What Is MTSS and Why School OTPs Belong at the Table Before the Referral Hits

I sat in a meeting early in my career — one of those meetings where you’re the only occupational therapist in a room full of people who think OT begins and ends with the referral form.

A second-grader had been struggling with handwriting since kindergarten. His teacher had been watching him for two years, adjusting her expectations, telling herself he’d catch up. By the time I got the referral and did the evaluation, he was eight years old, and had developed a inefficient grasp that would take significantly longer to address than if we’d intervened at five. 

To make things worse, he’d had already started telling people he was “bad at writing.”

I’m not sharing that story to criticize anyone in the room. I’m sharing it because it’s the story that most school OTPs recognize from their own caseload — and it’s the story that MTSS exists to prevent.

 

What MTSS Actually Is  

Multi-Tiered System of Supports (MTSS) is a data-driven, prevention-first general education framework that organizes school resources into three increasingly intensive tiers:

Tier 1 — Universal Core Instruction: High-quality instruction and support for all students. The goal is to prevent difficulties from developing in the first place through classroom practice.

Tier 2 — Targeted Group Intervention: Additional support for students who aren’t responding adequately to Tier 1, typically delivered in small groups with more frequent progress monitoring.

Tier 3 — Intensive Individual or Small Group Intervention: Just as the name indicates, it’s intensive support for students with significant needs, delivered through individual or small group instruction. This is for students who aren’t responding to Tier One and Tier Two interventions.

The Every Student Succeeds Act (ESSA, 2015) explicitly encourages school districts to use specialized instructional support personnel (SISP)  – which includes occupational therapy practitioners, as consultants within this framework, not only as direct service providers. That language matters. It’s the legal opening for school OTPs to be proactive partners in Tier 1 rather than responders to Special Education referrals. 

 

The Problem With Waiting for the Referral  

Here’s the pattern most of us know well.

A child enters kindergarten with emerging fine motor skills, perfectly normal, and doesn’t receive explicit grasp instruction because the classroom teacher isn’t sure whose job that is. By first grade, the grasp pattern is more entrenched. By second grade, the child is referred to OT for “handwriting problems.” The evaluation confirms that yes, there are handwriting problems and fine motor delays.

The child now needs direct services to address something that might have been handled at Tier 1 two years earlier with a few classroom-level strategies and some teacher coaching.

This isn’t a failure of any individual. It’s a systems problem. And MTSS is the systems solution.

When OTPs participate at Tier 1, what we’re actually doing is changing the conditions in which all students develop their fine motor skills. We’re not waiting for problems to rise to a level that triggers a referral. We’re enriching the soil.

This is the distinction between a reactive and a proactive OTP role in schools. The reactive role addresses existing deficits. The proactive role creates conditions where fewer deficits develop, and where the ones that do develop are identified earlier and addressed more efficiently.

What Occupational Therapy at Tier 1 Looks Like for Grip and Grasp     

Tier 1 OT involvement in grip and grasp development looks like this:

Professional development for classroom teachers. Most early elementary teachers have not received formal training on pencil grasp and fine motor development. They may think that a “tripod grasp” is generally preferred — but they don’t know that the lateral tripod, dynamic quadrupod, and lateral quadrupod are all equally functional (Donica et al., 2018). They may be correcting grasps that don’t need correcting and missing grasps that do. A 45-minute PD session from the school OT changes that for every child those teachers ever teach.

Universal screening. When OTPs are embedded in early elementary classrooms, they can identify children whose grasp patterns suggest developmental delays before those children are failing. Early identification is faster, cheaper, and far more effective than late intervention.

Teacher coaching on instructional strategies. This includes  grasp instruction during the kindergarten and first-grade years, use of visual cue posters in the classroom, appropriate writing tools (smaller pencils and crayons for developing hands — Wiles, 1943), and vertical surface opportunities embedded into the daily routine.

Classroom-level resources. This is where my Gripipedia book comes in specifically. The resource pages (visual cue posters, grasp progression charts, classroom reward systems, instructional handouts for parents) are Tier 1 tools. They’re designed to be used by teachers and shared with families without requiring the child to have a referral.

Consultation on environmental setup. Proper desk and chair sizing, pencil types, paper positioning, classroom traffic flow during writing time — these are Occupational Therapy contributions that benefit entire classrooms, not just identified students.

 The “Handwriting Teacher” Problem  

Many occupational therapy practitioners report feeling “pigeonholed” as handwriting teachers, the person you call when a child can’t write neatly. This happens because OTPs are often positioned reactively. The referral-based system makes it structurally difficult to be anything else.

MTSS creates a different position. When you’re in the kindergarten classroom on Thursday morning helping a teacher set up fine motor centers and coaching her on what to look for in the first two months of school, you are not a handwriting teacher. You are a developmental specialist contributing to universal instruction. The distinction matters, for your professional identity, for how teachers and administrators understand your role, and for how many kids you actually reach.

The research makes a useful point here: Cornhill and Case-Smith (1996) found that many of the factors that differentiate children with good handwriting from those with poor handwriting (such as in-hand manipulation skills, muscle tone, sensory processing) are not things that emerge from handwriting instruction alone. They’re developed through the full range of fine motor experiences children have across the school day. That’s why addressing grasp at Tier 1 isn’t just about pencils. It’s about building the hand function that makes everything else possible.

Starting the Conversation With Your Administration  

If you’re a school OTP reading this and thinking “I would love to do more Tier 1 work, but I can barely keep up with my caseload” – you’re describing a systems problem that MTSS is designed to address, but that requires administrative buy-in to solve.

The argument you need to make is a resource argument: the cost of one student receiving direct OT services for three years is substantially higher than the cost of a general education classroom-level prevention service that may mean that student never needs those services at all. Cahill (2019) makes this case compellingly in the context of Best Practices for Occupational Therapy in Schools in MTSS frameworks.

This is the conversation I’ve been having in my district and in advocacy work for years. It is slow, it requires data, and it is absolutely worth having.

The Bottom Line  

The referral-based model of school OT is not going away entirely, and direct services for students with significant needs will always be part of what we do. But if we are only showing up after the problem has been documented, measured, and assigned a billing code, we are not doing everything our expertise allows us to do.

MTSS gives school OTPs the framework to be where the research says we should be: at the beginning, with all students, before the struggle becomes a referral.

That’s where grasp work belongs, too.

References  

Cahill, S. M. (2019). Best practices in multi-tiered systems of support. In G. Frolek Clark, J. E. Rioux, & B. E. Chandler (Eds.), Best practices for occupational therapy in schools (2nd ed., pp. 211–234). AOTA Press.

Cahill, S. M., & Beisbier, S. (2020). Occupational therapy practice guidelines for children and youth ages 5–21 years. American Occupational Therapy Association.

Cornhill, H., & Case-Smith, J. (1996). Factors that relate to good and poor handwriting. American Journal of Occupational Therapy, 50(9), 732–739.

Donica, D. K., Massengill, M., & Gooden, M. J. (2018). A quantitative study on the relationship between grasp and handwriting legibility: Does grasp really matter? Journal of Occupational Therapy, Schools, & Early Intervention, 11(4), 411–425.

Every Student Succeeds Act of 2015, Pub. L. No. 114-95, 129 Stat. 1802 (2015).

Wiles, M. (1943). Effect of different sizes of tools on the handwriting of beginners. The Elementary School Journal, 43(7), 412–414.