When Does a Student Need School-Based OT?

How do you know if a student needs school-based OT? If you find yourself asking this, you’re not alone! This is a decision that even more experienced school-based OTs struggle with sometimes, and it’s not always a clear-cut answer. The good news is that it definitely gets easier to determine with practice! If you’re not even sure where to get started, here are the things I keep in mind when recommending school-based OT services.

The Scope of School-Based Practice

You might have heard that school-based OT has a more limited scope of practice. While I don’t necessarily agree with this, it definitely is more specific than OT under a medical model. Most importantly, school-based OTs must address deficits that have an educational impact. This is opposed to a medical model in which 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 be impacting a student’s access to their education. 

Still confused? 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. 

Now, 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. As such, school-based OT can focus on attention, executive function, sensory processing, social skills, ADLs/IADLs, vocational skills, and more. It all just depends on the needs of the specific child. 

Conducting Your OT Evaluation

Like other OT settings, the need for OT services is determined by the OT evaluation. However, unlike other settings, there’s not a lot of hard guidelines on what should be included or addressed in the eval in order to see if the individual requires OT services. Yes, you may use a standardized test or two, but per IDEA, OT is a related service that is available to any special education student that requires it to access their educational program. You may be surprised to learn that IDEA does not actually require specific standardized test scores at all, though some states or districts may adopt their own policies in this arena. Because of how the law is written, I’m very specific with my language when speaking to parents and school staff: students don’t qualify for OT, instead, they either do or do not require it to access their educational program. And while standardized scores can be helpful in making that distinction, your service recommendations shouldn’t hinge on them. The only exception to this is if you’re helping to determine if a student qualifies for special education under the Developmental Delay eligibility. There are specific scores delineated by IDEA required to qualify under this eligibility. Still, this is a separate conversation and decision from recommending occupational therapy services.

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So should you use a standardized test at all? That depends. Will it provide you with more information to help you understand the child and their needs? If so, it’s worth including. But if you feel that it wouldn’t be a good representation of a child’s abilities, skip it. It’s important to keep in mind that most of the tests were not standardized on children with disabilities, especially more severe ones. I’ve had kids do really poorly on a standardized test but be completely functional in school, and I’ve also had the opposite: kids who score perfectly on testing but are still really struggling with written expression, executive function, or participation.

While it can be a little frustrating to not have a clear standardized score to point to as the qualifying factor for school-based OT, I much prefer it this way for several reasons. For one, it helps the decision feel more holistic and guided by my clinical reasoning. And two, it helps navigate the sticky situation of determining services for a student who has plateaued but continues to score poorly on standardized tests. 

So what should you include in your evaluation instead? Here’s what I focus on:

  • The specific concerns of the teachers, parents, and student
  • Observations of a student in their natural environment (classroom, playground, lunch, etc.)
  • The student’s personal strengths, interests, and goals
  • Activity analyses of the tasks the student is struggling with
  • Descriptions of a student’s current performance with specific motor, self-help, executive function, and vocational tasks

Determining What is Needed

So this is the tricky part, right? After you’ve identified some weaknesses and areas for growth, how do you determine what services to recommend? 

Well, the first thing I keep in mind is that I’m not an island in the school system. I am a specialist and a related service provider, and I’m not necessarily the only or even the best person to help the student. In fact, many of my 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 therapeutic 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.

And it’s not always just teachers that I refer back to, either. I have recommended that teams look into speech therapy, AAC devices, physical therapy, adaptive PE, social work, counseling, and in limited cases, further medical intervention/services guided by the student’s pediatrician. While I’m careful not to say that students require any of these services, I do help families and IEP teams advocate for getting these evaluations done to see what other options there are for helping the student. 

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Beyond recommending services, don’t forget to consider what accommodations and modifications might help support your student as well. Whether I recommend services or not, I always have at least a couple accommodations or modifications I recommend to the IEP team. I love being able to use an OT lens to suggest changes to the structure or format of a student’s day to increase participation. And sometimes this is all a student really needs to be successful! 

Making recommendations for school-based OT services can feel tricky at first, but it definitely gets easier with time. I hope taking you through some of my thought processes made this topic clearer! And if you’re still looking for more support, my signature course, The Dynamic School OT,  goes over this topic in much greater detail. Some of the topics discussed include determining if students should be served via consultation or direct services, whether push-in or pull-out services are more beneficial, and how to work with teachers and school staff to ensure students are building skills outside of OT sessions. It also includes a tool that you can use to determine how many minutes of service to recommend based on a student’s areas of need, age, and other factors. You can sign up here, or if you have questions, feel free to email me at thedynamicschoolot@gmail.com. Cheers to providing great OT services to the kids who need it!

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