School Occupational Therapy Scope of Practice

If you are new to school based occupational therapy treatment, you may be confused about how this differs from the private medical model.  Once you have a few IEP/504s under your belt, you will become a master in defending what therapist in the school do (and do not do). Knowing the points of a school occupational therapy scope of practice is essential. This is a harsh reality, and takes a while to get used to this treatment model compared to outpatient OT. In this article, we will explore how school-based therapy differs from private therapy, and determine What School Based OT’s Should Address.

school occupational therapy scope of practice with school desks in front of a chalkboard

Another resource you’ll want to check out is how to request a school evaluation.

WHAT SCHOOL BASED OT’S SHOULD ADDRESS

Ideally in the helping profession, occupational therapists should “fix what is broken.”  This is the model I followed for 25 years before moving to the school district. School based therapy is a different ball game all together.  We are “related services,” meaning we provide a service to help students meet their educational goals.

This is where is gets tricky.  While it may be true that Johnny can not tie his shoes, will not eat cafeteria food, or wear button-down shirts, he is getting his education without the need to do these things.  Here is why: Johnny can wear Crocs or Velcro shoes, he can pack a lunch or survive on water during the school day, and can wear other clothes instead of a button-down shirt.

I had a high school student I inherited who had a buttoning goal. He only wore button-down shirts to church on Sundays, never to school. Number one, this was not affecting his education, and number two, if he had not learned buttoning by age 19 with years of training, my few minutes a month was not going to make much of a difference. For the record, I tried. I added the caveat that he had to wear button shirts to school to make it educationally relevant (this was a stretch), and made sure he was working on this every day.  After months of what I knew was going to be wasted time, we settled on Velcro shirts that have buttons attached to looked like a real button-down dress shirt. 

DOCUMENTATION ON SCHOOL OT VERSUS MEDICAL BASED THERAPY

There are differences in documentation in the medical model of occupational therapy and the school occupational therapy model. This is because of differences in intervention based on medical needs vs. educational needs. Here is what the American Association of Occupational Therapists has to say on school-based therapy versus a medical model. This is a great brochure to have on hand for parents and staff at your schools.

Does School Occupational therapy address self help skills?

What kind of self-help skills do you think OTs should look for in developing a treatment plan? Cooking, dressing, grooming, laundry, money management, chores?

What self help skills should a school occupational therapy practitioner address?

This depends on the educational setting. As a general rule, school-based therapist should not be expected to teach cooking, grooming, and laundry unless it is educationally relevant. One of our schools has a program that makes and sells cookies as part of their life skills class.  One student was having fine motor difficulty measuring, rolling, and cutting the cookies.  For him, this specific cooking and life skills goal was relevant to his education.

The student who just wanted to make pancakes, but this task served no educational purpose, was not in need of skilled therapy for this task.  If making pancakes were part of his educational program, then yes it might be relevant to address from a fine motor, or executive function skills angle.

self-help skill that may be addressed in School OT

Sometimes a school occupational therapy referral will target self help skills. And sometimes this is appropriate when it impacts education. Here are some things to consider:

  • Using utensils – maybe. While it is true that your student can get by using their hands to eat, is it safe?  Beyond safety there is social appropriateness, and improving fine motor skills to consider. Check out our resource on using a spoon and fork to assist with this area.
  • Grooming – maybe. If there is a reason your student must brush their hair or teeth at school as part of their educational program, then you may have a case to address this. Deodorant? Maybe not. This might come into play with the middle school student or high school student who is using the pool in the school physical education class.
  • Toileting – the physical aspects of toileting such as clothing management, hand washing, motor coordination, and adaptations, yes.  Maybe even as far as advising on a time schedule or visual supports. Sitting with a kid for 20 minutes waiting for them to go; maybe not. The Toilet Training Book is a good resource for supporting a variety of levels and needs.
  • Laundry – if this is part of their educational program. Some programs have life skills built in like laundry tasks.  If this is the case, this might be an educationally relevant goal.  If so, goals like these are often addressed at a problem-solving indirect level.
  • Chores – again educationally relevant ones.  These are all great life skills but what educational impact do they have to get specific therapeutic services?  Emptying trash cans, recycling, cleaning dishes, washing tables, etc. may be part of a classroom management routine, or may be just a life skill being taught at school.  Consider the relevance before committing to long term direct intervention on waste management.

WHAT HandwRiting Needs Should SCHOOL BASED OT ADDRESS?

Handwriting is a big one…it seems like every school based occupational therapy student has a handwriting goal. Check out my post on “How Long Should OT Address Handwriting Skills?” (Coming soon) in order to gain an understanding of when and how much intervention to provide in handwriting. Handwriting services at some point need to be dismissed if the student is not motivated, progressing, over a certain age, or producing functional work. 

Instead look for underlying causes of handwriting difficulties such as weakness, coordination disorder, sensory processing difficulties, or visual perception deficits. Address the underlying causes to improve overall fine motor skills and handwriting.

Some things to ask yourself are:

  • Does cursive handwriting need to be addressed or could this be done at home through a home program (likely much more effective with daily practice)
  • Should near point copying skills be addressed to support the ability to copy homework from a chalkboard?
  • What about pencil pressure? When the pencil markings tear paper and result in illegible written work, should this be addressed?
  • When should we target writing speed? When the written work is illegible because it’s too fast or when it’s so slow that the student can’t keep up with written material. What is the fine line between these areas.

The list could go on and on!

WHAT Sensory Processing Needs SHould SCHOOL BASED OT ADDRESS?

We all have sensory issues. Everyone has idiosyncrasies that make us unique. I am sensitive to smells, textures, and auditory input.  However, I function just fine in my work setting.  I wear clothes that I like, use gloves if I need them, and have ear plugs if something is too loud.  My sensitivities are bothersome at times, but not impacting my work to the point that I can not do it. 

Sensory processing difficulties can have some educational impact.  There are many students who are so sensitive to smells, sounds, or textures, that it impacts their learning, or the learning of those around them. Attention and behavioral challenges interfere with learning and acquiring new information.

Sensory based strategies can help set the foundation for improved learning. These techniques and adaptations are put in place with the sole purpose of helping students reach their academic milestones and participate in their education.

Social skills and social function in the school system

What school-based OTs should address in terms of social skill functioning depends on the expectations in the classroom.  There is a place for therapists to address social skills in class either in a direct or consultative model.  These might include:

How to Decide if a need is in the scope of practice for school occupational therapy

Because we are a helper profession, it is going to take some practice and reinforcement to truly understand the role of therapists in the school system. This advice is not just for occupational therapists.  Physical therapists and speech language pathologists go by the same standards.

When deciding what to address in therapy, ask yourself some questions:

  • Is this skill relevant to their education?
  • Can a teacher provide the same information/practice?  If so, you can provide recommendations and advice rather than direct treatment
  • Can this student perform all functions of their school day without this skill?  This is especially relevant when being asked to address shoe tying, eating, hair brushing, or buttoning.  *You can work on buttons and tying shoes as an activity to improve your fine motor coordination goal
  • Is this something that matters to the teacher and/or parent? If not, you will not get the carryover you need for success
  • Does the child have the necessary skills to function in their environment? Their handwriting might not be perfect, but at some point, it is functional, and works for their educational setting
  • Will adding OT have a positive or negative impact? Some students do not need to miss any instructional time being pulled out for therapy or having a therapist push into a classroom.  A consultative model or recommendations may suffice
  • Is it time for dismissal?  At some point the teachers know what to do to follow your OT plan of care, or your therapy interventions are not having any impact on the student’s education. Therapy can become a crutch for parents/teachers/students.  It is nice to feel wanted and needed, but opening your schedule to help new students is even nicer.

Thoughts from An experienced OT on the scope of school based occupational therapy

This is the end of my third year as a school-based OT. I am finally getting my head wrapped around my role in the school system.  After 25 years in outpatient private practice, it has taken me this long to reprogram myself. There are still times when I want to address something because the child needs it as a life skill.  I must go back to my list of questions above and ask myself if this is truly an educational need.

As my caseload grows, unfortunately some of these decisions are becoming easier based on time constraints.  I find myself prioritizing the students who truly need skilled therapy to survive the day at school, or have some sort of educational impact. Students who in theory should have more therapy due to their function level, get less because their needs are stable, they are not progressing, and their teachers are doing a great job helping them access their education.

Victoria Wood, OTR/L is a contributor to The OT Toolbox and has been providing Occupational Therapy treatment in pediatrics for more than 25 years. She has practiced in hospital settings (inpatient, outpatient, NICU, PICU), school systems, and outpatient clinics in several states. She has treated hundreds of children with various sensory processing dysfunction in the areas of behavior, gross/fine motor skills, social skills and self-care. Ms. Wood has also been a featured speaker at seminars, webinars, and school staff development training. She is the author of Seeing your Home and Community with Sensory Eyes.

school occupational therapy scope of practice- school desks in front of a chalkboard