Perceptions and practices of paediatric occupational therapists The challenges of implementing the national assessment of need (AON) process

Purpose – The purpose of this paper is to feedback the results of a survey of paediatric occupational therapists completed by the Paediatric Advisory Group (PAG) regarding perceptions and practices of the assessment of need (AON) process. This survey was completed to gather feedback from occupational therapists about the impact of the AON process on paediatric occupational therapy practice in Ireland. Design/methodology/approach – A questionnaire was developed by the authors, who were on the PAG committee, to specifically gather quantitative and qualitative information about the AON. A snowball sampling method was utilised. The results were grouped into themes related to the practices and recommendations from occupational therapists nationally. Findings – Surveys were returned from 98 paediatric occupational therapists with a wide national geographical spread with the majority working in the Health Service Executive (HSE). The amount of time spent on AON assessments, as well as the length of reports, varied nationally. The process of how assessments were completed (unidisciplinary or multidisciplinary) and whether a diagnosis was provided was inconsistent. Concerns were raised about the negative ethical impact of the AON on service provision and intervention and the need for further training of staff along with more frequent assessment reviews. The respondents also highlighted concerns about the increasing age of the AON criteria, with no increase in resources, and they provided suggestions for improvements for the future. Research limitations/implications – The survey was sent to all AOTI and PAG members via gatekeepers and then forwarded to others, resulting in a snowball sampling technique; however, this does not represent all paediatric occupational therapists nationally as membership in these groups is voluntary. Practical implications – The concerns and inequities raised in the survey regarding occupational therapy practices of completing the AON process need to be shared with relevant stakeholders both at the occupational therapy management level and in the HSE and Department of Health/Disability. The PAG will continue to highlight these concerns from their members to relevant parties and by disseminating findings in articles such as this. Social implications – Ethical concerns were raised by some members about the equity of access to interventions as a result of the AON process. The social implication of this for families and children is pertinent, particularly in the context of the increased age in the AON criteria without any increase in resources. Originality/value – The PAG aims to support paediatric occupational therapists nationally and the committee often gathers feedback from members regarding concerns which affect day-to-day practice in © Kate Murphy and Sarah Governey. Published in Irish Journal of Occupational Therapy. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/ licences/by/4.0/legalcode National assessment of need process


Introduction
Occupational therapists working in paediatrics aim to work with children with a variety of diagnoses to provide assessments, interventions and follow-up services (Case-Smith et al., 2000). The assessments utilised and format of assessment can vary as does the approach or frame of reference taken during assessment and interventions (Brown et al., 2005). In Ireland, the Disability Act (2005) dictates that children are entitled to an assessment of need (AON) if they meet certain criteria; however, anecdotally, members of the Paediatric Advisory Group (PAG) (a subcommittee of the Association of Occupational Therapists Ireland [AOTI]) have highlighted various concerns relating to this practice.
The PAG is a subcommittee of the AOTI which aims to encourage, promote, facilitate and support the advancement of the occupational therapy practice within the area of paediatrics. The PAG committee aims to advocate for and support occupational therapists working in paediatrics nationally by collating feedback to relevant stakeholders as necessary. To investigate how the AON is being utilised across Ireland, the PAG completed a survey with occupational therapists working in Ireland to gather feedback about current practice. The survey aimed to highlight how the AON is being completed by occupational therapists nationally and to highlight any discrepancies or concerns raised by occupational therapists working in paediatrics.
Background to the AON Under Part 2 of the Disability Act (Government of Ireland, 2005), children under five years (on 1 April 2007) with a disability are entitled to an independent assessment of their health and educational needs arising from their disability, an assessment report and a statement of the services they will receive. The AON is arranged by an independent assessment officer employed by the Health Service Executive (HSE). Following on from the assessment, a service statement is then drawn up by a liaison officer or case manager. There are also independent complaints and an appeals process for people who are dissatisfied with the assessment process. The Health Information and Quality Authority (HIQA) recently amended standards for the AON to stipulate that children born after the 1st of June 2002 are eligible to apply for an assessment.
Limited published feedback was identified about the experience of clinicians completing the AON; however, concerns regarding the efficacy of the process have been raised anecdotally. In 2011, the National Disability Authority (NDA) compiled a report along with the HSE (NDA, 2011) on the practice of the AON. The report aimed to describe the practice and understandings of clinicians completing the AON and to investigate parents' understandings, motivations and experiences of the AON process. The report highlighted a variation in the number of applications for the AON and the number of assessments completed within the statutory timeframes in different local health office areas (NDA, 2011).
The report found that the AON was being used to expedite special education assessments, and that diagnostic assessments were being completed to meet criteria for supports in health and education (NDA, 2011). The report also highlighted that areas with integrated early intervention services are better equipped to meet the demands of the AON, and comfort is increased with integrated/coordinated services, working with multidisciplinary teams and receiving on-going mentoring.
AON referrals tend to come from professionals rather than parents/guardians and can circumvent existing waiting lists for assessment, creating a two-tier system for entering services in some areas (NDA, 2011). The report highlighted a great deal of variation in how long assessors take to conduct an AON and many remain unclear as to what is required of them and have received very little guidance on the requirements of the Disability Act 2005. The report highlighted mainly positive parental experiences; however, this is related to whether or not their child received services or enhanced services after the AON process was completed (NDA, 2011). To improve the AON process, the report recommended legal clarity on the assessment process, further integration of early intervention and children's disability services, feedback for assessors with enhanced local management, resolving issues between the AON and resource allocation rules in the Department of Education and implementing smart working processes/systems to increase efficiencies (NDA, 2011). No follow-up research or documentation was identified from the NDA since this report.

Aim
The PAG considered it important to gain more insight into occupational therapists perceptions of completing the AON process with their client group. The purpose of the survey was to evaluate the level of understanding and knowledge that therapists have of the AON, as well as highlighting any concerns that are being faced in daily practice. The survey aimed to gather feedback from qualified occupational therapists who had experience using the AON. Participants who were not qualified occupational therapists or who had not administered the AON were excluded. The survey was distributed between September and December 2015 through email.

Method
Feedback from occupational therapists nationally was gathered through an online survey developed by the PAG committee, as no other appropriate questionnaire existed, and the questionnaire used by the NDA was not specific enough for the Occupational Therapy population. The survey aimed to help the PAG committee to gather further information from therapists in relation to their knowledge and experience of completing the AON and any concerns related to this area of practice. The survey consisted of 18 multiple-choice questions in total. Information was sought regarding how the AON process is carried out by occupational therapists in terms of the time involved with the AON and the value of the process. The questionnaire was designed to accumulate further information on the following areas of the AON: format of how the AON is completed, therapists' contact with other professionals involved with the child, the role it plays in diagnosis, the frequency of referrals and the impact it has on the other services provided (see survey questions Appendix 1).
The survey was initially piloted with committee members of the PAG who were familiar with the AON process in their practise. Survey questions were reviewed for content, clarity, organisation and understanding of the questions prior to its distribution. Following this, the survey was revised and adapted by incorporating recommendations made by the reviewers. The alterations involved rephrasing of questions and readjusting the sequence of the questions to allow for easier reading to the subjects. The survey was presented using an online survey tool (www.surveymonkey.com) for distribution purposes.
Background information was included in all emails which explained the purpose of the survey and the background of the PAG. All respondents were assured that their responses to the questionnaire were confidential, and the online results were stored in a password-protected account of the author of the online survey tool. Completion of the online survey implied the respondents' consent, responses were kept anonymous at all times, and respondents were made aware that their involvement in the study was entirely voluntary. Grady (2001) reported informed consent to be a process where respondents who are capable of making decisions are provided with sufficient information to promote a thorough understanding of the purpose, risks, benefits, alternatives and requirements and that they are aware of the voluntary nature of participation without coercion or undue influence. Because the AOTI and PAG membership are voluntary and both groups are supportive in nature aiming to support and advocate for occupational therapists, no ethical concerns were raised, and members were deemed low risk, for this reason, and the fact this did not constitute a research study, no ethical approval was obtained.
The email address of the committee member of the PAG group circulating the survey was included at the beginning of the survey for respondents if they wished to make contact, should they have any follow-up questions or concerns.
The survey was sent out to all AOTI and PAG members via gatekeepers to gather their feedback. All PAG members must also be members of AOTI; however, the AOTI membership does not represent all paediatric occupational therapists nationally, as joining the organisation is voluntary. Members of the AOTI and PAG received two reminder emails to complete the survey, and the participants were given a timeframe of approximately eight weeks to complete the online survey. A snowball sampling technique was utilised with PAG and AOTI members forwarding the survey to other paediatric occupational therapists who might be interested in participating also. Descriptive statistics were used to analyse the data with answers grouped.

Results
The survey was completed by 98 respondents (n = 98). In relation to the demographic data, the respondents represented a national geographic spread; however, a higher percentage were from Dublin North (16 per cent), Dublin South/Wicklow (20 per cent) and Cork (20 per cent) (see Figure 1).
The majority of participants who completed the survey were employed by the HSE (70 per cent) followed by voluntary organisations (18 per cent) and private practice (12 per cent) (see Figure 2).

Variety in practices and impact on intervention
The results highlighted variation in the amount of time spent on the AON, variety in the format the assessment took, whether a diagnosis was given or not, the length of reports provided and the impact of the AON on the ability to provide intervention. The majority of participants reported that the amount of direct time spent with clients was 1-4 hours, while the majority reported the indirect time spent to be 2-8 hours. This indicates that a typical AON can take a practitioner anything from 2 to 12 hours to complete the full process (see Table I). The results and comments highlighted that therapists often spend a lot of time on indirect contact with the client.
The format in which the AON is completed included: as a lone occupational therapist two or more occupational therapists, part of a multi-disciplinary team and as part of the early intervention team. The participants most commonly reported that they "always" or "frequently" liaise with other therapy disciplines, agencies or person's involved in the child's care. It is important to consider that this clearly requires extra time for the clinician to do.
A disparity was highlighted in terms of the role of the AON process with provision of diagnosis for children. Ten per cent of the occupational therapists reported that the AON is "always" used in the provision of diagnosis, 38 per cent stated "frequently", 17 per cent reporting "seldom" and 14 per cent said "never" (see Figure 3 below). There appears to be a disparity amongst occupational therapists as to whether they are competent or feel capable proving diagnoses such as developmental coordination disorder (DCD) to clients based on their AON and assessment. This feedback appeared to be mostly from occupational   National assessment of need process therapists working in primary care settings. Other examples from autism spectrum disorder teams suggested that providing a diagnosis as part of the AON process was more typical.
The length of the reports completed by occupational therapists for the AON varied between 1 and 10 pages, with the majority reporting 3-5 pages. The majority of occupational therapists reported that children required further occupational therapy assessments after the AON process. Many clinicians reported that children are then placed on the bottom of the Occupational Therapy waitlist for further assessment. The waiting time for further assessment varied hugely across the country. The majority reported that it can take eight months to two years, while 30 per cent reported that it would take less than six months.
The participants also highlighted that the AON process is impacting the level of service that they provide, with some commenting that referral for the AON assessment is the only way to access assessment in their areas and assessments or diagnoses are not available through direct referral. The impact of the volume of AONs was, therefore, reported to result in the inability to provide any intervention in some areas. With comments made including that there is: "less time for intervention with children who have been assessed as reports have to take priority, reducing time for therapy", "growing waitlists for intervention", "slows everything down, very confusing for parents", "children not part of AON process losing out" and "needs are identified but not met which is a huge shortcoming in the system". Furthermore, disparities were revealed for children who seek private assessments as they are then placed on a priority waiting list of 2-3 years. These inequities resulted in some ethical concerns being raised by occupational therapists who have difficulty completing "assessment only" and highlighting a need but then having to leave a child without intervention for up to three years in some areas.
Training, frequency of reviews and increasing age criteria Clinicians revealed that little training to complete AON assessments had been provided at both the local and national level. Only 25 per cent of clinicians reported receiving training on the AON process within their team/department with the majority stating that they had not received a copy of guidelines and how to refer to them and also were unaware of any guidelines and training available to them. Less than 20 per cent reported that they had received organised training from AON officers/teams or other external bodies. In terms of the feedback or mentoring received by occupational therapists in relation to the content and quality of the AON reports; the majority reported they never receive any from their managers, schools or the rest of the AON team.
In terms of reviews which are recommended in the Disability Act legislation, there was a huge variance nationally as to whether these are completed or not. Some clinicians reported being unaware that children are entitled to a review after 12 months under the AON. This appeared to vary geographically as to whether parents, school or practitioners were aware of this stipulation. The majority reported that they feel confident of their competency to complete all stages of the AON, including the assessment summary report and feedback. However, 25 per cent reported to only feeling "sometimes confident".
In light of the recent increase in age permitted to apply through the AON, many respondents reported that this is having a negative impact on their service with "increased demand on the service with no additional staff". In total, 97 per cent of the clinicians report that the increase in age for the AON criteria has led to no increase in services. Yet, the results indicate there is clearly an increased work load in terms of the numbers of AON applications received to a service, as well as the time involved completing a full AON.

Suggestions for improvement
Suggestions for how to improve the AON process were highlighted to include: "national template for reports", "liaison between AON officers and clinicians on monthly basis regarding AON referrals", "AON process is not useful for seeking a diagnosis and therefore specialist teams would be more beneficial", "assessment only is not fair or practical to parents", "increase in resources and staffing". Other respondents recommended establishing an AON committee and highlighted the shortfalls in the AON process, including no cover for sick leave of maternity leave for AON officers which results in a backlog in AONs being processed; however, this appears to vary across the country.
Some members questioned the cost of the AON and whether, in fact, the resources would be better suited to setting up a service for intervention rather than assessments.

Discussion and clinical implications
The results from this survey of paediatric occupational therapists in Ireland about the AON process highlighted various disparities in relation to the amount of time spent on assessments, the format in which they were completed, whether a diagnosis was given or not, the length of assessment reports and the impact on occupational therapy interventions. The results also suggest the need for improved training and frequency of reviews and raised concerns about the increasing age criteria with no increasing resources and provided some suggestions for improvements for the future.
A lack of consistency in the amount of time spent on AONs was highlighted, as well as variety in the format in which the AON assessment occurs. More time is spent on indirect client time required for the AON assessment rather than on direct client contact, and the AON process appears to impact on the ability to access intervention services. These results are similar to the report by the National Disability Authority (NDA, 2011) which highlighted that a diagnosis was provided for school resources, and that the AON can create a two-tiered system to circumvent local waiting lists for assessment. Feedback suggests, however, that this does not improve access to intervention, and many therapists commented on the negative and ethical concerns raised by the highlighted needs which cannot be adequately met with the current resources.
The importance of intervention strategies and methods was highlighted by Brown et al. (2005) during a comparison of paediatric occupational therapy practice between Canada and Australia which highlighted that, in both settings, interventions were completed in the areas of education, teaching and learning methods and training for activities of daily living/selfcare skills. In contrast, this survey highlighted that the AON process negatively impacts on the occupational therapists' ability to complete interventions with children due to lack of resources and occupational therapists highlighted concerns about the inequity of highlighting needs but not meeting them.
The results also identified a varied from area to area whether therapist and/or teams are providing a diagnosis as part of the AON process. This raises larger questions about the practice of occupational therapists providing diagnosis as part of paediatric occupational therapy practice. Bennett and Bennett (2000) highlighted that the occupational therapist's role is to identify deficits in performance components, occupational performance or role performance rather than traditional medical diagnosis or classifications. In contrast to this view, Missiuna et al. (2008) highlighted the important role of occupational therapists in recognising and facilitating the diagnosis of DCD. This discussion and debate requires further investigation both in Ireland and internationally.
Almost all of the occupational therapists reported a negative impact of the increased age criteria for the AON, with no extra resource allocations, and this appears to be having a knock-on effect on clinical intervention services. Some areas are reported to outsource AON assessments to private occupational therapists, while other areas do not, again creating inequities. Many areas are not completing review assessments under the AON process, and lots of disparities in access to intervention services after the AON process were raised. Despite training being recommended in the national "Standards for the assessment of need" document developed by the Board of the Interim Health Information Quality Authority (iHIQA) (HSE, 2007), only 25 per cent of the clinicians reported receiving training on the AON process. Many were also unaware of these guidelines and of any training available to them. These disparities and concerns raised by the PAG and AOTI members echo concerns raised in the last NDA report (NDA, 2011); however, with the increased demand on services and no increase in resources, waiting lists are continuing to grow as does pressure on therapists trying to provide an effective and equitable service. The PAG committee in its role as advocate for paediatric occupational therapists nationally have raised these concerns to the National occupational therapy Managers Group and have sent the findings to a representative from a HSE disability group to try and raise concerns and hopefully come up with suggestions for improvements.