A Fatal Flaw: Occupational Therapy’s Dependence on Mandates


New York’s Bill A.5474 proposes expanding the role of occupational therapy in schools by requiring the state commissioner to issue a guidance memorandum on OT services, particularly in early intervention and mental health support. Additionally, it calls for regulatory changes to formally include OTs within pupil personnel services and establish qualifications for a “school occupational therapist.”

On the surface, this appears to be a step forward in recognizing the value of OT beyond special education, but a closer examination reveals significant gaps. With no attached funding, no mandate for service expansion, and a reliance on bureaucratic implementation, this bill risks being more symbolic than substantive. Given the political climate of shifting federal education funding to the states, it’s worth asking: Is this bill a real investment in student services, or is it just another unfunded directive that leaves schools scrambling?

One of the biggest blind spots in A.5474—and in occupational therapy’s broader approach to service provision—is its continued reliance on mandates to structure service delivery. This is a strategic error that history has proven to be disastrous for both the profession and the people it intends to serve.

If occupational therapy wants to take a forward-looking approach, it must stop tying its fate to government fiat and instead create models of care that are flexible, responsive, and independent of bureaucratic mandates.

 

Lessons from the Past: The Consequences of Relying on Mandates

Occupational therapy has been here before—and it has not ended well. When the mental health system was deinstitutionalized, OTs had built their careers and service structures around institutional models of care. When that system collapsed, OTs were left behind, and their presence in mental health all but evaporated. The same happened in the intellectual and developmental disabilities (I/DD) system—when large-scale institutions closed, OTs were not embedded in the new community-based models, leaving a gaping hole in service provision. We must not forget this history.

These examples show the danger of building service models that are tied to regulatory structures rather than the actual needs of people. We have seen it time after time - when the system changes, the services disappear.

Now, with A.5474, we are seeing the same flawed approach - the bill attaches OT to a brick-and-mortar school-based mandate, but what happens when schools shift models (e.g., increase remote learning, privatization, or funding cuts)?

If occupational therapy services exist only because laws mandate them, then they cease to exist when those laws shift. No other healthcare profession relies on governmental fiat to this extent—physicians, nurses, and mental health professionals have diversified service delivery models that function independently of mandates. Why doesn't occupational therapy?


Breaking Free: A New Model for Occupational Therapy

If occupational therapy wants to thrive in the future, it must move away from reliance on physical locations coded in law. Instead of tying OT services to schools, institutions, or specific government programs, OTs should be embedded in private practice through wider community structures, digital platforms, and direct access models.


Establish independent service models

Other professions—like physical therapy and speech therapy—have developed cash-pay, insurance-reimbursed, and hybrid models. OT needs to be just as flexible and not dependent on a school district’s decision to fund a position.

 Emphasize preventive and proactive care, not just mandated interventions

Instead of waiting for state-mandated eligibility criteria, OT should build a presence in primary care, mental health, and community wellness—where it prevents functional limitations rather than waiting to be "needed" in a regulated setting. 


Innovate beyond traditional delivery methods

The world is moving toward telehealth, mobile services, and decentralized care—OT should be at the forefront of these shifts, not waiting for a mandate to grant permission to act within a school context.  That is as backwards thinking a model that we could possibly embrace.

 

Will Occupational Therapy Choose Growth or Repetition?

A.5474 reflects the same outdated approach that has caused OT to be left behind in other systems. If the profession doesn’t shift its mindset away from dependence on mandates, history will repeat itself—and the profession will once again find itself fighting for scraps when the system inevitably shifts again.

This bill is not a solution, it’s a temporary placeholder. True progress comes when OT stops relying on legal mandates to justify its existence and instead creates sustainable, independent models that serve people wherever they are, regardless of government policies.

So will we repeat the mistakes of the past and remain tethered to bureaucratic structures that will abandon it when priorities shift? Or will we evolve into a resilient, flexible profession that meets people’s needs regardless of whether a law requires it to do so.

It’s time for occupational therapy to stop waiting for permission and start building a future that doesn’t depend on regulatory mandates for survival.

 

Comments

Post a Comment

Popular posts from this blog

On retained primitive reflexes

Each year I receive several emails from colleagues about 'retained primitive reflexes.'  I am also seeing an increased number of reports from local 'health care' providers who are documenting these alleged problems so I thought I would write a summary of my opinion on this topic.   Predatory 'health care' providers including some OTs, PTs, chiropractors, and behavioral optometrists are creating a new 'market' for treating this alleged 'problem.'  Parents should be very wary of these practitioners and other professionals should challenge these practices whenever they are seen. The following is the kind of information that causes concern and was provided to me by a colleague as a sample from a student's IEP: The student continues to demonstrate the following retained primitive reflexes that at times interfere with his ability to demonstrate appropriate adaptive responses: Fear Paralysis Reflex, Moro Reflex, Palmer Reflex, Tonic Labyri...
Read more

Deconstructing the myth of clothing sensitivity as a 'sensory processing disorder'

Please note first that there is no formally recognized clinical designation of  'sensory processing disorder.'   It is a term constructed by occupational therapists that has not been formally recognized by the larger medical community. In our clinic we receive many referrals from local pediatricians when parents have concerns about children being overly sensitive to their clothing.  Most often the children referred are from four to seven years old and the families are severely disrupted by the children's behaviors and responses to clothing issues.  Commonly, children will have severely constricted tolerance for certain outfits, want to wear the same clothes repeatedly, complain that clothing is itchy/scratch/bumpy/wiggly/ouchie, and this all leads to disruption of daily dressing routines.  There is no doubt that the behavioral concerns are very real. The pediatricians tend to be appropriately conservative and provide families with good behavioral manage...
Read more

On Ideological Shifts in Occupational Therapy Education: Reflections on DEI and the Presidential Executive Order

Image
The Accreditation Council for Occupational Therapy Education (ACOTE) Standards have evolved over time, with the 2023 updates reflecting a continuation of a broader ideological trend in the profession. Specifically, these updates prioritize Diversity, Equity, and Inclusion (DEI) in ways that raise fundamental questions about the balance between professional accreditation requirements and academic freedom.  The 2018 Standards recognized diversity as an important foundation for occupational therapy education. While encouraging awareness of diversity issues, these standards avoided prescribing specific ideological frameworks. This approach respected the autonomy of educational institutions, allowing them to incorporate diversity as they deemed appropriate while maintaining space for academic freedom and intellectual diversity. In contrast, the 2023 Standards explicitly embed DEI principles, including equity and justice, as requirements for occupational therapy programs. Faculty are now...
Read more