Students with emotional and behavioural dif ﬁ culties in Irish post-primary schools: a role for occupational therapy

Purpose – Higher levels of participation in school are linked to greater academic performance, better health and well-being and positive long-term outcomes for young people. Evidence shows that for students with emotional and behavioural dif ﬁ culties (EBD), participation in school-based occupations is often restricted in comparison to their peers. Given the recent advancements towards introducing a new model of school-based occupational therapy in Ireland, this paper aims to discuss how occupational therapy can support students with EBD to increase their participation within the post-primary school context. The opinions in this paper are derived from the authors ’ experience in the development of this practice in the Republic of Ireland. Design/methodology/approach – The authors reviewed current literature and re ﬂ ected on current practice to describe the unique role of occupational therapy in supporting students with EBD in the school environment. Findings – Occupational therapists have potential to play a key role in school-based support for students with EBD. The authors describe how occupational therapists can promote whole school understanding of EBD and enable skill development, self-regulation, participation and school belonging, among youths with EBD. There is a signi ﬁ cant lack of literature guiding practice in this area. Further research is required to explore professional issues and identify best practice. Originality/value – This paper aims to provoke consideration of how school-based occupational therapists can play a crucial role in supporting students with EBD who are otherwise at risk of occupational injustice.


Introduction
Emotional and behavioural difficulties (EBD) is a term used to describe students who experience increased levels of emotional, behaviour or social difficulties compared to their peers and therefore require additional educational support (Offerman et al., 2022).In 2012, 0.9% of school-going children in Ireland were in receipt of support for low incidence EBD (National Council for Special Education, 2012).In the academic year 2015-2016, approximately 19% of students accessing support from resource teachers had EBD (National Council for Special Education, 2017).EBD prevalence rates of 25% have been identified amongst children from socially disadvantaged backgrounds in Ireland (Cooper and Jacobs, 2011;Hyland et al., 2014).In the post-primary school context, emotional and behavioural difficulties may be communicated through high levels of internalising behaviours (e.g.feeling anxious, withdrawn, negative self-talk) and externalising behaviours (e. g. aggression, non-compliance) which often interfere with the student's educational development.These challenges can lead to students feeling disconnected, having difficulty establishing relationships (Porter and Ingram, 2021) and experiencing exclusion from school activity (Marczuk et al., 2014).In addition, with the increased likelihood of academic failure, these students are at great risk of school drop-out and increased vulnerability to occupational injustice (Marczuk et al., 2014) which occurs when a student is denied, excluded from or deprived of opportunity to pursue meaningful school-based occupations (Whiteford, 2000;Wilcock and Townsend, 2009).Through collaboration with school staff, occupational therapists can support these students to participate in school occupations, to acquire skills, achieve physical and mental health and develop the social networks that are fundamental to their transition to adulthood (Rodger and Ziviani, 2006).

School-based occupational therapy
School-based occupational therapy (SBOT) is recognised as an effective way of achieving positive student outcomes (Fitzgerald and MacCobb, 2017;Hutton, 2009;Missiuna et al., 2012).In 2016, the World Federation of Occupational Therapists released a publication on the practice area clearly stating that SBOT should be occupation based and educationally relevant, while supporting student well-being and promoting and maximising student participation (World Federation of Occupational Therapists, 2016).Internationally, studies have produced evidence-based frameworks and models for SBOT that have the potential to support students' school participation, through the implementation of multi-tiered, workload models of service delivery, that concentrate on collaboration in the school context (Bazyk and Arbesman, 2013;Chu, 2017;Hutton et al., 2016;Lynch et al., 2020;Ohl et al., 2013).In Canada, Missiuna et al. (2012) developed Partnering for Change, a multi-tiered schoolbased intervention designed to support the inclusion and participation of students with developmental coordination disorder through collaboration working, capacity building and knowledge sharing between therapists, educators and parents.In the UK, Hutton (2009) developed a local initiative to pilot a whole school inclusive approach to occupational therapy in primary schools across two school terms.The pilot effectively increased teachers' capacity to enhance participation of students but identified that more long-term time commitments were needed to embed this change.In the USA, Bazyk and Arbesman (2013) developed a mental health promotion and prevention public health model, "Every Moment Counts", where occupational therapists implement a multi-tiered approach to promoting positive student mental health.Their aim is to build the capacity of all adults serving youth and for parents to be mental health promoters.

School-based occupational therapy and students with EBD
Despite these advances, there remains a scarcity of literature documenting the role of SBOT supporting post-primary school students with EBD.Furthermore, students exhibiting behavioural difficulties in disadvantaged mainstream postprimary schools have not been identified as a priority group for occupational therapy intervention, evidenced by the lack of research in the area.A study in 2003 found that while the majority of occupational therapists supported school-based intervention for students with EBD, they made up only 10% of their caseload and 91% of these therapists selected "handwriting only" as the focus of intervention for these students (Barnes et al., 2003).Research suggests that occupational therapists do not have a clear understanding of their role in supporting student mental health and emotional behavioural difficulties in the school setting (Salamat et al., 2021).

History of the development of school-based occupational therapy with students with EBD in Ireland
In 2008, the National Behaviour Support Service (NBSS) was set up to promote positive behaviour for learning through the provision of a systematic continuum of support in schools, addressing students' social, emotional, academic and wellbeing needs.Through collaborative consultation and specifically designed interventions they provided support at three levels: Level 1: universal school-wide support for all students, Level 2: targeted support for some students and Level 3: intensive individualised support for few students.The service worked with 150 post-primary schools nationwide, the majority of which were located in communities of social disadvantage and designated a "Delivering Equality of Opportunity in Schools" status within the Irish education system (Fitzgerald and MacCobb, 2017).
In 2008, a partnership between the Department of Occupational Therapy, Trinity College Dublin, and the NBSS was established with a view to developing evidence-based occupational therapy interventions within the school support service.Initially the partnership involved a Level 3 pilot project implementing occupational therapy supports in two schools with 32 students aged 12-16 years, who presented with significant behavioural difficulties and were at risk of school exclusion (MacCobb, 2012).The aim of the service was to support the students to actively participate in learning and school life with the ultimate goal of experiencing success and self-efficacy in their role as student (Fitzgerald and MacCobb, 2017).Both school staff and students reported satisfaction with the outcomes, and as a result of the success of this the pilot project, the collaboration continued and the occupational therapists worked within the support service in the provision of multi-tiered support to the 150 schools nationwide (Fitzgerald and MacCobb, 2017).Core occupational therapy values such as client centredness and student voice and choice were applied in these post-primary schools (MacCobb, 2012) and the Person-Environment-Occupation Model (Law et al., 1996) provided a framework for better understanding the students' behaviour and needs.Skill building interventions in the areas of regulation, self-management and positive relationships were developed specifically for use within the context of social disadvantage and aligned with national educational policy (National Behaviour Support Service, 2015a, 2015b;Fitzgerald and MacCobb, 2017).Research directly relating to this practice was conducted, as a way of responding to and contributing to practice in this emerging area (Fitzgerald and MacCobb, 2017;MacCobb et al., 2014aMacCobb et al., , 2014b)).
In 2017, the NBSS alongside the "Special Education Support Service" and the "Visiting Teacher Service for Children who are Deaf/Hard of Hearing and Children who are Blind/Visually Impaired" transitioned to become part of the National Council for Special Education (NCSE).This amalgamation aimed to establish one unified support service that integrated the provision of special education support to students, schools and families and ultimately improve outcomes for children with special educational needs (National Council for Special Education, 2018a).A Programme for a Partnership Government (Government of Ireland, 2016) acknowledged that providing earlier access to speech and language therapy services could make a crucial difference to students' future, leading to the Department of Education funding the "Demonstration Project", focused on the provision of an in-school speech and language therapy service in the academic year 2018/2019.As a result of the positive outcomes and research evidence demonstrated by NBSS occupational therapists during the period of 2008-2017, the project was extended to include the provision of occupational therapy services.The NCSE in partnership with the health service executive developed and tested a tiered model for the delivery of therapy support across 150 early learning centres, primary, post-primary and special school settings (National Council for Special Education, 2018a).The Demonstration Project built upon the expertise of existing models of tiered supports such as those adopted by the National Educational Psychological Services, the NBSS and the Special Education Teaching Model.
This project demonstrated positive outcomes for students' inclusion, learning and participation (Lynch et al., 2020) and was sanctioned to continue for an additional term.The project remains in place to date of publication of this article.In the Comprehensive Review of the Special Needs Assistant Scheme (National Council for Special Education, 2018b), the NCSE commits to the development of regional support teams, inclusive of occupational therapists, to build school and teacher capacity through continuing professional development and inschool support.The first of these teams was established in 2020 and the nature and composition of the occupational therapy school support has been informed by the evaluation of the Demonstration Project.

Occupational therapy strategies and collaborative practice
The challenges presented by students with EBD are complex and providing effective intervention for this population is challenging (French, 2019).Occupational therapists can play a distinct role in working with schools to support the inclusion and participation of this student group.At the core of occupational therapy theory and practice is the premise that engagement in occupations plays a powerful role in establishing and maintaining positive health and well-being (Christiansen and Townsend, 2011;Hocking, 2013;Krupa et al., 2010).Through the application of occupational therapy theory to school-based practice, occupational therapists can work collaboratively with teachers to address barriers to students learning and participation.Occupational therapists unique understanding of the inter-relatedness between the person, their environment and their activities (Law et al., 1996) enables them to support schools to design environments and implement interventions that promote inclusion and participation of students with EBD in school-based occupations (Laverdure et al., 2017;Missiuna et al., 2012;Whiting, 2018).This focus aligns with the Irish education systems' shift away from impairment focused models of disability (Department of Education and Skills, 2017) and provides a shared language and framework to support these students (Anaby et al., 2014;Bonnard and Anaby, 2016;World Federation of Occupational Therapists, 2016).
Research highlights the importance of occupational therapyteacher collaboration for positive student outcomes (Lynch et al., 2020;Villeneuve and Shulha, 2012).This collaborative approach to supporting teachers working with students with EBD is essential as research shows that these students pose the greatest challenge to teachers' views of their own professional and personal competence (Kuronja et al., 2019).The following section provides examples of the supports educators and occupational therapists can implement collaboratively to support students with EBD in the school setting.The practices discussed below are drawn from the authors' experiences of delivering SBOT supports and are grounded in occupational theory.
Promoting whole staff understanding of EBD How EBD is defined and understood by school staff is central to the level of success achieved in supporting these students in schools (Goldberg, 2019;Saminathen et al., 2021).The behaviour of students is commonly perceived as within their conscious control, which ultimately impacts the attitudes, judgments and behaviour of those working directly with this student population (French, 2019).Cooper and Jacobs (2011) recommend that Irish schools are supported in adopting a biopsycho-social framework to support teachers' understanding of the within child and environmental factors contributing to the challenges of students.This framework aligns with the Person-Environment-Occupation Model (Law et al., 1996), which supports a holistic perspective of the biological, psychological, social and contextual factors that impact students' occupational performance and participation.Through the provision of psychoeducation and coaching in the classroom, SBOT can apply this model to enhance teachers' awareness of factors contributing to participatory and performance difficulties (Hui et al., 2016;Missiuna et al., 2012).This supports teachers to re-frame the behavioural challenges they encounter and implement supports to meet students' needs (Hui et al., 2016;State et al., 2019).

Student skill development
The National Council for Special Education (2012) recommends that a range of educational supports and skill development opportunities are available to students with EBD at school.Occupational therapists are uniquely skilled in occupational analysis, the process of analysing the complexity of an occupation, that is, what is required for full participation, the meaning for the person and the contextual factors of occupational participation (Thomas, 2015).This enables occupational therapists to work collaboratively with teachers to identify the physical, cognitive, psychological and interpersonal skills that are required for students' successful performance in school-based occupations (Missiuna et al., 2012).For example, students with EBD often experience organisational skill difficulties (Op den Kelder et al., 2018;Toglia and Berg, 2013).Their challenges in managing their time and belongings impact their ability to successfully participate in school-based occupations.Occupational therapists can work collaboratively with teachers to tailor learning environments, classroom routines and teaching methodology to support students' organisational skill development, for example, implementing cognitive and contextual strategies such as bag packing checklists, visual timetables, clear signage systems, colour coding school materials, allocating class time to record homework/plan assignments and the use of modelling and demonstration for task instructions.As demonstrated in research conducted by SBOT in Ireland, occupational therapists are well positioned to support post-primary school teachers to develop and embed evidence informed skill development interventions within the educational curriculum (MacCobb et al., 2014a(MacCobb et al., , 2014b)).

Regulation and participation
Self-regulation is an overwhelming challenge for students with EBD (Barnes et al., 2008;French, 2019;Perry, 2008) particularly as many of these students have a history of adverse childhood experiences (Center on the Developing Child at Harvard University, 2011;Felitti et al., 1998).These students' difficulties in regulating their arousal states can make attending and participating in classroom activities challenging and can often lead to the onset of the fight/flight response, presenting as disruptive behaviours (French, 2019;Perry, 2008).Occupational therapists with foundations in relationship-based practice and sensory integration (Ayres, 1971) can support teachers to develop their capacity to co-regulate and create more regulation friendly classrooms.For example, adapting the physical layout of the classroom and incorporating sensorimotor strategies (e.g.restorative activities, movement breaks, access to a quiet space) can support students to achieve and/or maintain an optimal state for learning (American Occupational Therapy Association, 2015; Whiting, 2018).Occupational therapists can use coaching as a tool to work in partnership with teachers to integrate specific regulation-based interventions into the post-primary school curriculum (MacCobb et al., 2014a(MacCobb et al., , 2014b;;McQuaid, 2018;National Behaviour Support Service, 2015a).A study by Hui et al. (2016) found that teachers who participated in a one-day self-regulation workshop followed by eight individual coaching sessions with an occupational therapist demonstrated clinically significant improvements in their perceptions of classroom management of students who presented with disruptive behaviours.

School belonging
Occupational therapists support people to achieve and maintain health and well-being by enabling them to do and to be, and through the process of becoming and belonging (Wilcock, 1999;Wilcock and Hocking, 2015).School-based initiatives that nurture a sense of belonging in school are positively associated with the retention of students who are at risk of dropping out of school (Vaz et al., 2014).MacCobb (2012, p. 62) states "enjoying and participating in doing, especially in a shared context of we-ness in the classroom can be intrinsically satisfying and motivational for continued engagement in school activities."Occupational therapists are skilled in identifying the adaptations required to establish a goodness of fit (Law et al., 1996) between students' differences in social-emotional development and the schools' social and academic environments (Robbins, 2001).This supports teachers to introduce activities that appeal to students' interests, promote relationships with peers and provide opportunities for positive reinforcement and success (Greenwood and Kelly, 2019) which are paramount to helping students to begin to experience the necessary sense of belonging, for example, involving students in school environment group projects (e.g.library redesign/setting up a calm corner) or facilitating occupation-based groups within the Junior Cycle Curriculum Framework (e.g.gardening or crafting groups).

Conclusion
Students with EBD experience lower participation in schoolbased occupations and thus face increased risks of academic failure and school drop-out.These occupational injustices can result in negative physical and psychosocial outcomes for at risk students and lead to involvement in antisocial behaviours (Kronenberg et al., 2005).Students' social and emotional skills are significant predictors of long-term outcomes in adulthood, with childhood emotional problems negatively impacting income, employment, social mobility and relationships (Goodman et al., 2011).Occupational therapists have a responsibility to support all learners presenting with schoolbased occupational challenges (World Federation of Occupational Therapists, 2016) as a matter of occupational justice.Occupational therapists, with their unique approach framed in the theory of occupation, can work collaboratively with school communities to create learning environments that promote the participation and inclusion of students with EBD.Given the profession's interest in health, well-being and inclusion, this is an important time for occupational therapists in Ireland to position themselves within school communities to work towards occupational justice for all students.
Irish post-primary schools Sh ona O'Donnell et al.Irish Journal of Occupational Therapy Volume 51 • Number 1 • 2023 • 14-20 The current issue and full text archive of this journal is available on Emerald Insight at: https://www.emerald.com/insight/2398-8819.htm Reilly, Katie Robinson, Eimer Ní Riain and Judith Pettigrew.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) license.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 license may be seen at http://creativecommons.org/licences/by/4.0/legalcode