Abstract
This special section of the American Journal of Occupational Therapy presents important international developments in occupational therapy research related to sensory processing and participation across a range of contexts and occupations. Taken as a whole, this collection of articles provides evidence that sensory processing differences affect children across the developmental continuum, transcending specific diagnostic criteria and significantly influencing participation in diverse occupational environments. Although this may not seem like a novel insight to experienced occupational therapy practitioners, its significance lies in strengthening the empirical support underlying these practice-based “commonsense” claims.
This collection of articles presents important international developments in occupational therapy research related to sensory processing and participation across a range of contexts and provides evidence that sensory processing differences affect children across the developmental continuum, transcending specific diagnostic criteria and significantly influencing participation in diverse occupational environments.
Our profession has a long history of calls for, as well as challenges in achieving, a strong evidence base for its holistic, theoretically driven, occupation-based interventions, which may have strong clinical evidence but have often not been evaluated via rigorous, replicable, randomized, blinded clinical trials (Dirette et al., 2009; Lin, 2013). Years of well- organized efforts by pediatric occupational therapy researchers and clinicians have yielded notable progress in creating an increasingly strong evidence base for one of the most prominent sensory-based interventions, Ayres Sensory Integration® (ASI), such that it is now a manualized intervention with an established fidelity framework (Parham et al., 2007, 2011; Schaff & Mailloux, 2015). This has enabled multiple randomized controlled trials (RCTs) and led to its recognition as an evidence-based intervention for autistic children by the Frank Porter Graham Child Development Institute (Steinbrenner et al., 2020). Such dedicated efforts are critical not only for ensuring reimbursement, a complex challenge tackled by Glennon and Reynolds (2025) in their “The Issue Is” column in this special section, but also for addressing occupational therapy’s continued need as a profession to conduct evidence-based practice. The articles in this special section reflect the fruits of this work in ASI, expanding the existing evidence base for ASI and sensory processing measures. This collection of research also reflects a deepening of the understanding of sensory processing differences across the developmental continuum, in the diverse occupational contexts in which children learn, grow, develop, and play.
In addition, underlying these articles are strengths-based, child- and family-centered, neurodiversity-affirming perspectives, which we consider to be closely aligned with core occupational therapy principles. Particularly because occupational therapy practitioners must frequently navigate systems of care that are oriented around symptoms-based categorizations and deficits-focused labels, we are encouraged to see sustained commitment to core occupational therapy values reflected in these articles. The ongoing charge, as we see it, is to maintain such strengths-based orientations while continuing to establish occupational therapy as a scientifically rigorous profession with a robust evidence base warranting appropriate reimbursement.
Overall, this special section features eight articles that span a range of intervention types, practice contexts, and levels of evidence. We provide a brief description of each article and synthesize key commonalities across them while also highlighting important gaps and areas for future growth in this body of literature.
Expanding the Evidence Base: Ayres Sensory Integration
Kaplan Kılıç et al.’s (2025) RCT evaluates the effectiveness of ASI with 94 children (ages 6–8 yr) with attention deficit hyperactivity disorder (ADHD). They strengthen the ASI evidence base by providing the first clinical trial of ASI with this population known to have a high rate of sensory processing challenges. The children who received ASI showed significant improvements not only in sensorimotor functions but also in crucial higher-order cognitive domains, including attention, executive function, and emotional regulation, along with improvements in home, school, and community participation. This impact on complex skills reinforces the cascading model of sensory processing (Russo et al., 2025), which posits that a strong foundation in sensory integration facilitates the development of complex skills via activation of the prefrontal cortex, which is integral to attention and executive functioning (Deng et al., 2023). Kaplan Kılıç et al. (2025) found that the most substantial executive function gain was in the inhibitory control parameter, suggesting a powerful role for ASI in enhancing what is considered a core feature of ADHD.
Piller et al.’s (2025) systematic review of ASI interventions similarly expands beyond previous reviews by including children with diagnoses other than autism, as well as including a broader range of contexts. They also selected only studies that used outcomes related to participation, rather than a reduction in symptoms, supporting a neurodiversity-affirming approach. Among the 12 studies published since 2015 that met their inclusion criteria, which included meeting the ASI fidelity standards, the studies were approximately one-third RCTs, one-third nonrandomized trials, and one-third single-subject designs. They found strong evidence supporting ASI for goal attainment scaling and occupational performance, and moderate-strength evidence in support of improvement in daily living and self-care skills and social, communication, and play skills.
In measuring foundational sensorimotor abilities, the analysis by Chang and Yu (2025) provides an important step in normative age-based modeling of vestibular and proprioceptive functioning grounded in the theory of ASI. Using vestibular and proprioceptive subtests from the Evaluation in Ayres Sensory Integration (EASI), a standardized assessment explicitly designed to operationalize core constructs of ASI, they examined performance among typically developing children. They found that vestibular- and proprioceptive- related sensory integration abilities develop rapidly from age 3, slow down between ages 6 and 9, and reach a plateau after ages 9 to 10, whereas postural control skills improved most noticeably between ages 7 and 9. Together, these findings demonstrate the utility of the EASI for establishing preliminary age-related expectations for sensory integration functioning, with direct implications for assessment interpretation and intervention planning within ASI-informed practice.
Deepening Understanding of Sensory Processing Across Contexts
Like Chang and Yu’s (2025) study, other articles in this special section also contribute to an understanding of sensory processing across the developmental continuum. These studies recognized the ways in which sensory processing challenges can affect children across occupations and contexts, including school, early intervention, and within the family unit.
St. John et al. (2025) summarize the state of the science for feeding and eating, a key occupation that is often the first to be identified by caregivers as a developmental concern. Their review of the evidence highlights the high prevalence of sensory-based feeding difficulties among neurodiverse populations and underscores the importance of assessing the sensory aspects of food preferences and mealtime challenges. Feeding and eating difficulties are complex and multifaceted, but sensory processing differences often play a key role, and mealtime difficulties may be the catalyst prompting families to seek support (St. John & Ausderau, 2024). Occupational therapy feeding interventions use an array of sensory-based strategies, such as adaptive seating or modified utensils, and St. John et al. (2025) argue in favor of using evidence-based frameworks to guide clinical decision-making rather than adhering to strict protocols. In contrast, however, to the growing body of clinical trials supporting ASI, they note that feeding interventions in occupational therapy, while guided by strong theoretical and clinical evidence, have limited published evidence of effectiveness, identifying a critical area for further research.
In the school setting, the systematic review by Latifi et al. (2025) synthesizes the effectiveness of sensory activity schedules on school performance for students with sensory challenges. Although the strength of evidence is currently low, largely because of the predominance of studies using a single-subject design, sensory activity schedules resulted in positive outcomes, including decreased disruptive behavior in the classroom, improved on-task behavior, use of cognitive strategies, and task mastery. Notably, some of these interventions were implemented as whole-classroom sensory activities, suggesting their potential to benefit all children as Tier 1 interventions. Latifi et al. (2025) note the American Occupational Therapy Association’s recommendation that sensory-based strategies (along with ASI) be implemented across the multitiered system of supports (MTSS), emphasizing occupational therapists’ collaboration with teachers and administrators (Whiting et al., 2025; see Benfield et al., 2025, for a counterargument about ASI).
The impact of a child’s sensory processing differences within the family system is addressed by Muñoz-Sánchez et al. (2025), who examined the association between sensory reactivity in typically developing children and parental stress. Expanding beyond specific diagnoses and using a large population-based sample, their findings reveal that global sensory reactivity differences were associated with increased parental stress among mothers and fathers. This evidence underscores the necessity of addressing sensory reactivity difficulties as part of family-centered interventions to promote not only the child’s well-being but also the family’s. The findings point to the utility of including sensory processing assessments in early childhood screenings; supporting children and families early, regardless of diagnostic status, can enhance the occupational participation of the family as a unit.
Finally, expanding not only to early intervention settings but also to the professional development realm, Glennon et al. (2025) address the need for postprofessional education and mentorship in sensory-based interventions, specifically noting low levels of confidence among practitioners in their ability to effectively coach caregivers. They evaluated the impact of the Sensory Approaches to Infant/Toddler Learning (SAIL) program on practitioners’ knowledge and confidence in caregiver coaching, and they measured implementation outcomes (acceptability, appropriateness, and feasibility). The SAIL program, which included asynchronous training and mentorship, resulted in significant improvements in occupational therapists’ knowledge and confidence domains, and participants rated the program components as highly acceptable, appropriate, and feasible. These findings provide a critical step toward developing a strong evidence base for caregiver coaching, further supporting a family-centered model of care.
Alignment With Core Occupational Therapy Principles
The articles in this special section reflect a continued alignment with core occupational therapy principles, largely avoiding deficits- and symptoms-based framings of sensory processing differences. They focus on outcomes such as occupational engagement, function, and participation, reflecting child- and family-centered, strengths-based, and neurodiversity-affirming perspectives (cf. Dallman et al., 2022; Leinfuss & O’Hara, 2024; Taylor, 2023). The explicit emphasis on these foundational principles underscores their significance and shows that the profession can produce high-quality evidence for occupational therapy interventions that remain grounded in its values.
Muñoz-Sánchez et al.’s (2025) evaluation of sensory reactivity, like Chang and Yu’s (2025) normative age modeling, is important foundational research on sensory processing that is not limited by diagnostic categories. In their systematic review, Piller et al. (2025) included only research studies with outcomes related to participation rather than a reduction in symptoms, such as autistic traits, reflecting a shift toward strengths-based and neurodiversity-affirming paradigms. Kaplan Kılıç et al.’s (2025) ASI intervention also included a focus on participation. St. John et al.’s (2025) “State of the Science” column emphasizes the need for feeding and eating measures and interventions that view the child’s mealtime challenges through a holistic, culturally sensitive, affirming, and occupation-based lens. Glennon et al.’s (2025) focus on caregiver coaching similarly supports core occupational therapy principles of family- centered care, underscoring the critical importance of viewing the child as inextricable from the family environment.
Evidence-based practice has been called into question in occupational therapy (Hinojosa, 2013). Although we agree that there are challenges to establishing rigorous scientific evidence for holistic, occupation-based interventions, we argue that the studies in this special section demonstrate that we can produce high-quality evidence for occupational therapy interventions while maintaining clear alignment with our foundational principles.
Future Directions
In addition to the strengths we have described, we also note key areas for continued research and advocacy.
Rigorous Research Design
First, there is a continued need for rigorous research, particularly longitudinal, multisite RCTs to document the efficacy and effectiveness of occupational therapy interventions, including but not limited to ASI, among diverse populations and settings and across the MTSS, moving beyond the current predominance of low-strength evidence study designs. Piller et al. (2025) found that many ASI intervention studies had small sample sizes or used a single-subject design. Additionally, there is currently low evidence for sensory-adapted schedules; Latifi et al.’s (2025) review points to the need for more rigorous studies of such sensory-based supports in school settings, including classroom-wide interventions that may support children regardless of diagnosis. St. John et al.’s (2025) “State of the Science” column highlights the need for rigorous clinical trials evaluating the effectiveness of occupational therapy feeding interventions.
Kaplan Kılıç et al. (2025) discuss the importance of using blinded evaluators and note the potential limitation of nonblinded parent-report outcomes. Occupational therapy interventions are difficult to completely blind, particularly to caregivers, who may be hesitant to volunteer for a trial that involves a waitlist. In this way, rigorous comparative trials may be critical for the continued expansion of the evidence base (e.g., Schaaf et al., 2025). Future research also needs to clarify the optimal dosage and intensity of ASI, coaching, and feeding interventions, as well as the mechanisms of change in such interventions. Moving toward standards for reporting of dosage and intervention ingredients would help consolidate and strengthen future research reporting (Reynolds, 2023), and capturing data from multiple sources may be useful (e.g., parent-report, self-report, performance-based, physiological, and behavioral outcomes). Piller et al.’s (2025) review notes that some included studies combined ASI with parent training or other treatments, limiting the ability to determine whether ASI was the “sole agent of change” (p. 7). Mechanistic research can explore, for example, the underlying neural mechanisms that explain the relationship among sensory processing, higher-order cognitive functions (such as inhibitory control, demonstrated by Kaplan Kılıç et al., 2025), and everyday adaptive behavior.
To support rigorous research, we also need consistently used, validated outcome measures appropriate for ASI and occupational therapy interventions more broadly. Several articles (Latifi et al., 2025; Muñoz-Sánchez et al., 2025; Piller et al., 2025) used different outcomes for the same constructs, complicating direct comparisons. Piller et al. (2025) note how the lack of consistent outcome measures presents challenges for rigorous systematic reviews, and St. John et al. (2025) argue for the need for validated feeding-specific tools. We acknowledge the benefits of creating bespoke measurement tools, but efforts to establish a strong evidence base require validation and standardization of available tools for comparison across studies, whenever possible.
Collaborative Occupational Therapy Research and Practice
The articles in this special section also highlight the continued need for pediatric occupational therapists to articulate and demonstrate their unique expertise in multidisciplinary teams. This includes establishing collaborative training models to disseminate knowledge and strategies beyond traditional direct service delivery models (e.g., Tier 3). For example, the sensory-based strategies reviewed by Latifi et al. (2025) were initiated by occupational therapists but implemented by school staff. Literature suggests that teachers want to collaborate with occupational therapists to support students’ self-regulation and sensory needs (Truong & Hodgetts, 2017), and Latifi et al.’s (2025) review emphasizes the utility of classroom-wide implementation. Some studies in Piller et al.’s (2025) review combined ASI with teacher consultation, and St. John et al. (2025) underscore the importance of interdisciplinary approaches to feeding.
Ongoing collaboration with families is also critical. Despite the need for more high-quality and robust RCTs, we must not neglect the importance of lived experience and its impact on child- and family-centered care. Glennon et al.’s (2025) focus on improving occupational therapists’ skills and confidence in caregiver coaching is a critical step toward establishing standards for competencies that extend beyond entry-level preparation and may require additional training or continued education. There is also a need for creative strategies to overcome barriers to collaboration with caregivers in school-based settings to improve caregiver education and support implementation of sensory-based strategies at home (Latifi et al., 2025).
Although we recognize the importance of understanding caregiver experiences (Muñoz- Sánchez et al., 2025), we also acknowledge the impact on disability communities when research disproportionately focuses on caregiver stress or burden (Pellicano et al., 2014). Such findings can support family-centered approaches to sensory interventions and show how sensory needs are embedded in the family context, but we urge caution when focusing on caregiver stress without considering the lived experience of the child. Whole-family perspectives, presenting a balanced view of the lived experience of various family members and outcomes related to family participation, would be a valuable addition to understanding the complexity of sensory challenges within relational systems and family contexts.
Keeping with a strengths-based, neurodiversity-affirming framework aligned with core occupational therapy principles, we also advocate for research that attends not only to caregivers’ lived experience but also to the lived experiences, perspectives, and priorities of children, adolescents, and adults with disabilities. This can be achieved through qualitative research and the inclusion of stakeholders in participatory and community-engaged research. Encouragingly, in our experience, private and federal funders as well as scientific review committees are increasingly recognizing the value of such approaches, providing a critical support in obtaining funding for stakeholder inclusion in research.
Service Delivery, Policy, and Payment
Finally, the articles in this special section call attention to service delivery modes and the ways in which rigorous research can be used to advocate for policy that affects payment. It is essential that we ensure reimbursement for occupational therapy services. Discussions such as that of Glennon and Reynolds (2025) regarding billing codes are important in efforts to achieve comprehensive reimbursement for ASI, feeding, and school-based occupational therapy. Advocacy for legislation and policies must formally acknowledge that occupational therapy providers are qualified (and reimbursed) providers of services (e.g., feeding). This includes a strong evidence base for additional modes of service delivery, including telehealth, parent coaching, and school-based tiered models. Glennon et al.’s (2025) use of implementation outcomes is a critical model for future occupational therapy research, in addition to its exploration of structured postprofessional skill development.
In conclusion, this special section presents powerful evidence affirming that sensory processing is a foundational element of occupational performance across diverse populations and contexts. The challenge for the profession is threefold: (1) to continue generating robust evidence using the highest methodological rigor (Chang & Yu, 2025; Kaplan Kılıç et al., 2025; Latifi et al., 2025; Piller et al., 2025); (2) while maintaining strengths-based, affirming, child- and family-centered perspectives (Glennon et al., 2025; Piller et al., 2025; St. John et al., 2025); and (3) to ensure that advancements in fidelity, professional training (Glennon et al., 2025), and policy (Glennon & Reynolds, 2025) align, so that effective, empirically supported sensory-based interventions are universally accessible to all children and families navigating sensory processing differences (Muñoz-Sánchez et al., 2025).