Occupational Therapy in Schools (Guide + Directory)

Occupational therapy (OT) helps people participate in their daily activities when they have a health condition or disability that may make participation difficult.

For school-based occupational therapists, this means helping a child participate in their schooling when there are barriers to doing so.

You may have found this article because your child was referred to school-based OT, or you may be an aspiring school OT yourself. Either way, we will do our best to answer your basic questions about school-based occupational therapy.

Your child’s right to evaluation if they have a disability

In the United States, school districts must provide a free appropriate public education (FAPE) to children with disabilities.

This means public schools must identify and evaluate students who may have disabilities at no cost to families. (This rule covers children from birth to 21.) As the parent or caregiver, you have the right to request an evaluation if you have concerns.

You can read about this federal policy, called IDEA, here. Child Find is a resource that walks you through the process of reaching out to your school to schedule an evaluation.

Other important mandates related school OT for your child

In addition to the right to evaluation mandated under IDEA, there are a couple more mandates we should review to ensure you fully understand school-based OT.

If your child does qualify for services, IDEA gives them the right to 3 basic things related to OT:

#1 An Individualized Education Plan

The individualized education plan (IEP) is a written document that lays out a plan for meeting a student’s unique educational needs. The IEP is developed by an IEP team (which may include an OT).

#2 Education in the Least Restrictive Environment

Education should take place in the Least Restrictive Environment (LRE) possible. This means children should not be pulled out of the general education classroom unnecessarily.

#3  Parent Participation

Parents or caregivers have the right to equal participation in this process. They are entitled to:

• Request an evaluation.

• Receive notification of a planned evaluation.

• Access planning and evaluation materials.

• Be involved in all meetings regarding their child’s placement and services.

It is important to note that children may receive OT services in school even if they don’t have an IEP. IDEA part B provides limited funds to cover early intervening services (EIS) for children “who have not yet been identified as needing special education or related services but who need additional academic and behavioral support to succeed in a general education environment.”

Occupational therapy’s role in schools

Now that we know the basic mandates that guide our practice, we can look at the specific role of OTs in helping individual students.

According to IDEA, occupational therapy includes:

• Improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation;

• Improving the ability to perform tasks for independent functioning if functions are impaired or lost; and

• Preventing, through early intervention, initial or further impairment or loss of function.

The role of OT in schools involves a variety of service types, including:

• Direct services where therapists work 1:1 with students (either in a separate treatment space or joining the student in their own classroom)

• Indirect services like creating resources for the student’s classroom

• Conducting evaluations and observations of the student in the school setting

• Consultation with teachers and other school supports, and

• Attending IEP and other student progress meetings

Let’s look at the specifics of evaluation and treatment:

What does an OT evaluation and an IEP entail?

When a concern is raised, your occupational therapist will evaluate your child for any issue related to OT. For school-aged children and adolescents, OTs typically look at academics in addition to social participation, play and leisure, mental wellness, and self-care activities.

This blog post walks through the many steps of a school-based OT evaluation.

Here is a list of the standardized and non-standardized assessments a school OT may use (this gives you an idea of the specific areas OTs may look at related to your child’s ability to participate in school):

Strengths-based Assessments

• My Sensory Experiences Tool
  Dynamic Assessment of Social Emotional Learning
  My Self Advocacy Map

General Development and Motor Skills

• Assessment of Life Habits (LIFE-H)

• Bruininks-Oseretsky Test of Motor Proficiency | Second Edition (BOT™-2)

• Developmental Assessment of Young Children | Second Edition (DAYC-2)

• Developmental Coordination Disorder – Questionnaire (DCDQ)

• Little Developmental Coordination Disorder Questionnaire

• Test of Gross Motor Development (TGMD)

Communication Skills

• MacArthur-Bates Communicative Development Inventories (MB-CDIs)

• Preschool Language Scale, 4th Edition (PLS-4)

• Social Communication Questionnaire (SCQ)

• Social Responsiveness Scale, Second Edition (SRS™-2)

Executive Functioning Skills

• Behavior Rating Inventory of Executive Function (BRIEF)

• Mullen Scales of Early Learning (MSEL)

Occupational Participation

• Canadian Occupational Performance Measure (COPM)

• Child Occupational Self Assessment (COSA)

• Goal-Oriented Assessment of Life Skills (GOAL)

• Miller Function and Participation Scales (M-FUN)

• Peabody Developmental Motor Scales | Second Edition (PDMS-2)

• Perceived Efficacy and Goal Setting System (PEGS)

• Roll Evaluation of Activities of Life (REAL™)

• School Function Assessment (SFA)

• The Short Child Occupational Profile (SCOPE)

Mental Wellness

• Children’s Depression Inventory, Second Edition (CDI 2)

• Pediatric Specific Quality of Life Questionnaire (PedsQL)

• Self Perception Profile for Children (SPPC)

Sensory Processing

• Sensory Processing Measure

• Sensory Profile™ 2

Visual-Motor and Handwriting Skills

• Beery-Buktenica Developmental Test of Visual-Motor Integration | Sixth Edition (BEERY™ VMI)

• DeCoste Writing Protocol (DWP)

• Developmental Test of Visual Perception (DTVP-3)

• Evaluation Tool of Children’s Handwriting (ETCH)

• McMaster Handwriting Assessment Protocol (MHAP)

• Test of Visual Perceptual Skill (non-motor) (TVPS-4)

• Wide Range Assessment of Visual Motor Abilities (WRAVMA)

After the evaluation, goals are crafted for the IEP—ideally in close collaboration with the student and parents. As with any pediatric OT intervention, treatment is most successful when guided by child-set goals. These goals are reviewed at least once a year, but can be reviewed more frequently if needed.

What does OT treatment entail?

OT treatment often focuses on the actual activity that is in the child’s goal area.

We call this a “top-down approach” (versus a “bottom-up approach,” which focuses on specific body structures and skills). We take this approach because it is supported by the most robust evidence.

Here are the steps associated with a top-down approach:

1. Begin with the child’s goal.

2. Practice real-life activities in natural environments.

3. Use intense repetitions to activate neuroplasticity.

4. Use scaffolding to find “just the right challenge.”

Here is a blog post summarizing the evidence behind some of the most common pediatric interventions. (Not all of these interventions can be done in a school setting, but the article will give you a sense of the scope of pediatric OT.)

In conjunction with the top-down approach, your OT will take into account evidence-based treatment best practices for your child’s specific condition. For example, here is an overview of OT for cerebral palsy.

Beyond individual treatment, school occupational therapists support students by making recommendations for environmental changes (like implementing adaptive seating or making classrooms sensory-friendly); providing adaptive tools; and educating teachers about the supports a child needs to succeed.

School-based OT at every level

As kids progress from preschool and kindergarten through middle and high school, their needs and goals change dramatically. Occupational therapists provide skilled services to help students succeed at every grade level. Some general areas of OT intervention across the education spectrum include:

• Preschool: OTs work in preschools to help children meet developmental milestones and gain school-readiness skills. Areas of intervention in this setting might include self-care skills like feeding and dressing, fine motor skills, social-emotional learning, sensory needs, and academic learning.

• Elementary school: In addition to the areas addressed by preschool OTs, elementary school OTs may focus on setting students up for academic success by working on processing and learning skills, modifying the classroom environment, or adapting classroom activities to the child’s skills.

• Middle school: OTs continue to support children in middle grades as they tackle more complex academic and life skills. Middle school OTs may target organizational skills, social and communication skills, sensory needs, or mental health and self-identity.

• High school: Teenagers and young adults up to 21 may also receive OT services in school. At this age, OT intervention is focused on the transition to post-graduation plans—whether that’s attending college, entering the workforce, living independently, or participating in the community.

At all grade levels, OTs work to perform screenings and evaluations, provide education and resources to teachers, and collaborate with other professionals to support whole-classroom wellness.

How do OTs support the entire student body?

While the majority of OTs work with students via individual, one-on-one sessions, OTs in the U.S. are also uniquely suited to provide services to the entire student body, including students in both general and special education classrooms.

The recently adopted Every Student Succeeds Act (ESSA) is an important piece of legislation when considering OT’s role at the population or group level. One of the primary purposes of ESSA is to encourage districts to support all students via early intervention and prevention approaches. ESSA names multi-tiered services, including Response to Intervention, as one way to accomplish this.

ESSA explicitly names OTs as Specialized Instructional Support Personnel (SISPs) and argues that SISPs are well-suited to providing multi-tiered services to all students.

Here’s a nice handout on OT’s role in supporting the student body through ESSA.

The PATH program is one example of an innovative curriculum that leverages social-emotional learning to create positive school environments for all learners. You can hear about how the PATH program has supported marginalized children with emotional disabilities in New York City Public Schools by checking out this OT Potential Podcast episode.

How does a school OT spend their time?

As you can tell, OT professionals wear many hats in the school-based setting.

When you are focused on meeting the needs of students, teachers, and other staff, your work week can get busy! Here is a list of weekly responsibilities for school-based OTs, as noted in this article:

• Scheduling students for treatments, consultations, etc.

• Completing daily documentation

• Directing student intervention or one-on-one sessions

• Providing staff consultation and education

• Providing family or caregiver consultation and education

• Conducting evaluations, re-evaluations, and screenings

• Writing reports (e.g., evaluations, screenings, etc.)

• Attending team meetings

• Conducting student observations

• Traveling between schools

• Engaging in professional development

• Developing treatment plans and materials

• Completing Medicaid paperwork

• Providing behavioral support (e.g., helping a student get on/off the bus each day)

• Attending committee and/or special education meetings

• Participating in events (e.g., back-to-school night)

• Consulting with outside providers

• Facilitating multi-tiered systems of support or Response to Intervention

• Participating in research and advocacy

• Participating in school committees

• Grant writing

Trends in school-based OT

We’d be remiss not to mention some important trends in school OT.

1. Moving away from compliance-based interventions. 

Compliance-based treatments involve rewarding children for certain behaviors while punishing others. This can produce short term results, but it can lead to long-term damage. Pediatric OTs are part of a larger movement toward recognizing the potential harm of this approach. New behavioral strategies—such as redirection—are becoming more common.

The book titled, “Connections Over Compliance” is a great resource for learning more about the benefits of this paradigm shift.

2. Leveraging our training in mental health

OTs are unique among rehab professionals in that there is a focus on mental health in both our schooling and our scope of practice. And, there is a movement to utilize this dimension of our skill set to support the student body. See the website, Every Moment Counts, for a summary of occupational therapy-led mental health initiatives.

OT advocates are working hard to pass the Occupational Therapy Mental Health Parity Act, which would expand Medicaid coverage to allow OTs to provide more mental health and behavioral health services in schools and beyond.

3. Self-determination, strengths-based, and neurodiversity affirming approaches

Rather than focusing solely on the deficits that impact a child’s schooling, occupational therapists leverage a strengths-based approach to consider the whole child—utilizing the child’s skills, interests, and inherent strengths to find the “just-right” challenge that will guide them toward successful learning.

The self-determination theory posits that meeting a student’s need for autonomy, competence, and relatedness can increase their internal motivation to be self-directed, lifelong learners. These approaches are supported by evidence and aim to increase positive self-identity, self-regulation skills, and motivation to engage in school.

Neurodiversity-affirming approaches in schools recognize that neurological differences (such as autism, ADHD, learning differences and mental health conditions, among others) are natural variations of the human experience, rather than problems that need to be fixed. Neurodiversity-affirming education fosters positive self-identity, enhances school engagement, and supports the development of adaptive strategies by honoring each student’s unique way of thinking and interacting with the world.

Resources for school-based OTs

Phew! We’ve covered a lot of the essentials about school OT, but there is still more to learn! So, we will leave you with some resources for further exploration:

State-by-State Guidelines for OT and Special Education:

• If your state has a guideline, find the guideline here

Statements by the AOTA on school-based OT:

• Expanding the role of school-based OT practitioners (AOTA, 2024)

• New Medicaid guidance for school-based services (AOTA, 2023)

• Supporting practitioners in the public schools and early intervention (AOTA, 2022)

• Workload Approach: A Paradigm Shift for Positive Impact on Student Outcomes (Joint Statement by AOTA, ASHA, and the APTA, 2014)

• Transforming caseload to workload in school-based occupational therapy services (AOTA, 2014)

Brochures and resources from the AOTA:

• What is the role of a school-based OT practitioner? (For School Administrators)

• School Mental Health Tool-kit

• School-Based Occupational Therapy: Myth vs Reality

The emerging research behind multi-tiered systems of support

• Multi-tiered systems of support for preschool-aged children: A review and meta-analysis

• Including College and Career Readiness Within a Multitiered Systems of Support Framework

• Multi-tiered Systems of Support for School-Based Mental Health: A Systematic Review of Depression Interventions

Websites by and for school-based OTs: 

• Every Moment Counts

• OT School House 

• OT 4 ADHD

• Devon Bretihart

• WooTherapy

Resources for interventions: 

• Kelly Mahler’s Interoception Curriculum

• Autism Level-Up

• Kids Master Skills

• Handwriting Help for Kids

• Learn Play Thrive

Recommended books for OTs and caregivers

• ADHD is Our Superpower

• Connections Over Compliance

• The “How to Talk” Series

• The Out-of-Sync Child (Sensory Processing)

• The Power of Showing Up

• Trauma-Responsive Pedagogy

• The Whole-Brain Child

• Uniquely Human (Autism)

Find a school-based OT near you

If you are interested in taking a deeper dive into the world of school-based OT, it might help to connect with one. You can use the OT Directory to find a school-based OT in your area.

Conclusion

It is an honor for us as occupational therapists to serve students in a school-based setting. As OTs, it is our purpose and passion to meet our students exactly where they are—and we know our treatments are most effective when delivered in the places where people spend a lot of their time. So, it is meaningful for us to be working in a setting where kids spend so many of their waking hours.

We also know that helping children succeed can take a village. Working in schools gives us the awesome opportunity to partner with families, teachers, and other professionals who are invested in helping each and every child succeed.