Inclusive education policies in Portugal: implications for the practice of occupational therapists

Abstract

This essay aims to analyze the implications of the current value framework and inclusive education policies in Portugal for the practice of occupational therapists. Taking as starting point the need for a practice guided by the biopsychosocial model, a multitier model of services delivery, and the universal design for learning, we discuss reconfigurations needed for occupational therapists’ practice within the educational context. In such reflections, we oppose the established rehabilitation practices, which are individual (in resource rooms) and remedial, to the need of expanding occupational therapists’ actions towards environmental qualification, intervention in and with the school community, and preventive-oriented responses directed to the school as a whole. From these vectors of expansion, we highlight the need for structured approaches to collaborative work, participation-oriented assessment and intervention models, and preventive programs to promote successful participation in the entire school community.

Keywords:
Education; Inclusion; Occupational Therapy

Resumo

Este ensaio teórico pretende analisar implicações do atual quadro de valores e da política de educação inclusiva em Portugal para a prática dos terapeutas ocupacionais. Tendo como ponto de partida o imperativo de uma prática guiada pelo modelo biopsicossocial, pela abordagem multinível e pelo desenho universal para a aprendizagem, discutem-se as reconfigurações necessárias à prática dos terapeutas ocupacionais no contexto educativo. Assim, contrapõem-se as práticas estabelecidas de reabilitação, individuais (em sala de apoio) e remediativas, com a necessidade de expandir a ação dos terapeutas ocupacionais para a habilitação ambiental, para uma intervenção na e com a comunidade escolar e para respostas preventivas que abarquem a escola como um todo. Perante esses eixos de expansão, propõe-se a necessidade de incorporar na prática dos terapeutas ocupacionais abordagens estruturadas de trabalho colaborativo, modelos de avaliação e intervenção orientados para a participação e programas preventivos para a promoção da participação e sucesso de toda a comunidade escolar.

Palavras-chave:
Educação; Inclusão; Terapia Ocupacional

Introduction

In recent decades, significant developments have occurred in Portugal in the design of inclusive education policies. These developments have been marked by a progressive move towards a unified system of educational services, bringing a more effective presence of a diverse range of professionals into the school community (Portugal, 2024). As a result, the establishment of educational teams has been reinforced, comprising, among other professionals (e.g., teachers, special education teachers, psychologists, physical therapists, speech therapists), occupational therapists.

In the school community, the practice of occupational therapists is framed by a rationale of action that differs from that used in other contexts, such as hospital and clinical settings, placing their intervention at the service of a common goal: transforming the school to support the participation and inclusion of all students (World Federation of Occupational Therapists, 2016).

The philosophy and values of inclusive education cast a different light on occupational therapy, giving rise to a distinct branch of knowledge—School-Based Occupation Therapy (SBOT)—that adds new competencies and lines of action to the occupational therapist’s profile. In the Position Statement of the World Federation of Occupational Therapists (WFOT), SBOT principles for inclusion are defined as a practice based on occupation, collaboration, and context, with educational relevance (World Federation of Occupational Therapists, 2016).

Although these principles are broad in scope, their transfer to practice requires adaptation to the political and social circumstances of each reality, specifically in how inclusive education is understood and pragmatized. In the European context, despite fundamental discrepancies in the way policies and practices are organized due to each country’s history and context, there is relative consensus across jurisdictions regarding what defines inclusive education systems (European Agency for Special Needs and Inclusive Education, 2015, p. 1): “[…] inclusive education systems aim to ensure that all learners of any age are provided with meaningful, high-quality, educational opportunities in their local community, alongside their friends and peers”. This objective has led to the analysis and projection of policies based on indicators of students’ access, participation, and progress. It is within this general understanding of inclusive education that we will discuss the practice of occupational therapists in the light of inclusive education policies in the Portuguese context.

Inclusive Education Policy in Portugal

As in other countries, political initiatives for inclusion in Portugal are strongly rooted in special education, a movement associated with and established by the Salamanca Statement (United Nations Educational, Scientific and Cultural Organization, 1994). It was for children with disabilities that, in the 1970s, specialized teams began to be established within mainstream schools, responsible for identifying and implementing specialized supports. Today, nearly all children and young people with disabilities—including those with complex needs (profound intellectual disability, multiple disabilities, autism)—are educated within the regular education system.

The current framework for access to mainstream schools was significantly supported by Decree-Law No. 3/2008 (Portugal, 2008), reinforcing a trend that had begun in the 1980s, which involved reorienting special schools into “resource centers”, now referred to as Centers of Resources for Inclusion (CRI). The CRI served as a means of mobilizing specialized professionals to support the process of inclusion for students within regular schools (Portugal, 2007). Along with this mobilization, the decree marked an important shift in the processes of evaluating and determining the eligibility of students with special educational needs, introducing as a procedural requirement the use of the International Classification of Functioning, Disability, and Health (ICF) (World Federation of Occupational Therapists, 2007) as an assessment framework. This measure reinforced a biopsychosocial perspective in assessing needs by describing students’ functioning profiles based on their involvement in activities and participation (e.g., learning and applying knowledge, communicating, interacting) and relating body functions (e.g., mental, sensory, neuromusculoskeletal) to environmental factors (e.g., educational methods and products, support and relationships, attitudes).

This requirement made it clear that the school would not merely be a place visited by different professionals but would need to become a hub of interprofessional collaboration—i.e., intersecting different disciplinary and professional fields—to comprehensively analyze students’ needs, integrating their academic, behavioral, social, and emotional aspects, as well as the environmental factors of the school and classroom. This raised the need for a community culture, translated into a collaborative working environment where different professionals contribute toward common goals focused on the academic and social participation of all students (Sanches-Ferreira et al., 2014).

More recently, the publication of Decree-Law No. 54/2018 has accompanied the expansion of the ideology of inclusive education, no longer limited to a model centered only on students with special educational needs, but extending to “[…] all groups on the ‘margins’ of the system (e.g., ethnic minorities, migrants, students at social risk)” (Santos et al., 2021, p. 63).

As outlined in its preamble, the central guiding axis of this Decree-Law is

[…] the need for each school to recognize the value of its students’ diversity, […] adapting teaching processes to the individual characteristics and conditions of each student, mobilizing the resources available to ensure that all students learn and participate in the life of the educational community (Portugal, 2018, p. 2918).

Accompanying this broader conception of inclusion, educational support responses are now organized according to two methodological approaches (Pereira et al., 2018, p, 18): (i) the multi-tiered approach – “[…] a comprehensive and systemic model aimed at the success of all students, offering an integrated set of support measures for learning, adopted based on students’ responses”; (ii) universal design for learning – “[…] a curricular approach that is based on intentional, proactive, and flexible planning of pedagogical practices, considering the diversity of students in the classroom” (Pereira et al., 2018, p. 22). These approaches – viewed as progressive in the report by the Organisation for Economic Co-operation and Development (2022) – reflect the abandonment of the idea that categorization, i.e., obtaining a diagnosis or clinical label, is necessary for intervention. Instead, there is now a school-wide approach for all students, with a continuum of supports organized into three levels: (i) universal measures – aimed at all students through the intensification of, among others, the implementation of universal design principles, pedagogical differentiation, and the promotion of pro-social behavior; (ii) selective measures – when needs are not met through the application of universal measures, involving, among others, early intervention and reinforcement of learning and tutorial support; (iii) additional measures – when previous measures are insufficient, which may involve, among others, curricular adaptations and structured teaching methodologies and strategies. While selective and additional measures involve the activation of supports that go beyond those naturally available, universal measures aim to intensify inclusive pedagogy, incorporating universal design principles for learning into teaching and learning processes, i.e., the flexibilization and diversification of strategies and resources extended to all students (Capp, 2017).

Another key element of the current legal framework is the definition of responsibilities and roles of the so-called Multidisciplinary Teams for Inclusive Education Support (EMAEI), to which occupational therapy belongs, namely: designing, monitoring, and overseeing support measures and empowering the educational community for inclusive education. In each school, there is an EMAEI composed of a special education teacher, members of the management and pedagogical council, and a psychologist, along with classroom teachers and, when necessary, professionals from CRI (therapists, psychomotor therapists, social educators).

Whenever the need for learning support measures is identified—by parents, teachers, early intervention services…—the team is requested to assess the student’s needs, and together—after consulting the parents or guardians—a technical-pedagogical report is prepared. This report describes the needs, selects support measures, and outlines a plan for monitoring and evaluation (articles 12 and 20). Although these teams are called “multidisciplinary”, this decree was accompanied by a practice support manual (Pereira et al., 2018) proposing collaborative transdisciplinary dynamics, referring to teamwork focused on co-reflection, co-problem-solving, and co-planning of strategies. As articulated by McGregor (2015), the transdisciplinary approach seeks to transcend disciplinary barriers through collective and collaborative learning in the construction of common knowledge and solutions. It is within this transdisciplinary framework that occupational therapy practice is conceived in common directives, including: promoting spaces for reflection and education for inclusion involving the entire educational community, discussing and identifying inclusive pedagogical strategies, and empowering students to learn and participate in various school contexts.

Presence and Target Population of Occupational Therapists

According to the most recent estimates from the Directorate-General for Education and Science Statistics (Portugal, 2024), regarding the 2021/2022 school year, students receiving learning and inclusion support measures, that is, those with selective and additional measures, represent about 7% of the school population. Specifically, there are 83,431 students out of a total of 1,122,762, spanning from pre-school to secondary education in public schools in mainland Portugal.

Of this group of students, approximately 48% (a total of 37,337) receive support from at least one specialized professional, i.e., a physiotherapist, psychologist, speech therapist, occupational therapist, or other professionals (e.g., psychomotor therapist, social educator).

In the same academic year (2021/2022), 8267 students were supported by occupational therapy in public schools, representing around 14% of the students receiving support measures. The majority (80%) of students receiving occupational therapy support are in basic education, aged between 6 and 14 years. Nearly half, 46% (3819), of the students supported by occupational therapy follow an adapted curriculum—oriented toward personal and social autonomy skills—and fall under the most intensive level of support measures, designed for students with “[…] severe and persistent difficulties in communication, interaction, cognition, or learning that require specialized resources for learning and inclusion support” (Portugal, 2018, p. 2921).

Currently, there are approximately 1545 full-time equivalent specialized professionals in public schools. Around 131 belong to the occupational therapy professional group. Considering the full-time employment of occupational therapists in schools, it is estimated that the therapist-to-student ratio is about 1 to 63. Naturally, given this reality, it is easy to encounter various recommendations (see Portugal, 2020) regarding the need to develop staffing frameworks for these professionals that are more aligned with the schools’ needs. Most occupational therapists work in partnership with schools through CRI (60%)—which today form a national network comprising around 100 institutions—or are directly hired by schools (32%). These hiring origins also impact the work produced by occupational therapists and prompt reflections (e.g., Portugal, 2020) that are beyond the scope of this manuscript.

Looking back, these statistical indicators have fluctuated depending on the political and legal framework of each period, both in terms of the number of occupational therapists in schools and their hiring origins, as well as the number and type of measures provided to the supported students. However, there are difficulties in compiling data that would allow for reliable comparisons across different periods. Even so, over the past five years, there has been a clear upward trend in the number of students supported by occupational therapists, increasing from 6128 (8% of students receiving support measures) in 2015/2016 to 8267 (10%) in 2021/2022.

Implications for the Professional Practice of Occupational Therapists

The political context and the values of inclusive education necessitate the development of expansions to the common practice of occupational therapy—particularly the practice inspired and established in clinical and hospital settings—that we discuss around three fundamental vectors: (i) the expansion from rehabilitation to environmental habilitation, (ii) the expansion from individual work in support rooms to work with and for the school community, and (iii) the expansion from remediation-focused work to the development of preventive responses.

From rehabilitation to environmental habilitation

Etymologically, the word “therapy” comes from the Greek therapeia, meaning “act of healing” or “act of restoring” (Liddell & Scott, 1983). The object of restoration or healing, i.e., the target of intervention, however, is not a fixed entity and is subject to variation according to personal and contextual circumstances.

Historically, however, in the approach to disability, the target of healing or restoration has traditionally been associated with resolving problems located within the person when their functioning deviates from the standard demands of the context. This approach to restoration, excluding the environment where the person operates, was shaped by a biological perspective that dominated the approach to disability since the 19th century (Zaks, 2023). The social perspective, which brought the deficiencies of the environment and society into the sphere of restoration, emerged in the 1970s and broke with the hegemony of the biological perspective. According to this perspective, restoration is driven toward fundamental freedoms, via social policies (Hogan, 2019).

Nevertheless, it has been generally agreed that within the purpose of inclusion – guided by the commitment to ensure the right to participation, the biopsychosocial approach is, by excellence, the one that serves restoration, focusing on aligning environmental conditions with the person’s functional characteristics (Silveira-Maia et al., 2017b). This perspective—recognized as more useful to educational practice—has been successively reinforced in practice and in regulations concerning assessment and eligibility for support (Sanches-Ferreira et al., 2010). As stipulated in current legislation, assessment refers to the “[…] identification of factors that facilitate or hinder the student’s progress and learning development, including school, contextual, and individual factors” (Portugal, p. 2925).

We know, however, that the theoretical and political robustness of the biopsychosocial approach has not yet found strong continuity in the practices of assessing students’ needs in the educational context (Bodfield & Culshaw, 2023). Internationally, the biological perspective remains the starting point for organizing and activating support in many educational systems, relegating the planning of responses to diagnostic categories or types of disability (Holland & Pell, 2018). In Portugal, although the activation of support depends on a comprehensive assessment of students’ needs, the analysis (Silveira-Maia et al., 2017a, 2019) of technical-pedagogical reports produced by educational teams, which include occupational therapy, continues to reveal descriptions centered on limitations that are explained solely through deficiencies or insufficiencies of the body (“[…] difficulties in concentrating attention stem from psychomotor control deficiencies” – Silveira-Maia et al., 2017a, p. 7). In practice, this way of addressing needs and support has reflected in the persistence of an educational system whose responses are designed in a dichotomous way: either for normative needs (the majority) or for the needs of some, associated with types of disability or learning difficulties, in which the core intervention is a capacity-training model (Florian, 2008).

This diagnostic-prescriptive fervor in education has been characterized by a modus operandi of teams more absorbed by students’ differences than by learning objectives and content (Kavale, 2007). The same tendency is noticeable in school-based occupational therapy – as reflected in the constant contrast between a clinical versus an educational model (e.g., Jackson et al., 2006) and the need to develop practice guidelines conceived from an ecosystemic perspective (Sousa et al., 2015a). This ecosystemic perspective, outlined in a manual edited by the Directorate-General for Education and Science Statistics (Sousa et al., 2015a, p. 7), emphasizes an approach to occupational therapy focused on the interaction between the student and their contexts, and pragmatized through three modes of intervention: individual (“skill training”, e.g., “specific exercises for eye-hand coordination, visual perception…”; group (“peer dynamics […] aimed at developing specific skills… vestibular, bilateral integration…”); consultancy (e.g., “awareness-raising actions on sensory processing”). In the exemplification of these modes—in both the manual and SBOT literature in general (Lynch et al., 2023)—there is a recognizable departure from the ecosystem (the relational niche between the student and context) toward a practice that leans heavily on skill training, often confined to the student’s coordination, perception, and sensory processing.

In fact, although situated in the health field, the focus on Occupation and Activity inherently positions the occupational therapist as a hybrid agent – between the biological and the social, especially predisposed to consider a person’s performance based on both personal and environmental determinants. Despite the presumed hybridity of occupational therapy, historically (Gentry et al., 2018), the approach to Occupation has leaned toward an analysis dedicated to the relationship between activities and body functions. As documented in the national report on the work of CRI in schools (Sousa et al., 2015b), the assessment documents developed by specialized professionals, including occupational therapists, are almost exclusively centered on the student, with little or no emphasis on their learning contexts, revealing a focus on therapeutic dimensions.

This argument does not propose to neglect the recognition of occupational therapy in the educational field regarding its specialized contribution to the analysis of activity with reference to the child’s functioning and development. Instead, it seeks to emphasize the need to more firmly bring the analysis and intervention on the context and the school community into the practice of occupational therapy. This need aligns with the definition of SBOT for inclusion proposed by the American Occupational Therapy Association (2017, p. 1), which recognizes occupational therapists as professionals whose “[…] expertise includes activity and environmental analysis and modification with a goal of reducing the barriers to participation”.

It is through the use of the concept of environmental habilitation that we draw from this goal – as a process aimed at adjusting the characteristics of activities, the physical and relational environment, to support the participation of all students. While the importance of intervening with the individual is not excluded, when it is assumed that the highest indicator of inclusion (i.e., the focus of restoration) is participation – defined by engagement in activities and a sense of belonging (Imms et al., 2017), then the adjustment of environmental variables takes on a priority role.

The review by Grajo et al. (2020) sheds light on this pathway in the reorientation of practices, systematizing occupational therapy interventions focused on participation in the classroom, including: (i) educational participation (e.g., on-task behavior, engagement, sitting time, following classroom rules); (ii) literacy participation (e.g., frequency of reading and writing, motivation to read and write); (iii) handwriting (e.g., speed, legibility, and accuracy in writing, involvement in writing activities). The promotion of creative literacy activities embedded in or complementary to the classroom, as well as interventions mediated by parents and peers, were among the environmental habilitation actions analyzed (not all with sufficient levels of evidence). From this review comes the clear notion of a “literary void” in documenting and testing occupational therapy interventions aimed at participation, along with a deficit of assessment measures that allow for the evaluation of the outcomes of these interventions.

The reconfiguration advocated in this axis necessarily depends on biopsychosocial assessment approaches, centered on activity and participation domains that are educationally relevant and that simultaneously and dynamically support the identification of solutions and supports in the context(s) in which the child moves and connects with others and with their curriculum. The continuous questioning of “what is the problem of the problem?”—a lesson the author learned in a class taught by Granlund (2008) from Jonkoping University—underscores the resistance to a rationale in which the target of “problems/restoration targets” is still sought within the person (e.g., “the problem is the student’s sensory-seeking behavior”), redirecting the focus toward the problem/restoration target embedded in the context, that is, the problem at the level of participation (e.g., “the problem of the problem is the intensity of physical contact in peer interactions”). This questioning opens up broader lines of intervention that more directly include environmental solutions (such as peer proximity, classroom organization, task duration, and so on).

From support rooms to the community

With the culmination of the commitment to the biopsychosocial perspective, the experience of the widespread use of the ICF in the Portuguese educational system between 2008 and 2018 allowed teams to expand their focus on the environmental factors of the school, without neglecting the analysis of body (dys)functions (Sanches-Ferreira et al., 2014; Silveira-Maia et al., 2017a). A more conscious recognition emerged regarding the importance of body functions and environmental factors as part of a larger whole – in which assessment and intervention, as metaphorized by Sanches-Ferreira et al. (2010), are a gestalt that transcends the sum of the parts.

However, there were concerns about how the specialized input of professionals—particularly the occupational therapist—could be associated with the risk of bringing clinical practices into schools (Sanches-Ferreira et al., 2010). This concern was accompanied by evidence that, despite the greater recognition of the influence of environmental factors, the discourse of educational teams, including technical staff, still tended to describe needs solely based on the association between limitations and impairments.

Few, if any, studies specifically examine the work of professionals in schools in Portugal. Therefore, we draw on the report by Sousa et al. (2015b) – one of the few accounts in which we can situate the work of occupational therapists. This report revealed that support rooms (rooms complementary to the classroom for individual or group work) are the most commonly used setting by occupational therapists—similar to other technical staff—for direct intervention with students. The report reinforced the idea that their role needs to be expanded to include the natural and common learning environments (classroom, playground, cafeteria...) and indirect interventions aimed more fully at applying their specialized knowledge in the service of education. This aligns with the already established SBOT literature that pull-out practices (removing students from the common context), as the modus operandi of occupational therapists, are akin to the scenario of a “lone ranger” who enters and exits the school, denying the evidence that their field of intervention is not (only) the student, but the context in which they move.

Using handwriting as an example of an area of intervention, it is clear that readiness work on writing prerequisites (e.g., kinesthesia, visuomotor integration), typically performed in a support room setting, does not directly translate into improvements in handwriting performance (Grajo et al., 2020). This implies that, on the one hand, skills must be developed within and through the activity, and on the other hand, there are several environmental factors affecting this performance that are overlooked when students are pulled out from their context (Cahill & Beisbier, 2020).

The metaphor of the lone ranger also conveys the idea that occupational therapists, by occupying such a position, do not immerse themselves in the “field matters”, excluding themselves from the community movement that also defines inclusion, that is, learning and cooperating with others in co-solving problems and dismantling barriers (Mortier, 2020).

This brings us back to the affirmation of the classroom as the primary context for intervention and, by extension, to the requirement of collaborative work with other professionals. The need to step down from the horse and join others in and from the community has been widely discussed in SBOT literature (e.g., Villeneuve & Shulha, 2012), particularly through proposals centered on consultancy and the collaborative writing of individualized education plans (IEP). Other collaborative approaches, aligned with the perspective that inclusion is defined as a collective learning process based on the needs and dilemmas of each school, have also emerged, namely: (i) Communities of Practice¹ (Mortier, 2020); (ii) Lesson Study ² (Goie et al., 2021); (iii) Professional Learning Communities³ (Hudson, 2024).

These approaches differ from more traditional collaborative perspectives – restricted to an “expert” consultancy style, in which the occupational therapist is positioned as someone who provides others with knowledge and skills in a unidirectional manner (McWilliam, 2006). Instead, they structure partnership dynamics characterized by dialogue, power-sharing, and the creation of spaces for experimentation (Mortier, 2020).

The Partnering for Change (P4C) model exemplifies a collaborative process focused on co-solving problems through observations and interactions embedded in the common school contexts (Campbell et al., 2023). In the field of handwriting interventions, we can also find examples of collaboration within the classroom, such as co-teaching models between the teacher and the occupational therapist. An example of this is the Write Start program (Case-Smith et al., 2011), which utilizes teaching stations and a teaching team to promote legibility, fluency, speed, and written expression in first-grade students.

These developments, which position the occupational therapist’s practice as embedded within the school community, moving within common learning contexts and working closely with others, highlight the need to address the deficits in articulation and collaborative work reported in the Sousa et al. (2015b) report. It becomes clear from that assessment that the expansion of the occupational therapist’s role to include the school community—properly contextualized to the dilemmas and needs of the setting—is hindered by several constraints, not only of an organizational nature, such as schedule incompatibilities, limited hours, and itinerant work across dispersed geographic areas (Sousa et al., 2015b), but also in terms of training, regarding the opportunities to develop competencies for collaborative work (European Agency for Special Needs and Inclusive Education, 2022).

Thus, it is emphasized that the role of the occupational therapist in the context of inclusive education—committed to ensuring conditions for the learning and belonging of all students—is even more clearly marked by the need for the interpenetration of knowledge and perspectives, moving away from fragmented and specialty-limited discourses and practices. Beyond creating conditions for all students to learn and feel a sense of belonging, inclusive education also involves creating conditions for professionals to participate and learn as partners. Therefore, the collaborative work of the occupational therapist for inclusion requires space (temporal, physical, and social) and structured approaches that are integrated into the school routine.

From remediation to prevention

The multi-tiered approach and universal design for learning are two methodological options from Decree-Law No. 54/2018 that align with the necessary disruption of dichotomous support systems—regular versus special—to conceive responses that encompass all students. One of the key elements of these approaches is their preventive nature (Silveira-Maia et al., 2022), meaning the occupational therapist’s involvement in the collaborative development of responses at the classroom and school-wide levels.

This preventive nature refers to expanding interventions—beyond those directed at needs arising from disabilities and impairments—to include the more timely and efficient integration of supports in natural learning contexts aimed at the entire school population (Lynch et al., 2023). In Lynch et al.’s (2023) review, the distinction between preventive and remedial interventions (in terms of targets and intervention intensity) remains challenging. The P4C model (Campbell et al., 2023) stands out as the program that best reflects and systematizes the occupational therapist’s actions in a multi-tiered approach:

• at Tier 1, the occupational therapist observes children in the classroom and other school settings (e.g., gym, playground, cafeteria…), collaborating with the teacher to introduce changes—aligned with universal design for learning—that benefit all students. In Lynch et al.’s (2023) review, examples include classroom-based programs promoting handwriting and preventing literacy difficulties, as well as teacher capacity-building programs aimed at managing classroom behavior;

• at Tier 2, the occupational therapist engages in collaborative problem-solving processes with teachers, sharing observations, generating hypotheses, and experimenting with solutions, including strategies for pedagogical differentiation, to modify activity and context characteristics in line with the child’s needs. In Lynch et al.’s (2023) review, examples include group or individual interventions aimed at developing writing skills, behavior management, or general learning competencies, as well as indirect interventions through educators targeting behavior and self-regulation in specific students;

• at Tier 3, the occupational therapist collaborates with the teacher to design modifications to activities and contexts for an individual child, for instance, by using assistive products, adapting actions or tasks according to the child’s abilities, or adjusting auditory, visual, or social stimuli in the context. In Lynch et al.’s (2023) review, examples include actions to restore handwriting legibility, keyboard use, or self-regulation, as well as specific or complementary curricular approaches (such as programs promoting social interaction skills and activities of daily living).

Although there is currently no data documenting the implications of the multi-tiered approach for occupational therapy practice in the Portuguese context, it is expected that this approach will broaden the therapists’ role to encompass the entire school, integrating into their practice the co-planning of physical, social, and learning environments for all students (Campbell et al., 2023). This gap in documenting and developing multi-tiered approaches for occupational therapists in Portugal is echoed internationally in Lynch et al.’s (2023, p. 3) review: “[…] no study to date has examined SBOT in relation to tiered interventions in elementary schools.” In this review, which maps occupational therapy interventions across the three tiers of support, the prevalence of practices focused on skill restoration is highlighted. As Souza et al. (2021) conclude, the drive of occupational therapists in schools has been guided by the inclusion of the excluded, particularly for reasons associated with disability and impairment, in practices predominantly devoted to remediation. This assertion is reflected in the Portuguese context, where about half of the students supported by occupational therapy receive Tier 3 measures (targeting severe and persistent difficulties).

The necessary expansion, driven by the multi-tiered approach and universal design for learning, is—without neglecting the right to individualized support—to more strongly incorporate into occupational therapy practice actions and capacity-building programs directed at the school as a whole.

Final Remarks

This manuscript brings together the values inherent in inclusive education practices and the specificities of the Portuguese political framework as starting points for discussing occupational therapy practice in educational settings. Although the role of occupational therapists in schools has been discussed and differentiated from traditional clinical models for more than two decades, this distinction is still not evident in practice – as emphasized in Lynch et al.’s (2023) review, which highlights the predominance of direct and pull-out intervention approaches. In this essay, we systematize three movements that, similar to international contexts, remain necessary for occupational therapists to pragmatize in schools in Portugal: (i) the expansion from rehabilitation to environmental habilitation – through the adoption of biopsychosocial assessment and intervention models oriented toward participation-centered goals; (ii) the expansion from support rooms to the community – by acting within natural learning contexts and embedding structured collaborative work approaches into routine practices; and (iii) the expansion from remediation to prevention – implementing programs that promote the successful participation of all students, alongside individualized strategies and supports.

The transfer of these movements into practice necessarily depends on multi-systemic actions to ensure sufficient time, resources, collaboration, and training conditions that allow for convergent actions aligned with the goals of inclusive education. Strengthening the pathway toward inclusive education also requires monitorable data, aligned with public policies, to support ongoing reflection on the practices of the various stakeholders.

World Federation of Occupational Therapists – WFOT (2016). Position statement on occupational therapy services inschool-based practice for children and youth. Geneva: WFOT

• 1
  Communities of Practice are defined as a group of people who share the same goal and deepen their knowledge through regular interaction (Mortier, 2020).
• 2
  Lesson Study refers to an investigative process in which professionals collaboratively plan, implement, observe, and adapt lessons based on collected data (Goie et al., 2021).
• 3
  Professional Learning Communities are defined by the involvement of a group of professionals in intentional learning, focused on promoting benefits for students (Hudson, 2024).
• How to cite:
  Silveira-Maia, M. (2024). Inclusive education policies in Portugal: implications for the practice of occupational therapists. Cadernos Brasileiros de Terapia Ocupacional, 32(spe), e3796. https://doi.org/10.1590/2526-8910.ctoEN392337962
• Funding Source
  This study was financed by national funds through the Foundation for Science and Technology (FCT), Polytechnic of Porto, under the project UIDP/05198/2020 (Center for Research and Innovation in Education – inED).

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References

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Edited by

• Section editor
  Profa. Dra. Andréa Perosa Saigh Jurdi

Publication Dates

• Publication in this collection
  06 Dec 2024
• Date of issue
  2024

History

• Received
  09 Mar 2024
• Reviewed
  10 May 2024
• Accepted
  25 June 2024