Occupational Therapy Role in Early Intervening/Pre-referral

The school-based occupational therapist can play an important role in the instructional support/pre-referral/early intervening process. The purpose of this process is to provide students with the supports necessary to meet their needs within the general education setting prior to initiating the IEP/SPED process.


In many cases, this level of support may be sufficient to meet the student’s needs, and a referral for evaluation through special education may not be necessary. Therapists possess skills, using the OT Practice Frameworks, to analyze performance in areas of occupation client (child) factors, activity demands, and context. This analysis enables the therapist to make recommendations for strategies to address the student’s educational needs. The occupational therapist’s ability to consider the interrelationship of all these factors on the child’s educational performance can bring a unique perspective to this process.




Reported Problem - difficulty remaining upright in seat and difficulty focusing on whole class directions


The OT may provide the teacher with general information about the different types of movement and the potential effect on the student’s behavior and/or recommend:


~movement activities prior to seated work

~a trial w/ a seat cushion

~adjusting the desk/chair height

~changing the location of the desk

~providing directions one at a time

~providing a written or pictorial list of steps in a task for the student to check off


The chart below demonstrates how the analysis of issues in any of the domains of occupational therapy practice might lead to a specific strategy to support the student need. It is this analysis that helps to determine the strategy recommended.


Instructional Support Strategies - Example: Working Cooperatively with Peers





Turn taking during small group activity

Child Factor

Impulsivity and short attention span limits ability to wait turn, results in ‘off task’ and/or disruptive behaviors

-Have an adult provide tactile cue to shoulder as a reminder of need to attend and to wait.

-Set up reward system for successful turn taking

-Provide a tangible marker to indicate turn to speak. For example the student can speak when the picture is passed to his or her hands.

Activity Demands

Task requires lengthy turn for each student

-Adapt/modify task so that turns are shorter

-Give student a job to do related to the activity, such as recording the responses of others or keeping score so that he or she is engaged throughout the activity

-Provide another activity or fidget object while waiting for next turn

Context (Environment)

Distracted by other groups nearby and by books and other materials within easy reach of group activity area

-Position location of small group in least ‘busy’ area of classroom, away from other students and material

Sharing Materials

Child Factor

Takes materials from peers without asking and hoards materials, refuses to share with peers

-Start with allowing the student to have own materials or begin by sharing with only one other student

-Teach, post and review rule of sharing individually and as a class

-Set up chart/reward system for appropriate sharing

-Model how to share, including use of words

Activity Demands

Limited number of materials requires greater amount of sharing and disrupts the productivity of independent work time for student and others in class

-Provide own set of materials for certain independent work tasks

-Use timer for use of materials before passing

-Begin with smaller groups or pairs so that the student can practice structured turn taking

-Explain clear rules for sharing at the beginning of each activity through the use of social stories

Context (Environment)

Student is in desk cluster farthest from teacher desk making monitoring of sharing more difficult

-Reposition student in desk cluster close to teacher desk/area of instruction

-Have fewer peers in the student’s desk cluster so that turn taking is more manageable

Respecting Personal Space of others

Child Factor

Unaware of personal boundary guidelines, tends to get in peers’ space

-Teach appropriate personal space – use strategy such as ‘arms length’ or practice with and then visualize hula hoops around each person

-Provide each student with own space such as the use of mats during meeting time

Activity Demands

1. Activities require movement of limbs and bodies to music resulting in unintentional and unexpected physical contact with peers

2. Classroom routine involves an open concept so that students are free to use all spaces for learning activities. It is not clear to the student where to be.

-Select movement to music activities with controlled/structured movements rather than generalized or random movements.

-Determine personal space boundaries prior to each activity with tangible markers such as tape or a mat  specific to that activity

. -Designate spaces within the room that that can be used for specific activities.  For example, have separate desks available for all students who cannot work on unstructured table space.

Context (Environment)

Students seated randomly on carpet for circle time

-Provide carpet squares or other boundaries at circle time

-Perform some activities seated in chairs rather than on rug


Instructional Support Strategies - Example: Managing Clothing & Personal Belongings: Completing classroom routine





Completing AM routine upon arrival to classroom

Child Factor

Limited balance and fine motor skills interfere with removing outer clothing and putting personal belongings away

-Instruct classroom staff to assist in those aspects of specific tasks that the student is unable to perform (ex. hooking zipper, putting on mittens)

-Place a chair in the coat area to allow the student to sit when removing outer clothing

Activity Demands

Multiple factors interfere with completion of routine such as:

insufficient time, given motor control factors, and

too many students in the area to allow enough room to negotiate

-Allow student to begin first or have staff assist with the process.

-Reduce number of students in coat room at one time by using a staggered schedule

Context (Environment)

Coat room is a small area, hooks are located on two levels and student’s hook is in the middle on the top level, just barely within reach

-Change location of hook to lower level at the end of the row of hooks for easier access and to allow the student to use the wall for support when putting belongings away


Instructional Support Strategies  - Example: Illegible Handwriting






at Desk

Child Factor

Postural Control

Seat Cushion

Activity Demands

Sitting too long at one time

Shorten writing sessions, provide breaks

Context (Environment)

Desk/Chair Size

Appropriate size desk/chair

Letter Formation

Child Factor

1. Pencil Grasp

2. Poor letter formation habits developed

Pencil Grip

Practice correct letter formation at home

Activity Demands

Materials: Pencil, Paper

Alter materials: size and type of writing implement, line size and type of paper

Context (Environment)

Distracted by peers

Change seating location for writing

Writing Sentences

Child Factor


Provide word list

Activity Demands

Organizational demands of assignment

Provide template/graphic organizer

Context (Environment)

Unable to see board

Preferential seating near board


This pre-referral process of providing instructional support may include a screening, done by the occupational therapist, to determine the next steps necessary to address the student’s educational needs. A screening is a process of gathering information for the purpose of determining the need for formal evaluation. What constitutes a screening may be defined by state licensure law. A screening typically may include observation in various settings (classroom, gym, cafeteria, playground, during transitions, or other locations), and interviews with teachers, parents, and/or other adults involved in the student’s educational program.  It also may include checklists and record review. The pre-referral process may result in recommendations for accommodations or strategies (instructional supports), or in a referral for a formal evaluation.



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