Can OT Be the Only Service on an IEP?

Can OT be the only service provided on an IEP? If you work in special education, it’s likely you’ve heard some variation of this question before. And while many people might dismiss this question as a simple “no,” the reality is much more nuanced than that. Like most things in school-based occupational therapy!

What Does IDEA Say About Occupational Therapy? 

Anytime you have a question about what is or isn’t possible on an IEP, IDEA is a great place to start. It’s the federal law that defines special education in the US, and all states must follow it. While states can go above and beyond to provide more than what is required in the law (more on that later) all states must provide what is outlined in IDEA at the bare minimum.

OT info in IDEA is found on a list of related services, in contrast to specially designed instruction (SDI), which is what is typically meant by the phrase “special education.” Related services are defined as such:

“The term “related services” means transportation, and such developmental, corrective, and other supportive services (including speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, social work services, school nurse services designed to enable a child with a disability to receive a free appropriate public education as described in the individualized education program of the child, counseling services, including rehabilitation counseling, orientation and mobility services, and medical services, except that such medical services shall be for diagnostic and evaluation purposes only) as may be required to assist a child with a disability to benefit from special education, and includes the early identification and assessment of disabling conditions in children.”

The legislation then goes on to define OT specifically: 

“Occupational therapy—

(i) Means services provided by a qualified occupational therapist;

(ii) Includes—

(A) Improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation;

(B) Improving ability to perform tasks for independent functioning if functions are impaired or lost; and

(C) Preventing, through early intervention, initial or further impairment or loss of function.” 

You may notice that this is a pretty vague definition with a lot of potential for grey area (gotta love school-based OT, right?)

Further, IDEA goes on to state that certain things related to OT must be included in an IEP:

“(4) A statement of the special education and related services and supplementary aids and services, based on peer-reviewed research to the extent practicable, to be provided to the child, or on behalf of the child, and a statement of the program modifications or supports for school personnel that will be provided to enable the child—

(i) To advance appropriately toward attaining the annual goals;

(ii) To be involved in and make progress in the general education curriculum in accordance with paragraph (a)(1) of this section, and to participate in extracurricular and other nonacademic activities;

(iii) To be educated and participate with other children with disabilities and nondisabled children in the activities described in this section;”

You’ll notice that nowhere in these definitions does IDEA mandate specific qualifying scores or criteria for receiving occupational therapy services. That’s intentional. The goal is for students to receive whatever services are educationally necessary for them, with decisions made on an individual basis.

Qualifying for Special Education

But all of this is putting the cart before the horse. Because in order for a student to receive occupational therapy through an IEP at all, they first must qualify for special education.

IDEA also mandates this, mainly through 13 eligibility categories. To qualify for special education, a student must have a disability that matches this list, it must adversely impact their education, and they must require special education to address it. 

And while SLPs have it a little easier with a specific eligibility that tends to match the services they provide (Speech-Language Impairment), OTs don’t have it so clear-cut.

Yes, there are eligibilities where OT is more likely to be involved, such as Orthopedic Impairment, which covers conditions like cerebral palsy and spina bifida. 

But no eligibility requires an OT to qualify for. This is both good and bad. It means that we don’t have to evaluate based on diagnosis alone, and we’re not legally obligated to provide services for kids who really don’t need us. But it also means that it’s a lot harder for clinicians to know when and when not to provide services. 

And, it also creates scenarios that while rare, cause confusion for special education providers, general ed teachers, and families. 

When a Student Only Needs OT

Take for example a student who has decreased fine motor skills, which present as illegible handwriting and difficulty opening packages at lunch. Let’s even say that for the purposes of this exercise, an OT would recommend services. But how it will shake out depends on what else is going on with the student.

Do they also have academic concerns in reading and writing? A school psychologist may find that they have a Specific Learning Disability affecting their progress, and recommend an IEP. An OT could then add their related service to this. 

Do they have an ADHD diagnosis? After evaluation, the team may decide that this is impacting their education and recommend SDI in an area like study skills, to be provided with the resource teacher. Again, it’s easy for an OT to add service here. 

But what if you have a high-achieving student with no apparent academic concerns or other relevant diagnoses? In many places, this student would not qualify for special education, and thus, would not receive OT. 

In fact, if you’ve been a school-based OT for a while, I can almost guarantee you’ve had an evaluation like this – where you would have recommended services if the student had ended up qualifying for special education in general.

Let’s take another student. This one is a kindergartener with cerebral palsy. Their speech isn’t impacted, but their gross and fine motor function is. Academically and cognitively, they’re just like their peers. However, they are unable to navigate the school campus safely, complete toileting independently, hold writing utensils, cut with scissors, or play all the games in PE. 

Again, this is a kid who doesn’t appear to need special education on paper, at least not the kind typically provided by a special education teacher.

But they absolutely are screaming out for some support from an OT (and likely PT, too, who has very similar rules to us under IDEA).

In practice, I’ve found most districts will find a way to get this type of student the support they need, regardless of how that looks on paper. Often, this means creating an IEP with a very minimal amount of specially designed instruction provided by the special education teacher, who also will case manage. The bulk of the support is provided by OT. 

But some states make this a little easier.

When OT is SDI

Let’s go back to IDEA for a moment and see what it says about when a student appears to only need a related service like occupational therapy.. 

“(i) Subject to paragraph (a)(2)(ii) of this section, if it is determined, through an appropriate evaluation under §§300.304 through 300.311, that a child has one of the disabilities identified in paragraph (a)(1) of this section, but only needs a related service and not special education, the child is not a child with a disability under this part.

So, the legislation is pretty clear that IEPs with only related services should not exist. That’s why you might encounter situations like the ones described above with a minimal amount of special education minutes served by a special education teacher. And it’s why you’ll hear that OT can’t be the only service on an IEP. That’s definitely the simple answer and what will happen in most cases.

But the law goes on with an important caveat that many miss: 

(ii) If, consistent with §300.39(a)(2), the related service required by the child is considered special education rather than a related service under State standards, the child would be determined to be a child with a disability under paragraph (a)(1) of this section.”

Aha! Here’s the loophole that causes “OT is not a stand-alone service” to not be entirely correct. 

So, which states allow this?

Washington state is one:

“(1) Special education services means specially designed instruction, at no cost to the parents, to meet the unique needs of a student eligible for special education services, including instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings; and instruction in physical education.

(2) Special education services includes:

(a) The provision of speech-language pathology, occupational therapy, audiology, and physical therapy service as defined in WAC 392-172A-01155 when it meets the criteria in WAC 392-172A-01035 (1)(c);” 

New York is another. So is Ohio, when students qualify for special education under Developmental Delay – which is a whole other state-specific difference that takes a while to explain, and this article is already long enough! 

But in fact, many states have a provision like this buried deep in their dry educational legislation (fun reading, I know). But this is why it’s so important to be familiar with your state law in addition to federal. In other words, don’t take what you read in Facebook groups as gospel! 

Other Considerations Around Stand-Alone OT

So, if you don’t live in one of the states that allows OT to serve as SDI, all is not lost. If you feel strongly that a student needs school-based OT, consider providing it on a 504 plan, which has slightly different requirements than IDEA in regard to disability. 

Alternatively, see if your school would be open to you serving this student without an IEP or 504 plan. Many therapists are surprised that this is an option, but nothing in either of these laws prevents a school from providing OT to a student. Remember, these laws protect students with disabilities – they don’t really speak to what is allowed for students without them. 

In both of these scenarios, your school/district may need to double-check that your position isn’t funded entirely by special education, which would make it hard for you to provide services, even on a 504 plan, as that is considered a facet of general education.

But in any case, OTs are highly ethical clinicians who will find a way to do what’s right. 

Occupational therapy in the school system is a minefield of grey areas and exceptions. It can be hard to know what’s right! If you learned how to be a good OT in school but not how to navigate the school system, you’re not alone. If you’re ready to further your education, enroll in The Dynamic School OT Course. You’ll learn everything you need to know about laws, common practice, and weird situations like this one that are more common than you think. Most importantly, you’ll learn how to approach these scenarios so that you can be the best therapist possible for yourself and your students.