The Growing Body of Evidence Against Bottom-Up Approaches – NDT and SI in Pediatric Occupational Therapy Practice

NDT = Neuro-Developmental Treatment, SI = sensory integration.

Top-Down vs Bottom-Up

Most occupational therapy practitioners are familiar with top-down vs bottom-up approaches for OT theories, models, and interventions. Most OT practitioners also tend to favor top-down approaches over bottom-up approaches as the top-down approach is more holistic and client-centered.

“Some of the most established paediatric occupational therapy interventions NDT/Bobath and SI were originally developed as ‘bottom-up’ interventions. NDT/Bobath and SI originated in an era of medicine when intervention aimed to remediate the child’s body structural deficits, thinking function would emerge.”

Shift to Top-Down

Interestingly, non-traditional approaches such as NDT have shifted to a top-down approach with a focus on function.

Research has challenged the efficacy of NDT and SI as a clinical practice for various conditions and populations. Much of the data relates to older trials in which NDT and SI rarely demonstrate a significance over ‘no intervention’ at all. Many researchers note that these  RCTs contain many methodological flaws. 10  11  12 

NDT and SI treatment among the OT community has become controversial and maybe even divisive.

Some therapists have interpreted the uncertainty of the NDT/Bobath and SI systematic evidence as justification of continuance, whereas others in the profession recommend discontinuance because of the growing body of ‘top-down’ evidence that offer effective alternatives 13 

Novak & Honan conducted a systematic review of pediatric occupational therapy interventions for children with liabilities. Based on a traffic light grading system for evidence, e.g, red, yellow, green, they found more bottom-down approaches belonging to the red category.

“Of the seven motor intervention indications below the ‘worth it line’, coded on GRADE as weak negative or strong negative (red), 7/7 (100%) were ‘bottom-up’ approaches.” 14 


The results from this systematic review provide insight into how bottom-up approaches have a trend of lower statistical significance compared to top-down approaches. Despite many years of use in the clinical setting and its inception, I am surprised about the lack of strong methological statistics behind this body of research for NDT and SI. 15  This may be in part be due to the complexity of measuring outcomes and attributing causation to specific variables.

There is nothing wrong with top-down approaches. Bottom-up can provide a lot of insight into the client based on specific characteristics, signs, and symptoms. However, many consider the theory behind NDT and SI to be outdated. The SIPT, once considered a gold standard for measuring sensory integration deficits, is likely to be outdated. 16  Meanwhile, SIPT certification has been paused. 17  Many clients, parents, and occupational therapy practitioners claim approaches such as SI to be effective for ASD. But, how much of this is due to SI intervention alone, other variables in the environment, including medications, or just the natural developmental trajectory?

It would be interesting to see how It would be interesting to see the research on newer bottom-up theories holds up for the pediatric population and even for physical disabilities and mental health.

The most important take-away, at least for me is to be cautious when using some theories, e.g., NDT or SI, and to try to take a more top-down approach with more consideration for top-down interventions because the research supports its use in pediatrics. Occupational therapy practitioners should also caution clients and caregivers and educate them about better alternative interventions than ones such as NDT and SI.


7/13/2021 – A new measure is in development called the Evaluation in Ayres Sensory Integration (EASI). A feasibility study was published in AJOT. Researchers and OTs seem to be translating this into other languages.

The authors in this editorial titled, “State of the Science of Sensory Integration Research With Children and Youth”, make some great points about the current state of SI research. They describe some of the earlier lack of characterization of the sample to be generalized to the broader population as well as fidelity. Fidelity ensures that an intervention is delivered as intended. 18 

  1. Rodger, S.Brown, G. T. & Brown, A. (2005). Profile of paediatric occupational therapy practice in AustraliaAustralian Occupational Therapy Journal52 (4), 311-325[]
  2. Boyd, R. N. & Hays, R. M. (2001). Current evidence for the use of botulinum toxin type A in the management of children with cerebral palsy: A systematic reviewEuropean Journal of Neurology81– 20[]
  3. Brown, G. T. & Burns, S. A. (2001). The efficacy of neurodevelopmental treatment in paediatrics: A systematic reviewBritish Journal of Occupational Therapy64 (5), 235– 244[]
  4. Case-Smith, J. & Arbesman, M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapyThe American Journal of Occupational Therapy62 (4), 416[]
  5. Case-Smith, J.Clark, G. J. F. & Schlabach, T. L. (2013). Systematic review of interventions used in occupational therapy to promote motor performance for children ages birth–5 yearsAmerican Journal of Occupational Therapy67 (4), 413– 424[]
  6. Lang, R.O’Reilly, M.Healy, O.Rispoli, M.Lydon, H.Streusand, W. et al. (2012). Sensory integration therapy for autism spectrum disorders: A systematic reviewResearch in Autism Spectrum Disorders6 (3), 1004– 1018[]
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  8. Sakzewski, L.Ziviani, J. & Boyd, R. N. (2013). Efficacy of upper limb therapies for unilateral cerebral palsy: A meta-analysisPediatrics133e175– e204[]
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  10. Steultjens, E. M.Dekker, J.Bouter, L. M.Van De Nes, J. C.Lambregts, B. L. & van den Ende, C. H. (2004). Occupational therapy for children with cerebral palsy: A systematic reviewClinical Rehabilitation18 (1), 1– 14[]
  11. Watling, R. & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: A systematic reviewAmerican Journal of Occupational Therapy69 (5), 1– 12[]
  12. Weaver, L. L. (2015). Effectiveness of work, activities of daily living, education, and sleep interventions for people with autism spectrum disorder: A systematic reviewAmerican Journal of Occupational Therapy,  69(5), 6905180020p1– 6905180020p11[]
  13. Rodger, S.Brown, G. T. & Brown, A. (2005). Profile of paediatric occupational therapy practice in AustraliaAustralian Occupational Therapy Journal52 (4), 311– 325[]
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  15. Pfeiffer, B., May-Benson, T. A., & Bodison, S. C. (2018). State of the science of sensory integration research with children and youth. American Journal of Occupational Therapy72(1), 7201170010p1-7201170010p4.[]
  18. Breitenstein, S. M., Gross, D., Garvey, C. A., Hill, C., Fogg, L., & Resnick, B. (2010). Implementation fidelity in communitybased interventions. Research in Nursing and Health, 33, 164–173.[]