Analysis based on a September 25 American Journal of Occupational Therapy scoping review, federal IDEA regulations and inclusion guidance, and AOTA's school-based practice resources.
School-based occupational therapy is often reduced to a caseload number: how many students, how many minutes, how many sessions left in the week. A new review in the American Journal of Occupational Therapy finds a much larger job. Across 60 studies, practitioners worked directly with students, alongside teachers, inside classrooms, across tiers of support, and at the level of the school system. The same review found the work repeatedly narrowed by unclear roles, heavy caseloads, and too little shared planning time. For school leaders, the message is practical: inclusion depends partly on what happens between visits, when the adults responsible for a student's day have time to plan together.
In brief
- The scoping review included 60 studies published from 2010 through 2025; 56.7% used qualitative designs, and most came from high-income regions.
- School-based OT roles extended from individual intervention to classroom support, consultation, capacity building, environmental change, tiered services, and systems-level work.
- Recurring barriers included educator uncertainty about the OT role, caseload models that squeezed out joint planning, and attention concentrated on structured academic tasks.
- The review did not critically appraise study quality, so it maps the field and its gaps rather than proving that one service-delivery model produces better outcomes.
Sixty studies map a broader school role
The authors searched eight databases for English-language primary research published between 2010 and 2025. The 60 included studies described school-based occupational therapy in mainstream education through several overlapping roles: individualized direct service, classroom collaboration, consultation, teacher and staff capacity building, environmental adaptation, advocacy, and wider systems work.
That range matters because a student's performance changes with the setting. Handwriting at a clinic table, organizing materials during a crowded transition, joining a playground game, and managing the noise of lunch are different occupational problems. The review found practice models that followed those differences into classrooms and routines, including embedded and tiered approaches designed to reach students earlier and support the adults around them.
The evidence base was uneven. Mainstream primary schools accounted for 55% of the included studies. Early childhood, secondary school, transition, and higher education appeared less often. Most studies came from high-income regions, which limits how confidently the map travels across education systems, staffing models, cultures, and funding structures.
Planning time belongs in the service model
Collaboration is easy to praise and hard to schedule. The review repeatedly found high caseloads restricting the time available for shared planning. It also found role ambiguity among educators, which can leave teachers unsure when to involve OT or what kind of classroom problem belongs in the conversation.
Those two barriers reinforce each other. When a therapist's calendar is built almost entirely around direct-contact minutes, consultation becomes an extra task tucked between students. When teachers have little visibility into the OT role, they may bring a problem forward only after a routine has broken down. A service can look full on a spreadsheet while the collaboration required for inclusion remains starved of time.
AOTA's school-based resources place collaborative goals and interprofessional work inside ordinary practice. The new review adds a management question: does the staffing model actually reserve time for observation, teacher conversation, strategy design, follow-up, and adjustment? If those steps exist only in good intentions, the service model has left out part of the work.
Recess counts, too
The review also found an overemphasis on structured academic tasks, with less attention to nonacademic occupations. That is a consequential blind spot. School participation includes arrival, meals, toileting, movement between rooms, recess, clubs, social interaction, and the small routines that determine whether a student belongs to the day or merely gets through it.
Federal law already gives those settings weight. IDEA lists occupational therapy among the related services a child may need to benefit from special education. Federal inclusion guidance also points to nonacademic and extracurricular settings, including meals and recess, when describing participation with nondisabled peers and the supplementary aids and services an IEP team should consider.
The review therefore supports a wider audit of school goals. A student may complete a worksheet and still lose access at the locker, cafeteria table, playground, or dismissal line. Observation across the day can reveal environmental barriers and participation needs that a pull-out room will never display.
Role clarity has to reach the classroom
A clear role statement should describe problems teachers can recognize. It can explain that school OT may address task demands, tools, routines, sensory and physical access, self-management, transitions, and participation in school occupations. It should also explain how referrals or team questions move from observation to consultation, assessment, intervention, and review.
Useful clarity is specific. A teacher should know whom to contact when a student cannot manage materials during a fast transition, avoids a noisy lunchroom, tires before written work is complete, or cannot join a group activity with the tools provided. Families should be able to see how the proposed service connects to participation in the student's educational program. Administrators should be able to distinguish direct treatment time from the observation and coordination that make a classroom strategy usable.
This does not turn every school difficulty into an OT referral. It gives the team a shared language for deciding when occupational analysis, environmental adaptation, or a participation-focused strategy may help.
Read the map with its boundaries
A scoping review is designed to show what has been studied, how the work is described, and where the gaps sit. The authors did not critically appraise the included studies, and 56.7% were qualitative. The review cannot rank service models, set caseload limits, or establish a causal link between collaboration time and student outcomes.
Its international scope also requires care in a U.S. district. IDEA supplies the federal floor, while state rules, local staffing, IEP decisions, collective bargaining, and district procedures shape the actual service. Findings from one national system cannot simply be pasted into another.
The review is most useful as a mirror. It shows a recurring pattern across the literature: school OT expands when practitioners can work in context and with the people who shape that context; it contracts when the calendar recognizes only isolated encounters.
A practical audit for school OT teams
Start with one representative week. Separate direct service, evaluation, observation, documentation, teacher or family consultation, team meetings, materials preparation, travel, and follow-up. Then compare the calendar with the duties the district says its school-based OT service performs. A mismatch between the role statement and the funded time deserves attention before another initiative is added.
Next, sample several student plans across grade levels. Look for participation beyond structured academic work and ask whether the goals, supports, and progress information reach the natural settings where the problem occurs. Include a secondary or transition case if the program serves those ages; the review found those parts of the evidence base especially thin.
Finally, give teachers and families a short, concrete route into consultation. Name the kinds of participation problems OT can help analyze, the information that is useful at the start, and how the team will know whether a strategy is working. Inclusion is carried by routines. The school schedule should make room for the people who help those routines hold.