Common Ethical Concerns in School-Based OT

While school-based OT can be close to a dream job, ethical concerns are still something that crops up in this setting. As frustrating as these dilemmas can be to experience, being prepared for them can make a huge difference. This list represents the most common ethical concerns I’ve found in my personal practice and among the larger school-based OT community. 

A workload/caseload that is too large

This is probably the most common sticky situation I see in the school system. And while having a high caseload is not necessarily an ethical concern in and of itself, it can lead to many. If your workload is too high, it means that you will either work off the clock/past contract hours or just not get everything done. Or in the worst situations, both! Neither of these are preferable situations, but your work/life balance must be protected. So how do you actually do that?

When I’ve found myself in this situation in the past, I’ve gone to my supervisor and let them know that the workload was too high. This wasn’t an easy conversation to have in the first place, because part of my identity is wrapped up in being a hard worker who is super productive. And while things didn’t immediately get better as a result of that situation, they did start to shift. My district gave me guidance on what to prioritize. Sometimes this meant missing direct services to stay in compliance with assessment timelines. As OTs, it’s hard for us to deny a child services. But ultimately, staffing issues are the district’s responsibility and it is on them to provide OT, using compensatory services as necessary. 

Grouping too many students 

This is another dilemma that can result from having a caseload that’s way too big. While grouping students can be beneficial, it shouldn’t be the default. As the OT, you should be making a decision for each student on whether they would be more appropriate for group or individual therapy. But in practice, our supervisors often pressure or even dictate that we must group students, even if it’s clinically inappropriate.  

In one especially egregious case, I started the school year with 7 schools and a caseload that was in the 70s and climbing. I started grouping my self-contained students together and seeing them in their classroom in an effort to fit all the services in. These were huge, unwieldy groups of 7-9 students with grades that spanned from kinder to 5th. Needless to say, they weren’t very effective at helping these students meet their individual goals.

Eventually, after a conversation with my supervisor and some time, we were able to shift things so that the groups weren’t so huge. But if this situation happened to me again, I would never even attempt those large groups in the first place. I thought that I was doing the best I could to make sure all of the students I was responsible for got some OT, even if it wasn’t very high-quality. But in reality, I was just helping the district put a bandaid on their huge staffing issue. In the future, I’d speak up instead of kicking the can down the road. 

ethical concerns school-based OT

Inappropriate OTA supervision 

This can look many ways, and it’s important to stay on top of your state’s OTA supervision laws, whether you’re the COTA or the supervising OTR. You may find yourself in situations where an OT is asked to supervise more COTAs than the state legally allows. Or your state may require on-site supervision and your district is only providing it remotely. Or you may find that the OT is technically giving the frequency of supervision that state law dictates, but that the minimum isn’t enough for a brand-new COTA. And in one situation that a colleague shared with me recently, their non-OT special education director had trouble finding an OT so hired a PT to supervise the COTAs instead. 

This is one situation that you really don’t want to mess around with because getting it wrong puts both the OT’s and the OTA’s licenses at risk. If you are not being given adequate supervision, or given the tools/time to provide it, speak up immediately.  

School districts refusing to follow IEPs 

This ethical concern is one of the most demoralizing, because often, writing an appropriate IEP feels like the battle in and of itself. Once it’s done, we shouldn’t have to put in effort to make sure the district actually follows it!

At its lightest, this one looks like a gen ed teacher not providing a student with their accommodations because they were never informed or they forgot. But in one of the worst cases I’ve ever seen of this dilemma, a school district refused to provide assistive tech equipment that was already written into student IEPs. Once the IEPs were signed, sealed, and delivered, any attempts to actually order the equipment and software were ignored or delayed. Overall, it took me 6 months of advocacy in that district to make sure the legally required AT was provided. And as you can imagine, it’s hard to find energy for that advocacy when your workload is already too high. 

School districts refusing to evaluate struggling students 

Under IDEA, school districts have a legal obligation to identify and evaluate all children who are suspected of having a disability that may require special education. This is called Child Find, and you’ll notice that the law doesn’t require the student to actually HAVE a disability. This is by design. The law is written so that struggling kids are evaluated, even if their teachers aren’t positive yet that they do have an educationally-related disability. The whole point of the evaluation is to find out if they do.

Unfortunately, schools skirt their responsibilities in this area all of the time. Sometimes it’s for semi-legit reasons, like a student’s performance possibly being impacted by frequent absences.  Or a school district wants to go through the RtI process, try some less invasive interventions, and collect data. But ultimately, as soon as anyone on that team suspects a disability, that student is legally supposed to get a special education evaluation. Too often, this doesn’t happen for staffing reasons.  

ethical concerns school-based OT

Team pushing for OT services you’ve recommended against 

One of the unique aspects of the school system is that developing a plan for a student is a team effort. But this means that, unlike other OT settings, your service recommendations are a group decision. There have been many times where I’ve recommended no OT services and someone on the team (typically the family) disagreed. And in many districts, admin wants to take the path of least resistance and just add the services to the IEP. In reality, paying for those OT services is usually less costly than risking a case going to due process.

So what can you do if you find yourself in this situation? Well, you always have the option to sign the IEP but add a written statement of the parts you don’t agree with. Your district also has the option to offer the IEP with the level of service you’ve recommended, and parents can then choose to partially agree to the IEP, with any previous level of OT services staying put. Regardless of what happens, make sure your true recommendation is reflected somewhere in the IEP. Things may not change this year, but now there will be a record, which can make those future decisions and conversations easier. And whatever you do, don’t bill Medicaid for a service that you don’t find clinically necessarily. 

Team removing OT services from IEP 

In most of the cases of service level disagreement I’ve experienced, families and teachers typically want more OT services (flattering, but not always the right fit). But in one ethical dilemma I experienced, a team removed OT services from the IEP against my recommendation. Again, IEP services are a team decision, but this wasn’t done this way. After the IEP was agreed upon and signed by staff and family, the special education director removed OT services from the IEP because she didn’t believe they were necessary (and didn’t want to pay the contracting agency for them).

Modifying an IEP after it has been signed and agreed upon is more than just an ethical dilemma – it’s illegal. But school districts can get away with this kind of stuff, especially in areas where families aren’t aware of all of their rights under special education law, and don’t have the resources to hire attorneys or advocates to enforce them. 

Staff practicing OT without a license

Sometimes I think I’ve seen every ethical dilemma possible in school-based OT, but people still manage to surprise me. I once worked for a district that had trouble hiring and retaining OTs, and thus started the school year without one. When I got there a couple of months later, I found that the special education director/school psych had completed the OT portion of a student’s re-evaluation. And while technically motor skills can fall under the purview of a school psychologist, this individual had taken it one step beyond that and wrote legally dicey statements such as “As a result of this evaluation, this student continues to qualify for OT services.” What’s worse is when this situation was noted by the OT department, the director refused to let OT re-do the evaluation. 

I’m sympathetic to the plight of understaffed districts that are doing the best they can. But ultimately, if a district doesn’t understand why you need an OT license to do OT evaluations, it’s a huge red flag. 

Other staff using unethical teaching strategies 

While there is room in education to have different teaching styles, there are some strategies that are simply not ethical that we should all stop doing

In the first school district I worked in, I supported a self-contained classroom that was taught by a well-meaning, but very green intern teacher working on alternate certification. This classroom was also staffed by a paraprofessional who had been working in the schools a LONG time and was also working to become a fully certified teacher. I’m sure you can imagine the dynamic that created.

This para often had run of the room when the classroom teacher was absent, and in one of these situations, she had planned an art project with the students. Which is all well and good, except this para was much more focused on the product than the process. This resulted in the para using hand-over-hand to force my non-speaking, motor-impaired, intellectually disabled students to complete the art project the way she saw fit. Some of these students had sensory differences that impacted their willingness to touch the glue she was forcing them to use. All of them protested as best they could. 

As a new school-based OT, it was hard to speak up to someone who had much more school experience than I did. And when I did ask her to use alternate strategies like verbal or visual cues, she justified the hand-over-hand, stating that these students required it to learn. 

The classroom teacher and special education director in this scenario were both aware of this behavior and didn’t like it, either. But this was a rural district that had trouble hiring staff as it was, so this para kept her job and never really modified her behavior. And stuff like this – and sometimes worse examples of restraint and seclusion – is happening all over the country. It should not be acceptable.

Ultimately, ethical concerns are bound to happen in school-based OT. You’ll notice that many of these dilemmas have the common thread of being related to money. And until special education is adequately funded everywhere, these concerns will continue to happen. But being prepared for them can help you decide how to best respond to them. In some situations, simply bringing up the concern with district leadership will suffice. In others, you may have to make some hard decisions about what kind of ethical concerns you can tolerate in a workplace. And if you need more support with situations like these, come join us in The Dynamic School OT Course. You’ll learn more about your responsibilities under the law, how to work effectively with teachers, and what to do in difficult situations. 

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