What Occupational Therapy Is Actually Like

When you tell people you're an occupational therapist, what do they think you do?

They think I help people find jobs. Every single time. "Oh, like resume writing?" No. Not even close. The "occupation" in occupational therapy is any activity that occupies your time and has meaning to you. For a four-year-old, that's eating, playing, getting dressed, tolerating a car seat. For the adults I used to work with at the SNF, it was buttoning a shirt or getting from the bed to the toilet without falling. The word "occupation" is honestly the worst branding decision in the history of healthcare. We've been explaining this since the 1940s and people still think we're career counselors.

In pediatrics, what I actually do is evaluate and treat kids who have difficulty participating in age-appropriate activities. That sounds clinical. Let me be more specific. Last Wednesday, I spent 45 minutes on the floor with a four-year-old named Lily who gags when she tries to eat anything that isn't white. Goldfish crackers, plain pasta, white rice, vanilla yogurt. That's her entire diet. Her pediatrician told her mom to "just keep offering new foods." Which is like telling someone with a broken arm to "just keep lifting."

What was actually going on with Lily?

So the referral said "feeding difficulties." That's all I got. One line on a piece of paper from Dr. Chen, the developmental pediatrician who sends me a lot of referrals. When I read "feeding difficulties," my brain goes to about six possible categories. Could be oral motor. Could be behavioral. Could be sensory. Could be medical, like a swallowing disorder, in which case I'd refer to speech. Could be a combination.

Lily's mom, Teresa, brought her in on Wednesday morning. Teresa looked exhausted. She looked like she hadn't slept well in a long time, and I don't mean that in a judgmental way. I mean I could see the weight of two years of mealtime battles on her face. She sat down and before I even asked a question she said, "I know you're going to tell me she's just picky." And she started crying. Right there in the eval room. Because every professional she'd seen had told her some version of "she'll grow out of it" or "you're making it worse by accommodating her."

I let her talk for about ten minutes. That's not billable time, by the way. The eval is billable. Me listening to a mother describe two years of fighting with her kid over a spoonful of sweet potato is not something I can code for. But it's the most important ten minutes of the whole eval because now I know the family context. Teresa is a single mom, works full-time as a dental assistant, and has another child who is five and eats everything. She's been comparing the two kids and feeling like she's failing Lily. That context matters for my treatment plan because if I design a home program that requires 30 minutes a day of structured food play, Teresa doesn't have 30 minutes. So the plan has to be realistic for her life, not just clinically ideal.

How did you figure out it was sensory and not behavioral?

I put Lily on the floor mat and started with play. Not food. I'm watching her motor patterns, how she uses her hands, how she responds to different textures in the environment. Gave her some Play-Doh. She touched it with one finger, very cautiously, and then wiped her hand on her pants. Gave her a bin of dry rice to dig through. She pulled her hands back and looked at me like I'd asked her to put her hands in broken glass. Then I gave her the bumpy ball from my drawer, the one that has Lily's name on it now, and she held it. She squeezed it. She liked the deep pressure but not the light unpredictable texture.

That told me a lot. Lily's nervous system is interpreting certain tactile inputs as threats. The Play-Doh feels unstable and unpredictable to her. The dry rice is a thousand tiny unexpected touch points. But the bumpy ball is firm, consistent, predictable pressure. She can tolerate that. Now apply that to food: a banana is mushy and falls apart in your mouth. A piece of broccoli has bumps and an inconsistent texture. White rice is uniform, small, predictable. Vanilla yogurt is smooth, cold, consistent. She's not choosing white foods because she's picky. She's choosing the foods that her nervous system can process without triggering a gag response.

Mateo, my COTA, he co-treats with me on feeding cases. He's been doing this 11 years. He watched the eval through the observation window and came in afterward and said, "Classic sensory-based feeding disorder. I'd start with the SOS approach." And he was right, that's exactly where I landed too. SOS is Sequential Oral Sensory. It's a structured desensitization protocol where you move through steps: tolerating the food in the room, tolerating it on the plate, touching it, bringing it to the lips, licking it, putting it in the mouth. Each step might take weeks. It's slow. Parents want fast. Teresa wants Lily eating broccoli by Christmas. Realistically, we're looking at six to twelve months of weekly sessions to expand her repertoire by maybe eight to ten foods.

You mentioned the SNF. You started there and hated it?

Hate is strong. I hated what it did to me, not the patients. My fieldwork placement in OT school was at a skilled nursing facility in Northeast Philly. Eight weeks. I spent most of that time teaching people to put on socks using a sock aid, to get dressed with one hand after a stroke, to transfer from a wheelchair to a toilet. ADLs. Activities of daily living. And the patients were wonderful. There was a man named Harold who was 81, had a hip replacement, and his goal was to be able to get into his recliner and watch the Eagles. We worked on that for three weeks and the day he sat down in a recliner in the therapy gym and said "there it is," that was a real moment.

But the productivity requirements were brutal. The facility expected 90% productivity from their OTs, meaning 90% of my 8-hour day had to be direct billable patient contact. That's 7 hours and 12 minutes of hands-on treatment. The remaining 48 minutes covers documentation, bathroom breaks, eating, talking to nursing staff, and any clinical reasoning you need to do. It's not enough. You end up documenting during lunch or staying late. And the treatments start to feel like a factory. You have 14 patients on your caseload and you need to see each of them for their allotted minutes, and if Mr. Rodriguez needs extra time because he's having a bad day, that time comes out of Mrs. Park's session or out of your lunch.

I did one year at a SNF after graduation. Applied to pediatric positions exclusively. Got this job. The productivity expectation here is 75%, which is still tight but survivable. And the work feels different because the trajectory with kids goes up. In the SNF, I was helping people maintain function or slow a decline. Here, I watch kids gain skills. Lily is going to eat new foods. It's going to take a long time, but she's four. The arc of her story bends toward growth.

$400 of your own money on sensory toys. That feels like a lot on an OT salary.

It is. And I know it is. The hospital provides equipment. We have therapy balls and swings and bolsters and a sensory room with a ball pit. The stuff in my drawer is the extra stuff. The fidgets and textures and weighted animals that I've found work for specific kids. I started buying them because the procurement process for new therapy supplies takes about six weeks and three approval signatures. A kid is in front of me now. I can go to Target after work and spend $12 on a sequin pillow and bring it tomorrow.

My friend Asha, we were in OT school together at Jefferson, she went into acute care. She texts me sometimes at like 10 PM and says things like "I think I'm done." She's been doing acute care for four years, which means ICU patients, post-surgical patients, people who just had strokes. High intensity. She's considering travel OT now because the pay is better and she wants a change of scenery. I told her to do it. She told me to stop spending my own money on toys for other people's children. We're both probably right.

You mentioned Mateo seems to know things instinctively. Does that bother you?

Bother is the wrong word. It makes me aware of how early I am in this. Mateo has 11 years of experience. He's a COTA, which means he has an associate degree, not a master's. I have more formal education than he does. On paper, I outrank him. But he watches a kid walk into the therapy gym and within 30 seconds he can tell you their sensory profile. I watched him once observe a boy named Jaylen for about a minute, just watching Jaylen play with blocks, and then Mateo turned to me and said, "Proprioceptive seeker, tactile defensive, visual processing is fine, he's going to need a weighted vest and a chewy." I ran the formal evaluation. Took an hour. Mateo was right on every count.

That's experience I can't shortcut. And it's humbling because the OT profession has this hierarchy where the therapist is above the assistant, the OTR above the COTA, the master's above the associate. But the knowledge that matters most in a treatment room, the pattern recognition, the intuition about what a kid needs, that comes from years of hands-on work. Mateo has more of that than I do. I'm honest about it. I learn from him every week.

What's yours?

How much you think about the kids after you leave. I think about Lily at dinner. I'm eating something with texture, like a piece of bread with seeds in it, and I think about how that would feel to her. How her whole body would reject it. And then I wonder if Teresa managed to get her to try the lentil we talked about, or if the mealtime ended in tears again, and I realize I'm sitting in my apartment at 7:30 PM running a therapy session in my head for a patient I won't see for six days.

Nobody tells you in school that you'll carry them. They talk about evidence-based practice and clinical reasoning and treatment planning. They don't talk about the Tuesday night when you can't stop thinking about a kid's face when she gagged on a strawberry. They don't talk about the fact that you know more about some of these children's daily struggles than their own extended families do, because their parents tell you things in the eval room that they haven't told anyone else. Teresa told me she'd been skipping family dinners at her sister's house because she was tired of her sister saying Lily just needed "more discipline." That's not in the medical chart. That's in me. I carry it.

Most people don't know OTs can specialize in hands. How did you end up here?

Before OT school, I worked at a group home in Corvallis for three years. Adults with developmental disabilities. I had a psychology degree from Oregon State and no idea what to do with it, and the group home was hiring. It was good work. Hard work. You're helping people cook meals, manage their hygiene, get to appointments, participate in the community. One of our residents, a man named Frank, couldn't button his shirt. He'd been at the house for six years and nobody had addressed it. They just bought him pullover shirts. Which, fine, that solves the immediate problem, but Frank wanted to wear button-down shirts. He told me that. He said, "I want to look like I'm going somewhere."

Nobody on staff knew how to help him with that. I didn't know either. But I started looking into it and found out that occupational therapy was an entire profession built around exactly this kind of problem. Frank's issue was a combination of fine motor difficulty and reduced hand strength. An OT could have evaluated him, built a treatment plan, maybe adapted the buttons with a button hook or worked on his pinch strength. I applied to the OT program at Pacific University that winter.

The hand therapy part came during Level II fieldwork. I was placed at a hand therapy clinic in Lake Oswego and I watched a therapist named Diane fabricate a custom thermoplastic splint in about 20 minutes. She heated the material, molded it directly on the patient's hand, trimmed it, added straps, and the patient, a woman in her sixties who couldn't pinch a key to open her front door, put it on and immediately had functional pinch. Twenty minutes. That was the most concrete, immediate, tangible intervention I'd ever seen in any healthcare setting. I was done. I knew that's what I wanted to do.

Walk me through what happened Thursday with Gary.

Gary is 47. Ironworker. He was cutting rebar on a job site and the grinder slipped. Severed three flexor tendons in his left hand, the index, middle, and ring finger. Dennis, the hand surgeon who sends me about 60% of my caseload, repaired them six weeks ago. Thursday was Gary's six-week post-op visit, which is a big milestone because it's when we transition from protective motion to active motion. For the first six weeks after flexor tendon repair, you can only do passive and place-and-hold exercises. The tendon is healing and if you pull on it too hard, it ruptures. If it ruptures, you're back in surgery and the prognosis gets worse.

Gary came in and the first thing I noticed was his face. He looked scared. Gary is a big guy, 6'2", works with steel for a living, and he was sitting in my treatment room looking at his own hand like it belonged to someone else. That happens. When your hand doesn't do what your brain tells it to do, there's a disconnection that's hard to describe. He kept trying to make a fist and his fingers would get about halfway there and stop. The tendons don't have enough glide yet. The scar tissue is tethering them.

I measured his composite fist. That's the distance from the fingertip to the distal palmar crease when you try to curl your fingers all the way in. Full composite fist is zero centimeters, fingertips touching the palm. Gary was at 2 centimeters. Two centimeters doesn't sound like much. But for an ironworker, the difference between fingertips touching the palm and a 2-centimeter gap is the difference between gripping a wrench and not. His career depends on closing that gap. I have six more weeks of active therapy to get him there.

Two centimeters. What does the treatment look like to close it?

Tendon gliding exercises, four times a day. I taught Gary a sequence: full fist, hook fist, straight fist, tabletop position, and full extension. Each position pulls the tendon through a different range and breaks up adhesions. Then we do scar management. I'm massaging the scar with deep friction for about ten minutes each session to keep the tissue mobile. If the scar gets rigid, the tendon gets stuck to it. Dennis and I disagree about post-op protocols for flexor tendons, by the way. He's more conservative than I am. He wants patients in a dorsal blocking splint for eight weeks. The research supports six weeks for a modified early active motion protocol, and I've shown him the studies. He reads them and nods and then tells the next patient eight weeks. We've been having this conversation for about nine years.

I also started Gary on putty exercises for grip strengthening. He's using the yellow putty right now, which is the lightest resistance. He'll work up through red, green, and blue over the next several weeks. The putty costs about $8 a container. I buy it in bulk from a therapy supply company. Gary asked me Thursday if he could just squeeze a tennis ball instead. I told him no, because a tennis ball provides too much resistance at this stage and also doesn't conform to his hand the way the putty does. The putty lets me grade the resistance precisely. Tennis ball is pass/fail. Putty is a spectrum.

You said his career depends on this. How does that affect how you treat him?

It makes every session high-stakes. And the patient knows it, which changes the dynamic. Gary isn't here because he wants better quality of life. He's here because if his left hand doesn't regain functional grip in twelve weeks, he can't hold a wrench, he can't hold a rebar tier, he can't do his job. He's 47 with a high school diploma and he's been doing ironwork for 28 years. There is no lateral move. He told me Thursday that his foreman is holding his spot on the crew but "not forever." He said "not forever" like it was a sentence he'd been repeating to himself.

When the functional stakes are that clear, my job gets simultaneously simpler and heavier. Simpler because I know exactly what we're aiming for. I need 0 centimeters composite fist and at least 60 pounds of grip strength, because that's the minimum for his tools. His pre-injury grip strength was about 110 pounds. We won't get back to 110. But 60 is the floor. Heavier because he's watching me like I hold his future in my hands, which, in a very literal sense, I do. My hands on his hand, mobilizing the tendons, breaking up the adhesions, millimeter by millimeter. The margin between a career-ending outcome and going back to work is about 2 centimeters and 40 pounds of grip.

You have 200 splint photos on your phone. That's a lot of splints.

Ray, my husband, thinks it's weird. He teaches high school chemistry and he does not have 200 photos of beakers on his phone. But the splint photos are my reference library. When I get a new patient with a specific pathology, I can scroll through and find a splint I made for a similar case three years ago and see what worked. Every hand is different. The shape of the palm, the length of the fingers, the arch of the metacarpals. A splint that works perfectly on one person's hand might need a completely different design on someone with broader knuckles or shorter digits.

My favorite is one I made for a classical guitarist named Marco about five years ago. He had an extensor tendon repair on his right ring finger, his plucking hand, and he needed to get back to performing within a month. Dennis told him eight weeks minimum, no guitar. Marco was in tears. I designed a dynamic extension splint that protected the repair but allowed him to flex enough to pluck the strings. It had a rubber band outrigger that provided a constant low-load extension force, and I cut a window in the palmar piece so his index and middle fingers had full freedom. He was playing scales by week three. Not performing, but playing. Dennis was not thrilled that I'd gone around his timeline, but Marco's tendon healed fine and he played a recital at six weeks.

Val, my college roommate, she's a home health OT now. We talk monthly. She hears my splint stories and tells me about her patients who can't get out of bed, and we just sit on the phone realizing we have the same license and completely different jobs. She asked me once if I ever miss seeing the whole person. In hand therapy, I see one part of the body. The hand. Maybe the wrist. The elbow on a good day. I told her the hand is the whole person. Every job, every hobby, every act of self-care, every gesture of affection involves the hand. When Gary can't make a fist, he can't work. When Marco can't extend his ring finger, he can't play music. The hand isn't a body part. It's a biography.

You said you and Dennis disagree about protocols. That sounds tense.

It's been going on long enough that it's almost affectionate at this point. Dennis is an excellent surgeon. His repairs are clean, his outcomes are good, and he trusts me with his post-op patients, which took about four years to build. The disagreement is about timing. He trained in a more conservative era. He wants patients immobilized longer because he's seen ruptures and he never wants to see one again. I've seen ruptures too. But the research over the last ten years has consistently shown that earlier controlled motion leads to better outcomes with comparable rupture rates. He knows this. I've emailed him the studies. He reads them. And then the next post-op order still says eight weeks in a dorsal blocking splint.

The compromise we've landed on, without ever explicitly agreeing to it, is that he writes the conservative order and I progress the patient based on their tissue response. If a patient is ahead of schedule and the tendon is showing good glide and no signs of gapping, I move them forward. Dennis doesn't ask and I don't tell him until the follow-up, at which point he looks at the range of motion numbers and says, "Good progress." He knows what I'm doing. I know he knows. We just don't make it a thing.

What's yours?

The permanence of the bad outcomes. In most therapy settings, if a treatment doesn't work perfectly, you adjust and try again. In hand therapy, some losses are final. If a tendon repair ruptures and the second surgery fails, that finger doesn't work anymore. If a crush injury destroys the joint surfaces, we can splint and mobilize and do everything right, and the patient still ends up with a stiff finger at 40% of normal range. And they look at you like you should have done more. Because in their mind, they came to therapy, they did the exercises, they showed up three times a week, and their finger still doesn't close all the way.

I have a patient right now, a woman named Claire, who had a PIP joint fracture-dislocation eight months ago. We've done everything. Splinting, mobilization, exercises, ultrasound. She's at 65 degrees of flexion. Normal is 100 to 110. She's not going to get to 100. She might get to 75 if we keep working. And 75 degrees means she can hold a coffee cup but she can't make a tight fist. She asked me last week if it was going to get better and I said, "We're going to keep working on it," which is what I say when the honest answer is "probably not much more." I drove home that night and Ray had packed my lunch for the next day with a note that said "you're doing great" and I sat in the kitchen and cried. Not because of Claire specifically. Because of the accumulation. Eighteen years of knowing that some of my patients will lose something permanently and I was the last person who could have prevented it.

You were an ABA therapist before OT school. What made you leave?

The compliance piece. I worked as an ABA therapist for two years, right out of undergrad. Applied behavioral analysis. You're working with kids on the autism spectrum, running discrete trial programs, targeting specific behaviors. A lot of the work was about getting kids to do things that looked typical. Make eye contact. Sit still. Keep your hands in your lap. And the method works, in the sense that the behaviors change. But I started watching the kids' faces and I noticed something that my supervisors didn't seem to notice, or didn't seem to care about. The kids were complying. They weren't engaging. There's a difference.

A kid who's complying looks calm on the outside because the reinforcement schedule has shaped the behavior. A kid who's actually self-regulating is calm because their nervous system is organized. I can tell the difference in about 30 seconds now. The compliant kid has flat affect and tracks the reinforcer. The self-regulated kid has flexible attention and initiates. I couldn't unsee that once I noticed it. I started reading about sensory integration theory and OT's approach to autism, which focuses more on understanding why a kid is doing a behavior rather than just eliminating it. A kid who flaps his hands might be seeking proprioceptive input because his nervous system is under-aroused. The ABA approach says: stop flapping. The OT approach says: give him a replacement that meets the same sensory need. Squeeze a stress ball. Do chair push-ups. Jump on a trampoline. The flapping reduces because the need is met, not because the behavior was punished.

I quit ABA and did a post-bacc OT program at UT Health San Antonio. Kim, my wife, was very supportive of the career change, which is good because it also meant two and a half years of grad school on one income.

What does a Tuesday look like when you're covering four schools?

Chaos with a laminated schedule. I'm a contractor through a staffing agency, which means the district pays the agency and the agency pays me. I cover four elementary schools in a suburban district northwest of Austin. On Tuesdays, I'm at Ridgeline Elementary in the morning and Oak Meadow Elementary in the afternoon. Seven sessions total, plus an IEP meeting.

I pull up to Ridgeline at 7:45 with my rolling crate. The crate has everything. Pencil grips, weighted pencils, slant boards, fidget tools, therapy putty, scissors with spring assists, and a laminated visual schedule that I made for a kid named Nolan who does better when he can see what's coming. The crate weighs about 25 pounds. I roll it down the hallway and every teacher I pass says, "There goes Mr. Ezra with his box." I'm the guy with the box. That's my identity at these schools.

First session is at 8:15. Second grader named Aiden working on scissor skills. He has a diagnosis of developmental coordination disorder and his fine motor skills are about 18 months behind. We're using spring-loaded scissors that open automatically so he only has to squeeze, not open and close. After ten minutes, he can cut along a straight line within a quarter inch. A curved line is still hard. We'll get there. I see Aiden for 30 minutes once a week. Thirty minutes. That's what his IEP says. And in those 30 minutes, I need to make enough progress that it justifies the service on paper and actually helps him in the classroom. It's tight.

You mentioned Nolan's IEP meeting went sideways. What happened?

Nolan is eight. He's on the autism spectrum. I've been working with him since kindergarten. Three years. When I met Nolan, he was essentially non-verbal. He communicated through gestures and some picture exchange, and he had significant sensory processing difficulties that made the classroom overwhelming. The fluorescent lights, the cafeteria noise, the unexpected transitions. His body was in fight-or-flight for most of the school day.

Over three years, I've worked with him on sensory regulation strategies, fine motor skills, and self-care. He uses a weighted lap pad during circle time. He has a visual schedule on his desk. He takes movement breaks every 45 minutes. Tomoko, the special ed coordinator at Ridgeline, she and I designed his sensory diet together. And it's working. Last month, Nolan said his first full sentence during an OT session. He was stringing beads and he looked up at me and said, "I need the blue one." Four words. A full sentence with a subject, a verb, and a direct object. Tomoko was in the room and she put her hand over her mouth. I kept my face neutral because I didn't want to overwhelm him with a big reaction, but inside I was, I mean, that was three years of work in four words.

The IEP meeting on Tuesday was his annual review. His mom was there. Tomoko was there. The classroom teacher was there. And the district had sent a behavior specialist named Dan, who I'd never met, to observe and make recommendations. Dan had spent one hour in Nolan's classroom that morning. One hour. And his recommendation was to reduce OT services from 60 minutes a week to 30 because, and I'm quoting his report, "the student is meeting current benchmarks in fine motor and self-regulation."

Meeting benchmarks after three years of OT, and the response is to cut the OT?

That's exactly what I said. Maybe not as calmly as I'm saying it now. The benchmarks he's meeting are the benchmarks we set last year. He's meeting them because of the services. Because of the weighted lap pad and the movement breaks and the visual schedule and the three years of weekly sessions where I sat on the floor with him and worked on fine motor tasks while also teaching his nervous system how to tolerate a room full of second graders. Take away the support and the progress doesn't continue. It reverses. I've seen it happen. I've had kids who got reduced and within two months the teacher is filing a new referral because the behaviors are back.

I said all of this in the meeting. Professionally. I cited the data from my quarterly progress reports. I showed the trajectory: where Nolan was three years ago, where he is now, and the correlation between consistent OT services and his gains. Dan listened and then said something about "building independence from support services." Which is a real goal, eventually. But not for an eight-year-old who said his first sentence last month. Tomoko backed me up. Nolan's mom backed me up. The classroom teacher said, "I don't know what I'd do without Ezra's strategies." We kept the 60 minutes. But it took 45 minutes of arguing in a conference room to defend services that have taken three years to show results, against a recommendation from someone who observed for one hour.

You mentioned a teacher who thinks OT is "the handwriting class." Does that happen a lot?

All the time. A teacher at Oak Meadow sent me a referral last Tuesday for a first grader. The referral form said, "Student has poor handwriting and needs OT to fix it." That's the whole referral. No information about what "poor" means, whether it's a motor issue or a visual-motor issue or an attention issue or just that the kid is six and hasn't developed the hand strength yet. And the framing, "needs OT to fix it," tells me the teacher thinks I'm a handwriting tutor who visits the school with a magic pencil grip.

I went to observe the kid in class before responding to the referral. His name is Owen. He's six. His handwriting is, yeah, messy. But he's also sitting in a chair that's too high for him, so his feet are dangling and he has no core stability. His desk is at chest height instead of elbow height. He's using a standard No. 2 pencil with no grip, which for a six-year-old with a still-developing tripod grasp is like asking an adult to write with a broomstick. And the worksheet the teacher gave the class has lines that are a quarter inch apart. A six-year-old's fine motor control is not precise enough for quarter-inch lines. He needs half-inch lines minimum.

So is this an OT referral? Maybe. But the first intervention isn't therapy. It's adjusting the chair, lowering the desk, giving him a pencil grip, and changing the paper. Those are environmental modifications that any teacher can implement. If the handwriting is still a problem after those changes, then we talk about evaluation. I sent the teacher an email with the modifications and a link to the Handwriting Without Tears guidelines for first grade. She wrote back, "Thanks, but can you just work with him?" That sentence is my whole career in six words.

Tell me about the pencil grip spreadsheet.

OK. So there are, at last count, about 34 adaptive pencil grips commercially available. I've bought and tested all of them. The spreadsheet ranks them by four criteria: effectiveness for the target grasp pattern, comfort for the child, durability, and whether the kid will actually use it without constant reminding. Each grip gets a score from 1 to 5 in each category, and I sort by age range and hand size.

The Stetro grip, the triangular rubber one that's everywhere, gets a 2.8 overall. It's the default that every school district buys in bulk. It's cheap and it forces a tripod grasp, but it's rigid and uncomfortable and kids pull it off within five minutes. The Twist-n-Write pencil, which has a Y-shaped design that naturally positions the fingers, gets a 4.3. Kids actually like it. It's self-correcting, meaning you can't hold it wrong. But it costs about $3 per pencil versus 15 cents for a Stetro grip, so districts don't want to buy them. Audrey, the SLP I co-treat with on Tuesdays, she thinks the spreadsheet is "very you," which I choose to take as a compliment.

You co-treat with an SLP. How does that work?

Audrey and I share two students who have both OT and speech goals. On Tuesdays, we do a 30-minute co-treat session where I work on fine motor and she works on language simultaneously. The kid is doing a fine motor activity, like stringing beads or cutting, and Audrey is targeting expressive language through the activity. "Tell me which color you want." "Ask me for the scissors." It's efficient for the student because they get both services in one session instead of being pulled from class twice.

We disagree about oral motor skills. There's overlap between OT and speech when it comes to feeding and oral motor function. Audrey thinks oral motor is speech's domain because it involves the mouth and the mouth is a speech structure. I think oral motor is shared because feeding is an occupation, and feeding involves sensory processing of textures in the mouth, which is sensory integration, which is OT. We've been having this turf war politely for about two years. She's right that speech-language pathologists have more training in swallowing and oral motor physiology. I'm right that OTs have more training in the sensory processing piece. The answer is we should co-treat feeding cases, which we do, while each privately believing that we're the lead discipline. It works fine.

What's yours?

How much of the job is defending the job. Not doing therapy. Defending the existence of therapy. I spend maybe 60% of my time treating kids and 40% in meetings, writing documentation, and explaining to someone why OT services should continue. The IEP meeting for Nolan was 45 minutes of defending services. The email to Owen's teacher was me explaining why I can't "just work with him" without an evaluation. Every conversation I have with a district administrator about caseload or service minutes is me justifying why occupational therapy matters in schools.

Nobody has to explain why a math teacher matters. Nobody asks the PE teacher to produce quarterly data proving that recess improves learning outcomes. But OT is a related service, which in special education law means it's supplementary. We're not the main thing. We're the thing that supports the main thing. And when budgets get tight, the supplementary services get cut first. The behavior specialist shows up for an hour, recommends cutting OT minutes, and I have to build a data-driven case for why a kid who just said his first sentence needs me to keep showing up every week. That's the part they don't teach you in school. Not how to treat. How to fight for the right to treat.