframings.

TABLE 1.

Three issues identified in our study of school-based practice, and three alternative practices proposed to help us re-frame school-based practice

Issue	Example of Issues in Practice	Alternative Practices	Example of Alternative Practices in Context
Advocacy by Proxy	A clinically-based occupational therapist conducts a common assessment for a child, named Jill, and identifies some sensory-related challenges and strategies to overcome them. The occupational therapist provides an assessment report and recommendations to Jill’s mother. The occupational therapist believes this documentation will help Jill’s mother access appropriate school-based support for Jill. Jill’s mother similarly believes that these documents carry some “weight” at the school in terms of advocating for Jill to be supported.	Collaborative Dialogue	The clinician also includes her office phone number and suggests the school or teacher can call her directly should they have any questions. The clinician also offers to the mother that, she could schedule a ten-minute phone conversation with the school’s principal or Jill’s teacher. The clinician knows that it will be difficult to catch the principal or teacher by phone; however, a conversation up-front may save much time in the future, because a merely written report can be interpreted in many different ways. There may also be observations about Jill that the principal and teacher may provide that could be discussed collaboratively.
Governing Texts	The Diagnostic and Statistical Manual (DSM) determines that Sensory Processing Disorder (SPD) is not a disorder to be diagnosed. Therefore, SPD is not granted official status that can be identified in this school district. However, Jill clearly has some sensory challenges, whether or not they constitute a disorder; she requires sensory strategies/supports. The DSM is thus governing the available supports for Jill. Jill’s mother and Jill’s occupational therapists are both aware of this governing effect of the DSM, and their hands are tied.	Guiding Texts	In the same community, a clinician has learned, through ongoing interaction with the school boards in her region, that sensory processing challenges are not well-supported because SPD does not exist in the DSM. She, therefore, foregrounds some of Jill’s other challenges in her report to the school, and highlights a number of strategies that will support Jill’s overall needs including her sensory needs.
Playing the ‘right’ part	Jill’s mother is very careful that when she advocates at the school, she is dressed in her best outfits, she is polite, and she is just the right amount of “strong” without being “pushy.” She does not feel like a member of the team; rather, she feels like she is coming into meetings on the “offensive” with the rest of the team being on the “defensive.” She feels this way because there have been many obstacles to accessing support for Jill over the years.	Having a voice	Starting fresh, the clinicians and educators involved in Jill’s care and education see Jill as an interested mother. They are critically reflective and while they notice Jill’s mother’s intense frustration, they also appreciate the history that has led up to this frustration. They listen intently and think open-mindedly about ways to support Jill now. Jill’s mother feels welcome at the school, as a core member of the team that aims to find the most appropriate ways to support Jill, given the system’s inherent limitations. Jill’s mother is aware of these systemic constraints, and is also aware that everyone at the table, including herself, is working together, to find what will work, for Jill.

1. From Advocacy by Proxy to Collaborative Dialogue

Some aspects of school-based practice can be described as occurring “by proxy.” That is, practitioners espouse advocacy and perform this work by creating written documents and expecting parents to do the direct advocacy work with other practitioners across systems (Ng et. al, 2013a). For example, our data showed that parents experience frustration when working as intermediaries between health professionals and educators:

I have pages and pages of notes recording her medical history, so I can pull it out and show it to anybody. Because everybody has those questions, but nobody will actually phone somebody and say can you send it. […] It’s a full time job managing her. I would like to work. I can’t. The schedule is too crazy […] just trying to get her what she needs, it’s a full time job. [Frances, Mother]

Existing literature demonstrating the burden and burnout associated with parental advocacy for children with disabilities corroborates Frances’ experience (Golden & Nageswaran, 2012; Rehm, Fisher, Fuentes-Afflick, & Chesla, 2013).

Because advocacy by proxy is potentially problematic, we propose a reframing of “advocacy by proxy” (Ng et al., 2013b) to “collaborative dialogue.” Such a reframing would serve two purposes: 1) It would enable us to acknowledge the possibilities and pitfalls associated with health professionals’ recommendations and processes of communication and advocacy via documents in the school context, and 2) Relative to advocacy by proxy, it may more effectively initiate and invite dialogue between and within professions. We also envision a shift, enabled by this reframing, from advocacy across sectors to advocacy between sectors, in partnership with the family, for the benefit of the child. For example, instead of having a parent bring a clinician’s report to school to ask the school for a resource (which may or may not be what the school personnel think is appropriate, or may or may not be within the school’s resources to provide), the parent would bring a note to school indicating the clinician is hoping to participate in a conversation about what resources might be applicable based on the child’s needs and the school context. In this subtle shift, we move from advocating for a specific resource to advocating for the child in context. If we acknowledge that advocacy by proxy is a by-product of systemic constraints, recognize the work of parents and reclaim some of the burden, we may begin to reframe school-based practice from advocacy by proxy to collaborative dialogue. This reframing to a collaborative dialogue approach would promote shared decision-making and continuity of care within the clinic-school interface, as opposed to the advocacy by proxy approach, which constrains health and education professionals to uni- and multi-disciplinary modes of practice (Boon, Verhoef, O’Hara, & Findlay, 2004).

2. From Governing Texts to Guiding Texts

The second reframing relates to the power and potential of texts (in this usage, we mean written documents). In the critical social science perspective we are using, governing texts refers to a “boss text,” meaning a text or set of texts that supplies the context for interpreting and perceiving the social situation. These texts frame and filter our perspective, much like the specific cropping or framing of a photograph, and much like application of different digital filters to the photograph, can change what we emphasize and notice about the content and meaning of the photograph. “There are subsidiary documents that come into being and are organized under these [boss] texts, which are positioned at the top of a hierarchy of texts” (Bisaillon, 2012, p. 610). For example, in this context, the DSM diagnostic criteria, IEPs, and professional reports are considered texts that hold power because they shape expectations for action, and at times, these texts organize action. A professional report arriving at a school may call into action a team of professionals to address the needs identified in the report. Texts also relate to and influence one another; i.e. the professional reports may draw upon the DSM to make a diagnosis.

The following conversation is as recalled by Frances when she was interviewed, explaining how Jill’s sensory issues impact her performance at school despite receiving an “official” diagnosis.

Parent: I [need] some written documentation.

Occupational Therapist: I’m not actually qualified to do that.

Parent: Well, that’s what you’ve been telling me for two years.

Occupational Therapist: I mean as an occupational therapist I can see that, but I’m not qualified to diagnose that.

Parent: Can you refer me to somebody who can?

Occupational Therapist: No.

Parent: Well why not?

Occupational Therapist: Well, because it’s not officially recognized in the DSM.[…] we’ll have a new edition coming out.

Parent: yeah, I know but I’ve already researched it and SPD is not going to be in there.

This interaction exemplifies the DSM as a governing text in school-based practice, a text that is seen to elicit resources.

The DSM has been described as a powerful governing text that can enable access to special education funding, access to government funded health services, prescription of medications, reimbursement from insurance companies, and shape how we think about disorders and disabilities (Wang, 2012). Yet, if health professionals recognize the potential power of texts such as the DSM–that texts can shape people’s practices and perspectives - and instead, use the texts to guide practice, health professionals may be empowered to work within systems and between systems in more effective ways. For example, by reframing governing texts to guiding texts, it may be possible to circumvent common paradoxes such as the one described previously by Frances: “I’m kind of torn as a parent because I […] don’t want the label there and yet you can’t get any help without it there, nothing.”

Acknowledging the role of texts, and carefully considering how to use and create texts, may allow professionals and families to use texts strategically rather than be constrained by them, thus re-positioning texts from governing to guiding forces. This possibility was apparent within the larger dataset, as there appear to be some practitioners who are able to work with texts strategically to accomplish their goals for supporting children’s needs at school. For example, Lucy, a physician, explains her approach to documentation:

It has to be worded in a way that allows the child to access the services, so if we know this behavior problem doesn’t carry the clout, you have to say, is it attention deficit, is it with hyperactivity, is it with learning disability, is it with social problems, is it with OCD (Obsessive Compulsive Disorder) tendencies. So put in as much information as possible that the teacher gets the whole framework, and not just, this child has behavior problems.

3. From Playing the “Right” Part to Having a Voice

This case and the larger dataset demonstrate that it can be challenging for parents to know how and how much to advocate, when, and to whom. Hence parents may strive to learn what “part” they should play in a given situation, and then strive to play that part well. Jill’s case demonstrates parents’ continual struggle to learn their “part” in clinic-school encounters, particularly if they end up being labeled as “difficult” or “high maintenance,” which is an occurrence that both professionals and parents acknowledge. As Frances said:

It’s just a constant back and forth. It’s very frustrating because you don’t want to be, you know. I don’t want to be a bitch, I don’t. I want everybody to be happy. I don’t want anybody to go oh, it’s that woman again. But at the same time, nobody would stick up for her [Jill] if I don’t.

Similarly, consider Mary, a mother in the supplementary data set, who made it a point to volunteer in her child’s school in hopes that if she did so, she would become more of an insider:

If I wasn’t the kind of parent that was in there and telling the teacher do you mind if I check this equipment. And, if she didn’t know me, because if I hadn’t already been volunteering in her classroom, why would she trust me with thousands of dollars of equipment? […] it needs to be more individualized because he is an individual and he’s the square peg with this round hole and the School Board is about round holes, and he doesn’t really fit any where […]

We attempt here to reframe from the parent being unintentionally silenced to having an important voice as a pivotal member of the school-based practice team. In rehabilitation, there is an espoused emphasis on family-centered practice, seeing families as experts in their child’s health needs and seeking their collaboration in decision-making (King, Teplicky, King, & Rosenbaum, 2004; MacKean, Thurston, & Scott, 2005). Our data has revealed in both Jill’s case and the larger dataset that, at times, health and education professionals may fall short of enacting family-centered care as a result of discursive and systemic forces that may be unbeknownst to them (Goldszmidt, Ng, Haddara, & Lingard, 2014; Ng & Lingard, 2014; Ng et al., 2013b). Parents are then, often unintentionally, placed in a position of negotiating their identity on a team in which they feel powerless and devalued. For example, parents strive to exhibit acceptable levels and ways of involvement in their child’s life. They often feel they must avoid backstage murmurings as they come in for meetings, be perceived as helpful and engaged but not as “a squeaky wheel.” These experiences contribute to parental stress (Blum, 2012; Deatrick, Knafl, & Walsh, 1988; Innocenti, Huh, & Boyce, 1992; McKeever & Miller, 2004; Smith, Oliver, & Innocenti, 2001). If we begin to accept parents as members of the team with a voice to be heard we must become aware of our own power as therapists and professionals. Thus, we become able to dissipate power imbalances and enact a genuine family-centered approach (Mortenson & Dyck, 2006). We suggest a reframing of school-based practice that, at present, often leads parents into having to identify and then play the “right” part depending on what their child needs. We suggest that a deliberate recognition of the knowledgeable position that parents occupy, and the personal, historical, and experiential context that shapes parents’ current perspective, may prevent us as practitioners from unintentionally silencing parents’ voices and enable us to include parents as valued members of the interdisciplinary team.

IMPLICATIONS FOR PRACTICE

We posit some implications for reframing and re-thinking school-based practice based on a critical social science perspective. Even when all parties have good intentions and espouse inter-professional collaboration, inter-system collaboration can pose an additional layer of challenges. We have revealed some of the hidden barriers inherent in inter-system collaboration, including those textually imposed (see Table 1 for a summary of examples).

One area in which change can be immediately and practically enacted relates to the documents used in school practice. Practitioners working with schools can become savvy in how they create documents if they are aware that documents are shaped by discourses and policies (e.g. DSM, special education funding, professional discourses, medical model) and understand their purpose, audience, and power. And, with realization that documents may be passed on beyond their immediately intended recipient, practitioners may write them in more accessible and collaborative ways. For example, it is worthwhile for us to appreciate that parents often describe how they rely on the power of documents and diagnoses, and also paradoxically, dread labeling their children. By understanding how parents may put weight on documents and wield them as sources of power when they feel otherwise powerless, practitioners may better support parents when providing these documents. For example, they may explain that the document is the starting point, but not a prescription or order. In order to do this, the practitioner would also need to understand that the recommendations within the document may be resisted by school personnel for a variety of reasons–and that some of these reasons may be valid and worth discussing

We realize that a common question that will arise is: Are any of these proposed alternative practices feasible or practical? In our current research, we have seen situated examples of each of these three alternative practices in use on a small scale. For example, consider the reframing of governing texts as guiding texts previously described by Lucy (physician) in relation to her approach to report writing and attention to language. In the academic and grey literature (e.g. practice guidelines, policy frameworks), there is movement towards these ideals. For example, Missiuna et al. (2012) have written about a Partnering 4 Change (P4C) model to shift school-based occupational therapy practice from a direct service delivery model to a collaborative, classroom-based model. The findings of qualitative study of seven occupational therapists’ experiences with the model suggested it may hold promise toward overcoming barriers to collaboration (Campbell, Missiuna, Rivard, & Pollock, 2012). Ideishi et al. (2010) have examined perspectives of therapists’ roles in care coordination between medical and early intervention services for children with special healthcare needs. The authors call for family-centered care perspectives and strategies to improve care coordination and integration across systems.

As an example at the policy-level in Canada, the Alberta government has published a policy framework premised on the following statement: “An integrated, cross-ministry system of supports and services can assist in optimizing the well-being of children and youth with special and complex needs” (Alberta Children and Youth Initiative, 2011, p.4). Such initiatives aim to reduce barriers to service delivery, enhance family-centered practice, ensure shared funding and a commitment that services would be provided regardless of traditional roles of ministries, institutions, and agencies. The impact of these and other models is still being determined; it will be interesting to learn which practical ways forward will help achieve a reframing of underlying values for school-based practice. We suggest that only with a genuine shift in professional values will there be enactment of collaborative, interprofessional, family-centered practice in school-based settings.

CONCLUSION

Through critical analyses, we identified three school-based practice issues: advocacy by proxy, governing texts, and parents playing the “right” part. Drawing upon critical social science, we re-framed these issues to offer potential alternative practices. These re-framings were: collaborative dialogue, guiding texts, and parents having a voice as team members.

This paper has implications for school-based practice; it raises awareness of the influence of social systems on practices, calls attention to potential unintended influences and consequences of practices, and presents an opportunity to renew and improve practices by “re-framing” perspectives through critical social science approaches.