What They Did

School-based occupational therapists work within a complex web of influences that shape how they deliver services. Zeitlin and Schmidt wanted to get a clearer picture of what those influences actually are, so they used an ecological systems lens, drawing on Bronfenbrenner’s Ecological Systems Theory and the Person-Environment-Occupation model, to explore how factors at different levels affect practice. They combined this with the participation-focused knowledge translation framework, or P-KT, which looks at how therapists blend evidence, professional reasoning and the demands of their context into everyday decisions.

The research question guiding the study was: what factors influence the scope of occupational therapy practice in school-based settings? Rather than just looking at what individual therapists do, the researchers also wanted to capture how practice is shaped by policy, school culture and clinical reasoning.

Methods

This article is a qualitative research study. The researchers ran six focus groups with OTs who’d already taken part in an earlier nationwide survey and agreed to be contacted again. Findings were then organised using the P-KT model, across Bronfenbrenner’s three levels: macro, meso and micro. Twenty-one school-based OT across the United States took part, all women, and most were experienced, with over 60% having ten or more years in practice. Most worked in elementary schools.

The Results

Macro-level: policy and cultural shifts

At the broadest level, participants described a mismatch between state-mandated curricular expectations and children’s developmental readiness. One participant reflected that “the rigor of kindergarten was more like what first grade was… 20 years ago.” Many districts no longer provide explicit handwriting instruction, and participants linked this directly to rising referral numbers. I think the observations are very similar to the 2016 curriculum changes in the UK where the Year 1 curriculum became the reception curriculum overnight and the focus on phonics led to handwriting being taught via phonics which is not necessarily the best approach as it means children start learning to write ‘s’ first despite it being very complex. Participants also talked about broader cultural shifts towards valuing mental health, inclusion and universal design, which they felt were opening up new, more collaborative roles for OT in the classroom.

Meso-level: organisational structures and resources

At the school and district level, participants described a lot of variation in how evaluations were run and how OT fitted into Multi-Tiered Systems of Support. Some school based OTs had proactive, classroom-embedded roles across all tiers; others were restricted to Tier 3, individualised special education work only. Several described feeling “pigeonholed into handwriting,” with colleagues assuming fine motor was their only contribution. Some found themselves filling gaps left by unavailable specialists, like mental health providers, which created what the authors called “ethical tensions around scope of practice.” 

Micro-level: clinical reasoning and collaboration

At the level of individual practice, participants talked about leaning heavily on clinical reasoning and prior experience, often gravitating towards familiar, concrete areas like fine motor skills. They also emphasised the importance of student-specific data, including their own observations, student preferences, and input from family or teachers. Interventions shifted with the schooling stage; as students moved into middle and high school, participants moved away from handwriting and towards executive functioning, self-regulation and independence. Collaboration went beyond direct intervention too, with school based OTs providing team training on sensory processing, emotional regulation, assistive technology and environmental modifications, and advocating for individual students within the wider team.

One limitation of the study is that it is based on perceptions and reflections rather than observed practice, so it’s hard to know how consistently these tensions actually play out day-to-day. 

Practical Takeaways

For those of us working in schools, this study offers a useful way of making sense of why the role can feel so inconsistent from one school to the next. It’s not just about individual clinical judgement; it’s shaped by policy decisions well above our pay grade, and by how each school chooses to structure MTSS and evaluation processes.

If your referrals are dominated by handwriting concerns, this research suggests that’s often a symptom of broader curricular gaps rather than underlying disability, and it’s worth naming that explicitly when you’re advocating for a broader scope within your school. The “shape-shifting” many participants described, stepping into gaps left by physical therapists, mental health providers or literacy specialists, is worth reflecting on. It comes from a good place, wanting students to get the support they need, but it can pull us beyond our scope of practice and training. Being clear with your team about where your expertise lies and to continue to advocate for involvement from other relevant professionals.

And if you work across a range of year groups, this is a good reminder to keep shifting your lens as students get older, moving away from a fine motor default and towards executive functioning and self-regulation support as independence needs change.

This scoping review examined what helps and hinders new graduate occupational therapists (within three years of qualifying) working effectively with children and families. Following PRISMA-ScR and Joanna Briggs Institute guidance. It included 13 studies, mostly from Australia, with some from the US, New Zealand and Canada. Four themes emerged: preparedness for the role (university curricula and placement experience); setting or context (caseload complexity, clinical risk and workload); support and continuing professional development (supervision, mentoring and team support); and the new graduate experience itself (confidence, decision-making and resilience). New graduates in paediatric-specific roles generally had better access to supervision than those in generalist or sole-practitioner positions, such as many school-based roles. Workload and billable-hour expectations in the national disability insurance system (NDIS) system reduced time for reflection and contributed to burnout. Mentoring, especially from someone external to the organisation, was valued more highly than supervision, which some experienced as evaluative rather than supportive. I think this is a very interesting reflection, as it is standard practice for supervision and support to be delivered internally. The authors call for more structured transition programmes and consistent supervision to support new graduates entering paediatric practice. This advice may be different in other countries, for example in the UK, where there are not always new-graduate or even junior positions available on paediatric teams. To me this approach limits the opportunities for therapists to get started in paediatric practice.

This exploratory mixed-methods study investigated how paediatric occupational therapists in the USA decide on therapy frequency, intensity, duration and method of service delivery. Ninety-eight therapists working in outpatient and private practice settings completed a survey which included Likert-type ratings with open-ended questions. During data analysis, the authors identified five conceptual domains underlying dosage decisions. These were clinical and client characteristics, logistical and financial constraints, psychosocial and historical context, service coordination and delivery, and physician guidelines or waiting lists. Family goals and priorities were the most frequently selected top consideration for both duration and frequency decisions, while readiness for activity was most important for intensity. While this study focused on outpatient and private practice rather than school settings, the domains identified offer useful language for articulating and documenting the reasoning behind service recommendations, highlighting how dosing decisions integrate clinical judgement with practical, systemic constraints. For me the biggest limitation was that it didn’t actually explore or include the dosage that therapists were providing to clients, data that would probably have been reasonably simple to collect on the survey and would have added greater context to the themes.