What’s the difference between OT in the school system and OT in an outpatient clinic? This is a question that many parents, teachers, and caregivers find themselves asking. Truthfully, this is a topic that many occupational therapists are fuzzy about as well. As an OT who started my practice in the clinic, it wasn’t a difference I fully understood until I started working in the schools. While the core of the answer is simple, in practice it requires nuance and experience.

Educational Impact vs. Medical Impact

The biggest difference in these two models of service is that school-based OTs must address deficits that have an educational impact. This difference is subtle and sometimes challenging to see at first. Put simply, in a medical model, occupational therapy services can address any deficit area for the sake of remediating a deficit (as long as funding sources allow). But in a school model, OT services only address deficit areas that can be related back to the student’s education. The purpose of school-based OT is to help a child benefit from their educational program.

Still confused? To put it another way, school-based OTs attempt to help their kids be the best students they can be. In the medical model, pediatric OTs help their patients be the best tiny humans they can be in ALL of their roles.

Addressing Areas Other Than Academics

So does this mean school-based OTs are limited to addressing areas that are directly tied to academics?

Nope! Quite the contrary. We can address any area related to a student’s educational program, which for many of our students includes life skills. It’s important to remember that school isn’t just about reading and writing. Students also need to do things like keep their work organized, feed themselves and manage the cafeteria, pay attention during class, and play appropriately with peers on the playground. Basically, if there is any task that falls into the scope of OT in general, and it’s impacting the student’s access to their education, a school-based OT may address it – with some exceptions.

OT as a Related Service

Another big thing to keep in mind is that per IDEA, school-based OT is a related service. This is different than a primary service such as teaching provided by a special education teacher. So while school-based OTs have the ability to address pretty much any deficit area, not every student will require school-based OT even if they have needs an outpatient OT might address. For example, it’s likely that most students with severe disabilities in a life skills program will require assistance with meal prep skills. But this is an area that is well within the domain of a life skills special education teacher, and as such, they will be the primary point of contact in addressing this. A school-based OT still may serve some students with this deficit, but they will likely be students with more complex or unusual needs that require the specialized knowledge of an OT.

This was the biggest thing I didn’t fully understand about school-based OT when I worked in outpatient, and it took me a few months in this setting to really be able to identify the nuance. I recall working with parents in outpatient pediatrics who were frustrated that their child wasn’t receiving school-based OT, and I was frustrated for them. But in retrospect, the recommendations were likely appropriate. My patients’ needs were more than likely all being addressed by the school, they might have just also been addressed by teachers, school counselors, and other staff.

Student in wheelchair in gym

Now, the advice I would give to parents who are concerned that their child is not receiving enough school-based OT, or maybe none at all, is to make sure that all the needs are captured by the IEP. Make sure your student has goals in every area you and the rest of the team feel is relevant. Then, be open to what professionals make the most sense to address their needs in the school setting. You might be surprised! Give it some time, and then, if you ever find that your child is not making progress, you can always call for an IEP meeting to propose changes.

Setting Matters

One other important to keep in mind is the context a child is in. I’ve worked with many families as an outpatient OT who really benefitted from addressing things like attention, transitions, and sensory processing. However, when it came time for these students to go to school, they thrived in the structured environment. This isn’t to say that they didn’t still have challenges – but these were kids who by all accounts were doing well at school. Anyone who’s spent time around kids in multiple settings knows they can behave differently. Have you ever known a kid who is good as gold for Grandma but is back to their usual wild ways once they’re home? It’s the same with school. Now, this isn’t to minimize the challenges that families may be having at home and in the community – those are real. But they also might be difficult for the educational team to address if they’re not displaying them at school. In this case, outside therapies may be more relevant and valuable.

School-Based OT vs Medical Model OT Examples

So now knowing what you know about these differences, let’s practice identifying what services a student might receive.

Example: A second-grader has motor coordination difficulties and cannot tie shoes. However, the student wears velcro or slip-on shoes every day to school, including PE, and is comfortable and safe doing so. Should this student receive OT services?

Student with velcro shoes

Answer: An OT in a medical setting may work on shoe-tying for the sake of it. However, in the school setting, it would be challenging to justify school-based OT services for this deficit as the student is clearly accessing their educational program without this skill.

Here’s another student. A freshman in high school has handwriting that is challenging to read. His parents are dissatisfied with it. However, the student prefers to type his work and is able to do so at a rate commensurate with peers. Should this student receive OT services?

Answer: The student is able to access his education despite his deficit in handwriting. A school-based OT still might work with a student like this to make sure they have the appropriate accommodations in place, but they would likely not work directly on handwriting remediation.

I hope this explanation was helpful! Though this distinction was challenging for me to understand and articulate at first, it has definitely gotten easier with time. I imagine the same will be true for you. If you have any questions, I would love to have you join me in my Facebook group where I share videos and resources all about school OT.

Looking to take your learning even further? My course, The Dynamic School OT, is the perfect primer for therapists new to the school system. We’ll take an in-depth look at all of the topics discussed here, as well as evaluation, RtI, appropriate interventions, and how to manage difficult situations. If you have any questions, feel free to comment below!

To sign up for my mailing list to receive more great resources like this one, click here!