Primitive Reflex Integration: Bridging the Gap Between OT and Academic Achievement

Originally published May 5, 2025. Substantially revised October 2026 to reflect updated research and evidence-informed school-based occupational therapy practices.

From Primitive Reflex Observations to Functional School-Based OT Interventions: An MTSS Approach

Moving beyond primitive reflex identification to evidence-informed evaluation, targeted intervention, and measurable improvements in school participation.

By Irene Hannam, MS, OTR/L | Write Expectations™

Introduction: Identifying a Motor Challenge Is Only the Beginning

A third-grade student struggles with handwriting despite receiving additional instruction and practice. His teacher observes inconsistent letter sizing, difficulty stabilizing notebook paper, and frequent changes in sitting position.

During an occupational therapy observation, the student also demonstrates difficulty maintaining a stable hands-and-knees position while moving his head.

Could primitive reflex activity be contributing to his challenges?

Possibly. However, observing a movement pattern associated with a primitive reflex does not establish that the reflex is responsible for his handwriting difficulties.

More importantly, identifying a possible underlying motor challenge does not tell us which intervention will help the student succeed in the classroom.

This is where clinical reasoning becomes essential.

School-based occupational therapists must connect observations of motor performance to the actual occupations of school: handwriting, written communication, cutting, managing materials, participating in classroom routines, and developing functional independence.

The goal is not simply to identify or inhibit a primitive reflex. It is to understand what interferes with the student’s participation and determine how occupational therapy can help.

A Multi-Tiered System of Supports (MTSS) provides a framework for delivering proactive classroom strategies, targeted interventions, and increasingly individualized supports while monitoring functional progress.

This article explains how occupational therapists can move from primitive reflex-related observations to meaningful interventions within an MTSS framework.

1. Understanding the Role of Primitive Reflex Observations in School-Based OT

Primitive reflexes are automatic motor responses that emerge during prenatal development or infancy. These responses are gradually inhibited or modified as the nervous system develops and voluntary motor control becomes more sophisticated.

Occupational therapists may consider primitive reflex activity when evaluating children who demonstrate unusual movement patterns, postural difficulties, or challenges with motor coordination.

However, it is important to distinguish three concepts:

1. A Primitive Reflex Response

An automatic movement response elicited under specific conditions.

2. A Functional Motor Difficulty

An observable challenge involving skills such as postural control, bilateral coordination, balance, or motor planning.

3. An Occupational Performance Limitation

A difficulty participating in a meaningful activity, such as writing, cutting, dressing, managing school materials, or completing classroom routines.

These concepts may be related, but they are not interchangeable.

For example, a student may demonstrate elbow bending when lowering the head in a hands-and-knees position. This observation may lead an occupational therapist to examine head–body coordination and postural control.

It does not automatically establish that a retained symmetrical tonic neck reflex (STNR) is causing poor handwriting.

What Does AOTA Recommend?

The American Occupational Therapy Association (AOTA), through its Practice Smart! initiative, advises practitioners against using reflex-integration programs for individuals with delayed primary motor reflexes without clear links to occupational outcomes.

AOTA emphasizes that the presence of retained reflex responses does not necessarily indicate functional impairment.

When reflex-integration approaches are being considered, standardized assessment approaches are needed to establish a meaningful connection between the identified impairment and occupational performance.

The central principle is that intervention should improve occupational participation and performance rather than focus solely on reflex integration.

For school-based practice, this means moving beyond the question: “Which reflex is retained?”

And asking: “What functional skill is difficult, what factors are contributing, and what intervention will improve the student’s participation?”

For additional information about primitive reflex development and classroom observations, see our related article:

Helping Kids Succeed: Understanding Primitive Reflexes, Movement, and School Performance

2. A Functional Clinical Reasoning Process for School-Based OTs

When a student demonstrates motor difficulties, a systematic clinical reasoning process can help determine the most relevant intervention.

Step 1: Identify the Functional Concern

Begin with a meaningful school activity.

Examples include:

• Difficulty forming and placing letters on notebook paper
• Inconsistent word spacing or letter sizing
• Difficulty stabilizing paper while cutting or writing
• Reduced independence managing classroom supplies
• Difficulty manipulating clothing fasteners
• Reduced participation in playground or movement activities
• Difficulty completing classroom routines without excessive assistance

Avoid beginning with the assumption that a particular primitive reflex is responsible.

Step 2: Observe the Student Performing the Actual Task

Functional observation is essential.

For a student experiencing handwriting difficulties, observe the student during a representative writing activity.

Consider:

• Seating and foot support
• Trunk and shoulder stability
• Position of the paper
• Use of the assisting or helper hand
• Pencil grasp and control
• Letter formation, sizing, and placement
• Handwriting legibility and writing speed
• Visual-motor demands
• Attention and task endurance
• Classroom expectations and available accommodations

A student may demonstrate adequate gross motor skills during a movement activity but still struggle with handwriting because of limited letter-formation knowledge or difficulty organizing written language.

The reverse may also occur: a student may demonstrate postural challenges while maintaining functional handwriting performance.

These distinctions matter when selecting intervention.

Step 3: Examine Relevant Performance Components

Once the functional difficulty is established, evaluate contributing skills that are relevant to the concern.

These may include:

• Postural Control: The ability to maintain and adjust body position during functional activities.
• Bilateral Coordination: Using both sides of the body together, including stabilizing materials with one hand while manipulating them with the other.
• Visual-Motor Integration: Coordinating visual information with motor output.
• Fine-Motor Coordination: Controlling the hands and fingers during manipulation and tool use.
• Motor Planning: Organizing and carrying out movement sequences.
• Sensory Processing: Responding to sensory information in ways that support participation.
• Task and Environmental Demands: The influence of seating, materials, instructional methods, time expectations, and classroom organization.

Primitive reflex-related observations may provide additional clinical information when appropriate, but they should not replace a comprehensive assessment of functional performance.

Step 4: Identify a Measurable Functional Outcome

Before selecting an intervention, determine what successful participation will look like.

Example 1: ATNR and Bilateral Coordination

Instead of targeting: “The student will improve ATNR integration.”

Consider: “Given appropriately positioned writing materials and a visual reminder as needed, the student will independently stabilize the writing paper with the assisting hand during a five-minute classroom writing task in at least 4 out of 5 observed opportunities across three data-collection sessions.”

Clinical Rationale: This objective measures functional bilateral coordination and paper stabilization during a meaningful school task rather than an isolated reflex response.

Example 2: STNR and Functional Postural Stability

Instead of targeting: “The student will improve STNR integration.”

Consider: “Given appropriate seating and positioning supports, the student will maintain a functional writing position while completing a five-minute classroom handwriting task, with no more than one verbal cue for postural adjustment in 4 out of 5 observed opportunities.”

Clinical Rationale: Rather than measuring a change in a primitive reflex response, this objective focuses on the student’s ability to maintain functional postural stability during a meaningful classroom activity. Progress is measured through observable performance and the level of support required.

These objectives are illustrative examples, not standardized goals. The conditions and performance criteria should be individualized using the student’s baseline data and educational needs.

Step 5: Select Intervention and Monitor Progress

Intervention should directly address the identified barrier whenever possible.

For handwriting difficulties, this may involve explicit handwriting instruction, modified paper, appropriate seating, and strategies for paper stabilization.

For bilateral coordination difficulties, intervention may involve cutting, manipulating objects, managing containers, and other meaningful two-handed activities.

For postural-control challenges, intervention may include positioning modifications, graded reaching, functional movement tasks, and practice maintaining stability during classroom activities.

The most important question is: Is the student becoming more successful, efficient, comfortable, or independent in the school activity we identified?

3. How Occupational Therapy Fits within MTSS

A Multi-Tiered System of Supports (MTSS) is a school-wide framework designed to identify student needs early, provide appropriate instruction and intervention, and use data to determine whether supports are effective.

According to the Center on Multi-Tiered System of Supports, the framework includes four essential components:

1. Screening
2. Progress monitoring
3. A multi-level prevention system
4. Data-based decision-making

Occupational therapists can contribute expertise in functional performance, environmental adaptations, motor development, sensory processing, assistive technology, and school participation.

Piller et al. (2023) describe the developing role of school-based occupational therapy within MTSS, particularly in supporting access and participation through classroom-wide and targeted strategies.

MTSS is a framework for organizing educational supports.

Tier 1: Universal Supports for All Students

Purpose: Improve classroom access and participation through strategies available to all students.

At Tier 1, occupational therapists collaborate with teachers to identify barriers affecting groups of students and recommend strategies that can be incorporated into everyday instruction.

Examples include:

• Developmentally appropriate classroom seating and positioning
• Handwriting instruction and paper selection
• Classroom routines encouraging bilateral hand use
• Accessible fine-motor centers
• Movement opportunities during the school day
• Organization of classroom tools and materials
• Visual supports and environmental modifications
• Age-appropriate motor activities

Example: Kindergarten Handwriting Readiness

A kindergarten teacher reports that several students have difficulty stabilizing paper, forming basic strokes, and using classroom drawing materials.

Rather than screening the entire class for retained primitive reflexes, the OT collaborates with the teacher to examine functional readiness skills.

The team may introduce:

• Explicit instruction in foundational strokes and letter formation
• Visual demonstrations and modeling
• Appropriate paper and writing tools
• Activities requiring one hand to stabilize while the other manipulates
• Short fine-motor practice opportunities
• Environmental adaptations for students who need additional support

Tier 1 Progress Monitoring

The team may examine student work samples, task completion, independence using classroom materials, and progress toward instructional objectives.

The goal is to determine whether the supports improve classroom participation.

Tier 2: Targeted Small-Group Intervention

Purpose: Provide additional structured instruction and practice for students who need more support than universal classroom strategies alone.

Tier 2 supports may involve small groups, targeted consultation, teacher-led interventions, or collaborative instruction, depending on school procedures and professional responsibilities.

Examples include:

• Targeted handwriting groups
• Scissor-skills instruction
• Bilateral coordination activities linked to classroom tasks
• Visual-motor skill practice
• Fine-motor manipulation groups
• Classroom organization and independence supports

Example: Second-Grade Handwriting Group

Several second-grade students demonstrate difficulty with letter sizing, word spacing, and paper stabilization.

The OT and teacher organize a targeted intervention group focused on these skills.

Instruction may include:

• Explicit teaching of letter placement and sizing
• Visual models and structured writing paper
• Direct practice with word spacing
• Paper-positioning and stabilization strategies
• Feedback using student writing samples
• Gradually increasing task independence

The group may include brief postural or coordination activities when an identified motor need makes those activities relevant.

However, the intervention’s success is measured through improvements in actual handwriting performance.

Tier 2 Progress Monitoring

Possible measures include:

• Percentage of correctly sized letters
• Percentage of words with appropriate spacing
• Number of prompts required to stabilize paper
• Legibility in comparable writing samples
• Independence completing classroom writing tasks

Progress should be reviewed regularly to determine whether to maintain, modify, intensify, or discontinue the targeted support.

Tier 3: Intensive Individualized Support

Purpose: Address significant or persistent barriers to school participation through more intensive, individualized intervention.

Tier 3 may include intensive general education supports, individualized consultation, or services coordinated with an IEP or Section 504 plan, as appropriate.

Tier 3 does not automatically mean that a student has an IEP or qualifies for occupational therapy services.

School-based OT involvement depends on educational needs, evaluation findings, applicable laws, and district procedures.

Example: Third-Grade Student with Persistent Written-Work Difficulties

A third-grade student demonstrates knowledge of letter formation but produces written work with inconsistent sizing, poor spacing, and difficulty maintaining legibility on notebook paper.

The student also has limited keyboarding proficiency.

The OT examines multiple performance factors, including:

• Functional handwriting legibility
• Writing speed
• Paper stabilization
• Visual-motor demands
• Seating and positioning
• Letter placement
• Keyboarding ability
• Classroom writing expectations

An individualized intervention plan might include:

• Structured handwriting paper with a plan to gradually reduce visual supports
• Explicit instruction in spacing and sizing
• Environmental modifications
• Direct handwriting practice using classroom assignments
• Keyboarding instruction and assistive technology consideration
• Collaboration with the classroom teacher to support written communication

If postural control or bilateral coordination contributes to the student’s difficulties, relevant motor activities may be included.

However, a primitive reflex score is not used as the primary measure of success.

Tier 3 Progress Monitoring

The team may monitor:

• Functional writing legibility
• Correct letter sizing and placement
• Independent use of spacing strategies
• Writing efficiency
• Keyboarding development
• Ability to complete classroom writing assignments with appropriate supports

The intervention should be revised according to meaningful functional progress.

An Important MTSS and Special Education Safeguard

MTSS interventions must not be used to delay or deny an appropriate special education evaluation for a child suspected of having a disability.

The U.S. Department of Education has clarified that parents may request an initial evaluation at any time, regardless of whether their child has participated in MTSS.

This means targeted classroom intervention and evaluation procedures may occur concurrently when appropriate.

Schools should follow applicable federal and state requirements and local procedures.

4. Writing Functional OT Objectives: From Impairment to Participation

One of the most important responsibilities of a school-based OT is translating assessment findings into meaningful, measurable objectives.

A useful objective identifies:

• The functional activity
• The conditions under which the student performs it
• The expected level of performance
• The amount of support or assistance allowed
• The method for measuring progress

The following examples are illustrative targets, not standardized developmental norms or automatically appropriate IEP goals.

Example A: Functional Postural Stability During Handwriting

Functional Concern: The student frequently leans heavily on the desk, demonstrates difficulty maintaining a comfortable writing position, and requires repeated reminders to reposition the body during written work.

Sample Objective:

Given individualized seating and positioning supports, the student will maintain a writing position that allows stable paper placement, effective use of the writing hand, and participation in a five-minute classroom handwriting task, requiring no more than one verbal cue for positioning in 4 out of 5 observed writing sessions.

Measurement: Structured classroom observation documenting positioning, number of verbal cues, and ability to complete the handwriting task.

Intervention Connection: Seating and positioning, postural endurance, environmental adaptations, and functional handwriting practice.

Clinical Note: A functional writing position does not require rigid or motionless posture. Appropriate movement and postural adjustments are normal. The OT should individualize positioning criteria based on the student’s physical abilities, comfort, and functional performance.

Example B: Bilateral Coordination and Paper Stabilization

Functional Concern: The student does not consistently use the assisting hand to stabilize writing paper.

Sample Objective:

Given appropriately positioned writing materials and a visual reminder as needed, the student will independently stabilize paper with the assisting hand during a five-minute classroom writing task in at least 4 out of 5 observed opportunities across three data-collection sessions.

Measurement: Direct observation during classroom writing.

Intervention Connection: Paper positioning, helper-hand practice, bilateral coordination, and task-specific instruction.

Example C: Handwriting Legibility

Functional Concern: Inconsistent letter sizing and word spacing reduce the legibility of classroom written work.

Sample Objective:

Given modified writing paper and a visual model, the student will produce a five-sentence classroom writing sample demonstrating at least 85% accuracy in letter sizing and at least 85% accuracy in word spacing across three consecutive data-collection sessions.

Measurement: Classroom writing samples scored using predefined, separate criteria for letter sizing and word spacing.

Intervention Connection: Explicit handwriting instruction, modified writing paper, visual supports, feedback, and repeated functional writing practice.

Clinical Note: Letter sizing and word spacing should be measured separately to identify specific areas requiring intervention. The writing sample length, accuracy criteria, and level of support should be individualized according to baseline performance and educational needs.

Example D: Scissor Skills and Bilateral Coordination

Functional Concern: The student has difficulty stabilizing and rotating paper while cutting.

Sample Objective:

Given appropriate scissors and a clearly marked cutting path, the student will use the assisting hand to stabilize and rotate the paper while cutting a designated shape, remaining within the established cutting boundary for at least 80% of the path across three consecutive trials.

Measurement: Direct observation and scored cutting samples.

Intervention Connection: Scissor positioning, helper-hand placement, paper rotation, visual guidance, and functional cutting practice.

Example E: Classroom Organization and Independence

Functional Concern: The student requires frequent assistance to organize materials and begin written work.

Sample Objective:

Given a three-step visual checklist, the student will retrieve required materials, position the paper and writing tool, and begin the assigned writing task with no more than one adult prompt in 4 out of 5 observed opportunities.

Measurement: Classroom task-analysis checklist.

Intervention Connection: Visual organization, environmental modifications, routine practice, and gradual reduction of prompting.

Clinical Consideration: Goals and objectives must be individualized to evaluation findings, baseline performance, educational needs, and student priorities. Avoid selecting arbitrary percentages or criteria simply because they appear in an example.

5. Functional Progress Monitoring: What Should We Measure?

Meaningful progress monitoring helps determine whether a selected strategy is effective.

A primitive reflex score alone does not establish improvement in school participation.

Instead, select measurements that reflect the student’s functional needs.

Functional Skill	Possible Measure	Data Source
Handwriting legibility	Percentage of legible letters or words	Dated writing samples
Letter sizing and placement	Percentage meeting defined criteria	Handwriting rubric
Word spacing	Percentage of correctly spaced word boundaries	Writing samples
Paper stabilization	Percentage of opportunities with appropriate helper-hand use	Structured observation
Cutting accuracy	Percentage of cutting path within the designated boundary	Cutting samples
Classroom organization	Number of steps completed independently	Task-analysis checklist
Functional endurance	Duration of participation with adequate support and performance quality	Classroom observation
Written-work completion	Amount of assigned work completed using appropriate supports	Classroom records

A Practical Five-Step Data Collection Process

Step 1: Define the Target Skill

• Select a skill that directly affects classroom participation.
• Example: Independent paper stabilization during handwriting.

Step 2: Collect Baseline Data

• Observe the student during a representative classroom task before changing the intervention.
• Document the task demands, supports, and current performance.

Step 3: Implement a Specific Strategy

• Introduce an intervention, such as adjusting paper position, providing an initial visual cue, and explicitly teaching use of the assisting hand.

Step 4: Measure Progress Under Comparable Conditions

• Use similar writing tasks, observation periods, scoring methods, and levels of assistance whenever possible.

Step 5: Adjust the Intervention

• If progress occurs, consider gradually reducing support or generalizing the skill.
• If progress is limited, examine whether the strategy is appropriate, implemented consistently, and targeting the actual source of difficulty.

Example: Tracking Paper Stabilization

• The following numbers are fictional and demonstrate a possible data-collection method.

 

Observation	Independent Stabilization
Baseline	2 of 10 opportunities
Week 2	4 of 10 opportunities
Week 4	7 of 10 opportunities
Week 6	9 of 10 opportunities

These data suggest improved performance on the monitored task.

The OT should also determine whether the improvement is maintained during different writing assignments, classroom settings, and levels of task difficulty.

It would not be appropriate to conclude that a primitive reflex has been integrated simply because paper stabilization improved.

6. Clinical Case Examples: From Observation to Intervention

• The following fictional scenarios demonstrate how clinical reasoning can guide intervention planning.

Case 1: Quadruped Instability and Handwriting Difficulties

Student: Second grade

Observation: The student has difficulty maintaining a hands-and-knees position when moving the head. Handwriting also demonstrates inconsistent sizing and spacing.

Clinical Reasoning:

• The quadruped observation may raise questions about postural control and head–body coordination.
• However, it does not establish that retained STNR causes the student’s handwriting difficulties.
• The OT examines handwriting mechanics, helper-hand use, visual-motor skills, positioning, and letter-formation knowledge.

Intervention:

• Direct handwriting instruction is prioritized. Postural-control activities may be included if assessment identifies them as relevant to classroom performance.
• Appropriate seating and positioning supports may also be provided.

Functional Outcome:

• Progress is measured through handwriting legibility, sizing, spacing, writing-position support needs, and classroom participation.

Case 2: Frequent Hand Switching During Cutting

Student: Kindergarten

Observation: The student frequently changes hands while cutting and struggles to rotate paper using the assisting hand.

Clinical Reasoning:

• Hand switching may occur for several reasons, including emerging hand preference, coordination challenges, fatigue, or task demands.
• The behavior does not independently indicate retained ATNR.
• The OT observes scissor grasp, cutting control, supporting-hand coordination, paper rotation, and visual-motor accuracy.

Intervention:

• The student practices functional cutting tasks using appropriate scissors, explicit helper-hand instruction, visual cutting boundaries, and graded paper-rotation activities.

Functional Outcome:

• Progress is measured through cutting accuracy, use of the assisting hand, and decreased assistance during classroom cutting tasks.

Case 3: Movement-Seeking and Difficulty During Transitions

Student: Third grade

Observation: The student frequently moves around the classroom, taps objects, and has difficulty transitioning to written work.

Clinical Reasoning:

• The OT collaborates with the teacher to understand when the behaviors occur and how they affect school participation.
• Possible contributing factors include task difficulty, attention, sensory preferences, environmental conditions, and difficulty initiating work.
• A retained Moro reflex should not be assumed to explain the behaviors.

Intervention:

• The team introduces predictable transition cues, an organized workspace, appropriately timed movement opportunities when helpful, and a visual routine for beginning work.

Functional Outcome:

• Progress is measured through transition independence, task initiation, meaningful engagement, and the level of adult support required.

7. Building a Collaborative MTSS Model

School-based occupational therapy is most effective when intervention strategies can be understood and implemented by the educational team.

Occupational Therapists

OTs contribute by:

• Evaluating functional barriers to school participation
• Identifying relevant performance components
• Recommending evidence-informed intervention strategies
• Collaborating on universal and targeted supports
• Providing direct instruction or individualized services when indicated
• Developing measurable goals and objectives
• Monitoring intervention effectiveness

Classroom Teachers

Teachers contribute by:

• Identifying functional classroom concerns
• Implementing agreed-upon strategies
• Providing consistent instructional opportunities
• Collecting manageable data
• Communicating changes in student performance
• Participating in intervention decisions

Special Education Teams

Special education personnel contribute by:

• Coordinating supports with instructional goals
• Identifying barriers to curriculum access
• Monitoring IEP-related outcomes where applicable
• Supporting generalization across educational settings
• Collaborating on accommodations and service decisions

Families

• Families provide valuable information about the student’s strengths, daily routines, functional independence, and priorities.
• Home activities should complement the child’s educational needs and family routines.
• Families should not be expected to perform specialized reflex-integration programs solely because a primitive reflex response was observed at school.

Administrators and School Leaders

Administrators can support implementation by:

• Providing opportunities for OT–teacher collaboration
• Supporting evidence-informed instruction and intervention
• Ensuring access to appropriate classroom materials
• Promoting accessible and inclusive environments
• Supporting meaningful progress monitoring
• Recognizing OT contributions beyond individual treatment sessions

The specific way occupational therapy participates in MTSS depends on local procedures, staffing, state requirements, and student needs.

8. Common Mistakes to Avoid

Mistake 1: Assuming Every Motor Difficulty Is Caused by a Retained Reflex

• Poor posture, handwriting difficulties, hand switching, or fidgeting may have multiple explanations.

Better Approach: Complete a functional assessment and consider relevant performance and environmental factors.

Mistake 2: Using Reflex Scores as the Primary Measure of Progress

• Changes in reflex responses do not necessarily demonstrate improved school participation.

Better Approach: Track handwriting performance, cutting accuracy, classroom independence, or other meaningful outcomes.

Mistake 3: Replacing Direct Skill Instruction with Generalized Motor Exercises

• Motor activities may provide opportunities to practice foundational skills, but they do not automatically teach letter formation, word spacing, cutting, or written communication.

Better Approach: Include direct practice of the functional skill.

Mistake 4: Implementing the Same Movement Program for Every Student

• Children differ in their physical abilities, developmental needs, preferences, and responses to movement activities.

Better Approach: Select and modify activities according to functional goals and observed performance.

Mistake 5: Treating MTSS Participation as a Prerequisite for Evaluation

• A student suspected of having a disability does not have to complete every intervention tier before an appropriate special education evaluation may occur.

Better Approach: Follow IDEA requirements and applicable school procedures while continuing appropriate supports.

9. A Practical OT Decision-Making Checklist

Before beginning an intervention, consider the following questions.

Functional Assessment

• What meaningful school activity is difficult?
• How does the difficulty affect participation or independence?
• What strengths can the student use?
• What task, environmental, or performance factors may contribute?

Intervention Planning

• Is the intervention directly connected to the functional concern?
• Is there evidence or a sound clinical rationale supporting the strategy?
• Does the student need direct instruction, an accommodation, an environmental modification, or a combination?
• Can the strategy be implemented consistently within the educational environment?

Progress Monitoring

• What observable outcome will demonstrate improvement?
• How will baseline performance be measured?
• Are the scoring criteria clearly defined?
• When will the team review progress?
• What changes will be made if the student does not improve?

Clinical Reflection

• Are primitive reflex observations contributing meaningful information to the intervention plan?
• Am I avoiding unsupported assumptions about neurological causes?
• Is the student’s functional participation improving?

This checklist helps ensure that clinical observations lead to purposeful, measurable intervention.

10. What Research Supports This Approach?

Evidence-informed school-based occupational therapy integrates occupation-centered clinical reasoning, direct instruction, appropriate environmental supports, and progress monitoring.

AOTA: Focus on Occupational Performance

• AOTA’s Practice Smart! guidance emphasizes that reflex-integration interventions should not be used without clear links to occupational outcomes.
• This supports examining the student’s meaningful school activities rather than making reflex integration the sole treatment objective.

Occupational Therapy within MTSS

• Piller et al. (2023) describe how school-based occupational therapy practitioners can contribute to universal and targeted supports within an MTSS framework.
• Their article focuses particularly on sensory needs, environmental adaptations, and participation-related interventions at the classroom and group levels.
• This supports collaboration beyond traditional individual treatment sessions.

Evidence for Classroom-Embedded Handwriting Intervention

• Case-Smith et al. (2014) investigated the Write Start program, in which occupational therapists and teachers collaborated to provide handwriting instruction to first-grade students.
• The study compared 80 students receiving the program with 58 students receiving standard instruction.
• Students in the Write Start group demonstrated greater improvements in handwriting legibility and speed following intervention.
• Writing fluency and written composition did not differ significantly between groups immediately after intervention. However, writing fluency was higher in the intervention group at a six-month follow-up.
• This research provides a relevant example of collaborative, classroom-embedded occupational therapy supporting measurable handwriting performance.

Evidence for Curriculum-Based Handwriting Programs

• Engel et al. (2018) conducted a systematic review of 13 studies examining curriculum-based handwriting interventions for children from preschool through second grade.
• The researchers found small-to-medium improvements in handwriting legibility. However, evidence regarding handwriting speed was mixed, and evidence for fluency improvements was insufficient.
• These findings support purposeful handwriting instruction and emphasize the need for clearly defined functional outcomes.

MTSS and Data-Based Decision-Making

• The Center on Multi-Tiered System of Supports identifies screening, progress monitoring, a multi-level prevention system, and data-based decision-making as central components of MTSS.
• These principles provide a structure for identifying student needs, selecting supports, and determining whether interventions should be maintained or modified.

Research Limitation: The studies and professional guidance discussed here support occupation-focused assessment, classroom collaboration, direct skill instruction, and functional progress monitoring. They do not establish that a particular MTSS-based OT program integrates retained primitive reflexes or guarantees academic improvement.

Conclusion: Moving From Reflex Identification to Functional Success

Primitive reflex observations may provide useful information during an occupational therapy evaluation, but they should never become the sole explanation for a student’s learning, motor, or participation difficulties.

The most meaningful clinical reasoning begins with the student’s functional needs.

• Can the student stabilize paper while writing?
• Can the student cut classroom materials independently?
• Can the student maintain a comfortable and functional position during schoolwork?
• Can the student organize belongings, manage classroom routines, and participate meaningfully in educational activities?

These are the outcomes that matter.

Within MTSS, occupational therapists can support students through universal classroom strategies, targeted interventions, and intensive individualized services when appropriate.

By connecting assessment findings to direct instruction, environmental supports, collaboration, and measurable goals, school-based occupational therapy can make a meaningful contribution to student success.

At Write Expectations™, our focus is on helping students develop the functional skills they need for independence, learning, and successful school participation.

References

• American Occupational Therapy Association. (n.d.). Practice Smart! https://www.aota.org/practice/practice-essentials/evidencebased-practiceknowledge-translation/practice-smart
• Case-Smith, J., Weaver, L., & Holland, T. (2014). Effects of a classroom-embedded occupational therapist–teacher handwriting program for first-grade students. American Journal of Occupational Therapy, 68(6), 690–698. https://doi.org/10.5014/ajot.2014.011585
• Center on Multi-Tiered System of Supports. (n.d.). Essential components of MTSS. https://mtss4success.org/essential-components
• Engel, C., Lillie, K., Zurawski, S., & Travers, B. G. (2018). Curriculum-based handwriting programs: A systematic review with effect sizes. American Journal of Occupational Therapy, 72(3), 7203205010p1–7203205010p8. https://doi.org/10.5014/ajot.2018.027110
• Piller, A., Teng, K., Andelin, L., Kocher, E., Wiles, A., Niblock, J., & Johnson, L. (2023, November 1). An overview of school-based sensory interventions using the multi-tiered system of support. American Occupational Therapy Association. https://www.aota.org/publications/sis-quarterly/sensory-integration-processing-sis/sipsis-11-23
• S. Department of Education, Office of Special Education Programs. (2021, August 24). Return to school roadmap: Child find under Part B of the Individuals with Disabilities Education Act. https://sites.ed.gov/idea/idea-files/rts-qa-child-find-part-b-08-24-2021/

Educational and Professional Disclaimer

This article provides general educational and professional information. It does not replace individualized occupational therapy evaluation, school-based eligibility procedures, medical assessment, or clinical decision-making.

Illustrative objectives and case examples demonstrate principles of intervention planning and progress monitoring. They should be adapted to individual evaluation findings, educational needs, professional standards, and applicable school procedures.

Write Expectations™ | Occupational Therapy Resources for School Success

© 2026 Write Expectations™. All rights reserved.