Understanding Top-Down vs Bottom-Up Approaches to Pediatric Occupational Therapy

Occupational therapists use two main approaches when supporting children: the top-down and bottom-up approaches. While both aim to improve a child’s participation in daily activities, they differ in focus and intervention style.??

Top-Down Approach

The top-down approach first considers the child's ability to perform meaningful activities, considering functional participation before impairment. The therapist would then modify the environment, use an assistive tool, or adapt the activity to facilitate success.??

Examples of Top-Down Asks in a School Setting:

How can we help the child complete a handwriting assignment despite difficulties?

- Which strategies can be implemented to maintain the child sitting and attentive in class??

- How are we able to support a child in dressing independently for recess with no frustration???

Example: A student is having difficulty with handwriting. A therapist might explore adaptive writing tools, adjust posture, or visual-motor strategies to enhance function with the full participation of the student.?

Bottom-Up Approach

The bottom-up approach targets foundational skills that are critical for participation, such as sensory processing, fine motor control, or core strength. It assumes that improvement in these underlying deficits will enhance overall function.?

Examples of Bottom-Up Asks in a School Setting:

- How can we improve hand strength to support better pencil control? ?

- What activities can help develop postural stability for better sitting endurance?

How can we optimize sensory processing to become less distractible and more focused???

Example: A student cannot cut with scissors because their hand muscles are too weak. A bottom-up occupational therapist might first incorporate hand strengthening activities, such as squeezing putty or using tweezers, before addressing scissor use directly.?

Which Approach is Best?

Both are valuable, and therapists often combine both approaches depending on the child's needs. A top-down approach assures participation right away; a bottom-up approach helps to build foundational skills that will be helpful for a lifetime. Balancing both allows therapists to help kids achieve meaningful and lasting progress beyond school.