What is the Scope of Practice in School-Based OT?

The scope of practice in school-based OT is surrounded by much confusion and misinformation. Despite occupational therapy being one of the most broad, holistic fields, school-based OTs are often pigeonholed into roles as “handwriting specialists” or “fine motor therapists.” And what’s worse is when school-based OTs push back against these limitations, they are often met with resistance and told to “stay in their lane.” Most frustratingly, some of the individuals purporting this limited scope of practice are other school-based OTs! So what is within the school-based OT scope of practice anyway? 

IDEA and the Scope of Practice in School-Based OT

When considering what falls into our domain in the schools, we should first look at the Individuals with Disabilities Education Act (IDEA), the federal law that governs special education and the main source of how OT functions in the school system. 

IDEA defines OT as:

“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.” 

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;”

So Do School-Based OTs Only Address Fine Motor Skills?

Nope! This one is interesting to me because as you can see above, nowhere in the IDEA definition of OT does it refer to motor skills at all. So why have school-based OTs been pigeonholed into being fine motor therapists? I’m not sure, but it’s important to note that both IDEA and AOTA (and likely your state laws too) support you utilizing your full scope of practice as an OT as long as it is related to the student’s education. That means we should be assessing and addressing way more than just fine and visual motor skills.

So What IS in the Scope of Practice in School-Based OT?

Truthfully, anything that is within OT’s scope of practice in general that helps a child benefit from their educational program is within our domain in the schools. While we don’t work on academic skills like multiplication or biology, we do support pretty much all of the skills that go into being ready to learn about those things! Think things like: 

• Activities of daily living
• Attention
• Assistive technology
• Environmental modifications
• Executive function
• Fine motor skills
• Gross motor skills
• Leisure skills
• Play
• Rest and sleep
• Seating and positioning
• Sensory processing
• Social skills
• Visual motor skills
• Vocational skills

Are There Limits to the Scope of Practice in School-Based OT? 

While OT can address all of the skills listed above, in the schools, it’s not enough for a student to simply have a deficit in one of these areas. Instead, there must be a demonstrated need that is related to that student’s access or independence with their educational program. You’ll often see this compared as the educational model vs the medical or clinical model. In the medical model, occupational therapy services can address any deficit area for the sake of remediating a deficit (as long as funding sources allow). While these often may end up being the same deficits, the difference is that in the school system, those deficits have to have educational impact. 

To put it another way, in the medical model, pediatric OTs help their patients be the best tiny humans they can be in ALL of their roles. In the schools, OTs help their kids be the best students they can be. 

And remember: this doesn’t mean that all of the things we address in schools are tied to academics. We all know that being a good student involves a lot more than just making good grades. So don’t forget to think of the other tasks your students need to do that require attention, executive function, sensory processing, emotional regulation, ADLs/IADLs, and vocational skills. 

Sharing Parts of Our Scope

Now, something else to keep in mind is that you are not an island in the school system. You are a specialist and a related service provider, and not necessarily the only or even the best person to help the student. Just because something falls into your scope of practice doesn’t mean that a student will require school-based OT services to address it. In fact, many of my school-based OT evaluations reveal areas of need that I recommend other professionals fulfill. 

What does this actually look like in practice? Take handwriting – one of the most common OT referrals – for example. I might assess a student who’s struggling with handwriting. But through that assessment, I might find out that the student never had explicit handwriting instruction. I might also find that their underlying fine motor skills are actually pretty good. I might find that they tend to rush in class, but can write neatly when they slow down. In these cases, I usually don’t recommend school-based OT services and instead put the ball back in the court of teaching staff. I educate my teams on how important it is to have explicit handwriting instruction and practice, and recommend some ways they can add this to the student’s routine. In some cases, I’ll even recommend a specific curriculum and offer to co-teach a lesson to orient the teacher and students. In these cases, the student doesn’t need OT intervention – they just need more opportunities to learn and practice.

To put it succinctly, each time I identify a deficit, I ask myself this question: “Does this student require the specific knowledge of a school-based occupational therapist to address this deficit?” If the answer is no, the student doesn’t require school-based OT for that area of need. But they may require the services of a special education teacher, speech-language pathologist, or physical therapist.

How Can I Help My Colleagues Understand the Scope of Practice in School-Based OT?

If you work with people that think of you as a fine motor therapist or a handwriting teacher, you’re definitely not alone. And if you’ve ever gotten pushback about addressing something “outside your scope” by a non-OT, try to think of it as a learning opportunity instead of getting frustrated. When these situations happen, politely but assertively inform people that it actually is within your scope, and you have all of the experience and education needed to address it. Offer to send them resources, such as the OT Practice Framework or your state’s guidelines for school-based OT, if they have one. When I find myself in these situations, I try to keep it short and sweet, especially if I’m in an IEP meeting. But I make a note that I need to be more proactive in the future, by doing things like offering inservices, delivering services in classrooms, and screening students. 

I hope this article cleared up the scope of practice in school-based OT and you feel empowered to step into a more holistic role! And if you’re looking to have your unique contributions valued and recognized, I’d love to have you in The Dynamic School OT. You’ll learn how to break out of the mold of being the fine motor therapist or handwriting teacher to become a highly valued, effective, and provider in your school.