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The American Journal of Occupational Therapy logoLink to The American Journal of Occupational Therapy
. 2026 Jul 19;80(5):898–907. doi: 10.1177/19437676261464084

Occupational Therapy Interventions in Down Syndrome: A Scoping Review

Katherine L Long 1,✉, Mario Sergio Barrios Lago 1, Eliza L Nelson 1
PMCID: PMC13640413  PMID: 42698320

Abstract

Importance

Individuals with Down syndrome experience multiple conditions requiring occupational therapy intervention, but no review papers have explored the research literature to support such intervention.

Objective

To map the literature on occupational therapy interventions for individuals with Down syndrome across the lifespan and identify gaps in the evidence base for future research and education that require attention.

Data Sources

Six databases were searched: OTSeeker, PubMed, PsychINFO, PEDro, CINAHL, and Cochrane Library for studies published on or before June 19, 2025.

Study Selection and Data Collection

This review was conducted according to PRISMA-ScR and Joanna Briggs Institute methodology for scoping reviews. Included studies had participants with Down syndrome, were published in English, contained an OT intervention, and were peer-reviewed. Excluded studies lacked participants with Down syndrome, were not in English, did not have an OT intervention, or were not peer-reviewed.

Findings

We retrieved 421 records and included 21 articles in this review. While most studies utilized rigorous designs (n = 16), none were designated “High Quality” due to multiple methodological flaws, such as failure to assess treatment fidelity or lack of random assignment to condition.

Conclusions and Relevance

This review suggests a need for studies with more methodological rigor, that address adults with Down syndrome, and that detail a greater variety of interventions. Practitioners and scholars should emphasize data-driven decision making, implementation of practice guidelines for Down syndrome, and the promotion of continuing education opportunities on Down syndrome.

Keywords: Down syndrome, occupational therapy, interventions, evidence-based practice, lifespan development

Plain-Language Summary

Although people with Down syndrome receive occupational therapy almost from birth, therapists often do not receive training on how to address the specific needs of individuals with Down syndrome. Families of individuals with Down syndrome have expressed a desire for research specific to Down syndrome, including occupational therapy research, to inform treatment. This study summarizes the existing research on occupational therapy interventions for people with Down syndrome across the lifespan and identifies areas of need for future research and practice. This study supports efforts to ensure that clients with Down syndrome receive the highest-quality care from informed providers. Future studies should target interventions for adults with Down syndrome and should include a broader variety of interventions to better reflect the scope of occupational therapy practice.

What This Article Adds

This article highlights areas of strength and areas of need in the literature on occupational therapy interventions for Down syndrome and makes recommendations for therapists and scholars looking to contribute to improving evidence-based practice.

Positionality Statement

The first author is a white heterosexual cisgender woman who has been working in the disability field for 14 years, first in direct support and then as an occupational therapist. Her work is centered around intellectual disability, Down syndrome, and functional rehabilitation. The second author is a dyslexic Cuban LGBT cisgender man who has been working in mental health and behavior analysis for approximately 10 years. He has developed his career around neurodiversity and data-driven interventions to improve accessibility for disabled individuals. The third author has a family member with Down syndrome and is an associate professor at an R1 research university. She specializes in fine motor skills.

Due to advances in prenatal care and the accessibility of genetic screening tools, many families know in advance that their child will be born with Down syndrome. Down syndrome is a developmental disability characterized by distinctive facial features, musculoskeletal impairments such as hypotonia, developmental delays, and other medical conditions and is present in one in 707 births in the United States (Mai et al., 2019). While Down syndrome arises from an extra copy of chromosome 21, the condition is marked by considerable variability (Tsou et al., 2020). A diagnosis of Down syndrome does not, with certainty, predict impairments in precise areas, as individuals can display both strengths and needs within a single domain (e.g., language or self-care skills). Down syndrome places an individual at risk of multiple conditions which would necessitate habilitative care such as feeding difficulties, cardiac abnormalities, vision/hearing impairments, gastrointestinal conditions, and others (Baumer et al., 2023). As a result, a diagnosis of Down syndrome qualifies an infant for Early Intervention services depending on their individual needs which may include physical therapy, speech therapy, occupational therapy, or other skilled services (Bruder, 2010).

Infants with Down syndrome often receive occupational therapy services from a very young age to address engagement in meaningful occupations such as education, Activities of Daily Living (ADLs; e.g., toileting, dressing, or bathing), Instrumental Activities of Daily Living (IADLs; e.g., community mobility), and others (American Occupational Therapy Association, 2020). They may continue to receive skilled occupational therapy services into childhood, adolescence, or even into adulthood depending on functional needs. Despite the importance of occupational therapy for individuals with Down syndrome and their families, no systematic or scoping review papers exist to support the provision of occupational therapy for this marginalized population.

Existing reviews highlight this gap. A systematic review of the literature on pediatric occupational therapy for children ages 5 to 21 with difficulty completing ADLs reported strong evidence for occupational therapy, but included studies lacked participants with Down syndrome (Laverdure & Beisbier, 2021). Another review of the literature on pediatric occupational therapy included some studies on Down syndrome, however, these were grouped alongside other diagnoses (Novak & Honan, 2019). A systematic review of the literature on physical therapy for individuals with Down syndrome supports physical therapy services for people with Down syndrome, but no such review exists on occupational therapy and Down syndrome (Ruiz-Gonzalez et al., 2019). Recent review papers of occupational therapy in pediatrics (Laverdure & Beisbier, 2021; Novak & Honan, 2019) have included few studies on occupational therapy and Down syndrome relative to conditions such as cerebral palsy or autism. Parents of children with Down syndrome have stated that research on Down syndrome is severely lacking, and this appears to be the case for research on occupational therapy and Down syndrome (White et al., 2021). A clearer understanding of the literature on occupational therapy and Down syndrome—including gaps and areas of strength, would allow for a more representative literature supporting occupational therapy as a whole.

Scoping reviews, as opposed to systematic reviews, are designed to survey the literature on a given topic where there are relatively few studies, especially if there are few rigorous studies such as randomized controlled trials (Arksey & O'Malley, 2005). The objective of the current scoping review is to systematically map the literature on occupational therapy interventions for individuals with Down syndrome, identify sources of evidence, and describe gaps in the available literature. The following research questions will also be addressed: (1) What occupational therapy interventions for individuals with Down syndrome have been researched?; (2) What research designs were utilized to examine such interventions, and were they rigorous, as defined by the National Technical Assistance Center on Transition (NTACT)?; (3) What outcomes were used to determine effectiveness of occupational therapy interventions for individuals with Down syndrome?; (4) Which occupations were targeted in individuals with Down syndrome participating in occupational therapy intervention research, and what are their durations?; and (5) Which age groups were studied in occupational therapy intervention research for individuals with Down syndrome?

Method

A preliminary search for similar scoping review papers was conducted by searching Google Scholar, and two papers were located: a systematic review and meta-analysis of physical therapy interventions for Down syndrome (Ruiz-Gonzalez et al., 2019), and a systematic review of occupational therapy interventions for children with disabilities including those with Down syndrome (Novak & Honan, 2019). The current review paper examined occupational therapy for individuals with Down syndrome of all ages.

This review utilized the Joanna Briggs Institute (JBI) methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR) to develop a protocol (Aromataris et al., 2024; McGowan et al., 2020; Tricco et al., 2018). The review protocol was then published via Open Science Framework (OSF) on June 17, 2025 (Long et al., 2025; https://osf.io/fauy5/). The Arksey and O’Malley (2005) framework guided the review process.

Inclusion and Exclusion Criteria

Studies were included if the following criteria were met: (1) at least one participant in the sample carried a diagnosis of Down syndrome; (2) the study was published in English; (3) an occupational therapy intervention had been conducted according to the Occupational Therapy Practice Framework, meaning that it addressed engagement in occupation(s) or performance skills supporting occupation(s) (OTPF-4; AOTA, 2020); and (4) the study was peer-reviewed. Studies were excluded from the review if: (1) no participants carried a diagnosis of Down syndrome; (2) the study was not published in English; (3) interventions were not conducted at all, were not conducted by an occupational therapy practitioner (e.g., occupational therapist or occupational therapy assistant), or were outside of the scope of occupational therapy as defined by the OTPF-4; or (4) the study was not peer-reviewed. Studies were included only if investigated interventions were conducted by an occupational therapy practitioner to reflect the definition of skilled occupational therapy in practice, as occupational therapy practitioners are not permitted to practice occupational therapy unless they are credentialled occupational therapists or occupational therapy assistants. This review did not limit sources based on publication date in order to provide a full map of the literature. Sources such as book chapters, review papers, or unpublished dissertations or theses were excluded. Studies were not restricted based on place, context, or geographical setting in which they were conducted as long as inclusion criteria were met.

Search Strategy

Potential studies were located by searching six databases: OTSeeker, PubMed, PsychINFO, PEDro, CINAHL, and Cochrane Library. Search terms included: “occupational therapy” and “Down syndrome.” MeSH terms were used to search PubMed. Reference lists of identified articles were hand searched for relevant articles. See Appendix 1 for key search terms by database. Records were then uploaded to Covidence, a web-based collaborative software platform that streamlines the production of systematic and other literature reviews (Veritas Health Innovation, 2025). Two researchers, including the first author and the second author who were trained in the inclusion/exclusion criteria, screened all study abstracts and titles for eligibility using Covidence. Each title/abstract was rated “yes” for inclusion in the review, “no” for exclusion from the review, or “maybe” for uncertain inclusion or exclusion from the review. Disagreements were resolved through discussion. All full-text articles marked “maybe” or “yes” were reviewed by two researchers for possible inclusion, and disagreements were resolved through discussion. For all included articles, reference lists were hand searched to locate potentially relevant studies. A diagram of the search strategy process is included in Figure 1.

Figure 1.

Figure 1.

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PRISMA flow diagram of the study selection process. The flowchart illustrates the stages of screening and inclusion, mapping the number of unique records identified, screened, assessed for eligibility, and ultimately included in the systematic review. Managed and generated via Covidence systematic review software.

Data Extraction

Included data were extracted using a chart developed by the first author (Table 1) which included the following: sample size, study setting, study design, provider types, disability types, ages of participants, interventions, duration, occupations targeted, outcome measures, treatment effects, and results of a quality assessment scale developed by the NTACT with two versions: One for use with studies comparing groups (National Technical Assistance Center on Transition, 2021) and the other for use with case studies (National Technical Assistance Center on Transition, 2016). The first author applied the quality assessment scale to all references while the third author provided consultation for areas that were unclear.

Table 1.

Data Extraction Chart.

Source N Setting: Design Provider(s) Disability Type Age Intervention Duration Occupation Outcome Measure Treatment Effect? Rigorous Design?a
Jenkins et al. (1983) 44 US: RCT OTR DS, ID, behavior disorders, communication disorders 3–5 years Sensory integration 2 × 25min sessions/week for 17 weeks Functional Mobility PDMS-GM, ASIPC − Yes
Edwards and Yuen (1990) 1 US: single case study Multidisciplinary including OTR DS 11 months NDT and sensory stimulation 1 × 30min session/week for 38 weeks Functional Mobility, Play, Social Participation BSID, reflex testing, oral and feeding assessment, REELS + No
Uyanik et al. (2003) 45 TR: quasi-experimental study OTR DS 7–10 years NDT and sensory stimulation 3 × 1.5hr sessions/week for 12 weeks Play, Functional Mobility PPP, clinical observations ± No
Heller et al. (2004) 53 US: RCT Multidisciplinary including OTR DS 30–54 years Exercise and health education program 3 × 2hr sessions/week for 12 weeks Health Management, ADLs, Functional Mobility CEBES, EPS, SEERS, CIS, CDI ± Yes
Gibbons et al. (2007) 1 US: single case study OTR DS 6 years Oralmotor procedure 5–11 × 20min sessions/day for 3 weeks and 3 days Feeding, eating Behavioral coding + Yes
Champagne and Dugas (2010) 2 CA: multiple case study OTR DS 28–37 months Hippotherapy 1 × 30min session/week for 11 weeks IADLs, Play GMFM-88, accelerometry ± No
Karimi et al. (2010) 18 IR: quasi-experimental study OTR DS 6–18 months NDT, Rood approaches, sensory stimulation 3 × 45min sessions/week for 24 weeks Functional Mobility GMFM-88 − Yes
Wuang et al. (2011) 105 TW: quasi-experimental study OTR DS 7–12 years Virtual reality 2 × 60min sessions/week for 24 weeks Play, Functional Mobility BOT-2, VMI, TSIF + Yes
Lin and Wuang (2012) 92 TW: RCT OTR DS 13–18 years Exercise, virtual reality 3 × 35min sessions/week for 6 weeks Functional Mobility, Health Management Dynamometer, BOT-2 + Yes
Nadkarni et al. (2012) 3 UAE: multiple case study OTR DS 7–9 years Visual-spatial skills 5 × 30min sessions/week for 4 weeks ADLs, Education Clinical observations + Yes
Silva et al. (2012) 28 US: RCT Multidisciplinary including OTR DS, CP 0–4 years Qigong massage 1 × 15min session/day for 20 weeks ADLs, Social Participation, Sleep SSC, PDMS ± Yes
Gawand and Nandagaonkar (2014) 28 IN: quasi-experimental study OTR DS 1–2.5 years “D” chair 2 × 45min sessions/week for 12 weeks ADLs, Play DASII, EDPA + Yes
Gokhale et al. (2014) 10 IN: quasi-experimental study OTR DS 2–6 years Play-based therapy 2 × 60min sessions/week for 4 weeks Play, Social Participation, Functional Mobility RKPPS + Yes
Satiansukpong et al. (2016) 16 TH: quasi-experimental study OTR DS Grades 1–6 (ages not listed) Thai elephant-assisted therapy 16 sessions for 8 weeks IADLs, Functional Mobility VMI, BOT-2, PDMS, clinical observations ± Yes
Silva et al. (2017) 27 PT: RCT OTR DS 18–60 years Virtual reality therapy 3 × 60min sessions/week for 8 weeks Leisure, Functional Mobility, Health Management Waist circumference, ETB, BOT-1 + Yes
Wan et al. (2017) 76 TW: quasi-experimental study OTR DS, WD 6–20 years Computerized visual perceptual training 1 × 60min session/week for 48 weeks ADLs, Education, Work, and Leisure TVPS-3, T-HVOT, FPMT + Yes
Pelosi et al. (2019) 13 BR: quasi-experimental study OTR DS 10–13 years Computer games 1 × session/week for 6–8 weeks Play, Leisure, Functional Mobility, Health Management Informal questionnaires ± No
Reyneke and Hoosain (2020) 3 SA: multiple case study OTR DS 10–12 years Stability ball seating 4 × 45min sessions/week for 15 weeks Education Behavioral coding + Yes
Udiaver (2020) 15 IN: quasi-experimental study OTR DS, ASD, ADHD, FX, ID 15–25 years Balance and coordination training 2 × 45min sessions/week for 24 weeks Education, Functional Mobility, IADLs, Work SRLS, SLLS, HWTT, teacher ratings + No
Raghupathy et al. (2022) 36 IN: RCT Multidisciplinary including OTR DS 6–10 years Traditional Indian dance 3 × 60min sessions/week for 6 weeks Leisure, Functional Mobility TGMD-2, FSST + Yes
Gomes et al. (2024) 14 BR: RCT OTR DS 9–12 years Canine-assisted therapy 1 × 30min session/week for 12 weeks Play, Functional Mobility VMI, TOP, behavioral coding, vasopressin concentration ± Yes
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Note. ADHD = attention deficit hyperactivity disorder; ADL= Activities of Daily Living; ASD = autism spectrum disorder; ASIPC = Assessment of Sensorimotor Integration in Preschool Children; BOT-1 = Bruininks–Oseretsky Test of Motor Proficiency-First Edition; BOT-2 = Bruininks–Oseretsky Test of Motor Proficiency-Second Edition; BR = Brazil; BSID = Bayley Scales of Infant Development; CA = Canada; CDI = adapted Children's Depression Scale; CEBES = Cognitive-Emotional Barriers to Exercise Test; CIS = Community Integration Scale; CP = cerebral palsy; DASII = Developmental Assessment Scale for Indian Infants; DS = Down syndrome; EDPA = Erhardt Developmental Prehension Assessment; EPS = Exercise Perceptions Scale; ETB = Eurofit Test Battery; FPMT = fMRI Full Picture Matching Test; FSST = Four Square Step Test; FX = Fragile X; GMFM-88 = Gross Motor Function Measure-88; HWTT = Hand to Wall Toss Test; IADL= Instrumental Activities of Daily Living; ID = intellectual disability; IN = India; IR = Iran; NDT= neurodevelopmental treatment; PDMS-GM = Peabody Developmental Motor Scales-Gross Motor; PPP=Pivot Prone Position Test; PT = Portugal; RCT=randomized controlled trial; REELS = Receptive Expressive Emergent Language Scale; RKPPS = Revised Knox Preschool Play Scale; SA = South Africa; SEERS = adapted Self-Efficacy to Exercise Regularly Scale; SLLS = Standing on Left Leg Test; SRLS = Standing on Right Leg Test; SSC = Sense and Self-Regulation Checklist; TGMD-2 = Test of Gross Motor Development, Second Edition; TH = Thailand; T-HVOT = fMRI resized Hooper Visual Organization Test; TOP = Test of Playfulness; TR = Turkey; TSIF = Test of Sensory Integration Function; TVPS-3 = Test of Visual Perceptual Skills, Third Edition; TW = Taiwan; UAE = United Arab Emirates; VMI = Developmental Test of Visual Motor Integration; WD = without known disabilities; OT = Occupational Therapist; OTR = Registered Occupational Therapist. + indicates a treatment effect, − indicates an absence of treatment effect, and ± indicates mixed results. a N indicates total sample size while n indicates number of participants with Down syndrome in the sample. *As defined by the National Technical Assistance Center on Transition Quality Indicator checklists (National Technical Assistance Center on Transition, 2016, 2021).

Results

A total of 421 studies were identified from six online databases, with 103 duplicates removed and 315 studies entering the screening process. Of these 315 records, 206 were removed due to not meeting inclusion criteria and 109 were retrieved for full-text review. Of the full-texts retrieved, 88 were excluded, with n = 2 not being in English, n = 1 not being peer-reviewed, and n = 85 being the wrong intervention. A total of 21 studies met inclusion criteria and were included in this scoping review.

Included studies originated from 11 different countries, including the United States (n = 5), India (n = 4), Taiwan (n = 3), and Brazil (n = 2). Each of the following countries, listed in alphabetical order, added one study to this review: Canada, Iran, Portugal, Thailand, Turkey, United Arab Emirates, and South Africa. Only 19% of studies were published within the past 5 years (n = 4), while 38% were published within the past 10 years (n = 8). Most of the research had relatively small total sample sizes including participants with Down syndrome and participants with other disabilities in some studies, with the majority having a sample size of 25 or less (n = 10), followed by 26 to 50 participants (n = 6), 75 to 100 participants (n = 3), 50 to 74 participants (n = 1), or 100 + participants (n = 1). The most common study design was quasi-experimental (n = 9), followed by randomized controlled trials (n = 7), multiple case studies (n = 3) and single case studies (n = 2). The majority of interventionists were registered occupational therapists (n = 17) although some were multidisciplinary teams which included registered occupational therapists (n = 4). The largest number of studies had samples made up of only individuals with Down syndrome (n = 17), although some samples included participants with other disabilities (n = 3) or a comparison group without known disabilities (n = 1). Children ages 3 to 12 years were represented in the largest number of studies (n = 13) followed by infants or toddlers ages 0 to 3 years (n = 7), adolescents ages 13 to 17 years (n = 4), emerging adults ages 18 to 30 years (n = 4), and adults ages 31 or older (n = 2). One study did not report ages of participants but instead reported grade levels 1 to 6 (Satiansukpong et al., 2016).

The most common area of intervention was sensory-based interventions (including massage, sensory stimulation, and sensory integration; n = 6) followed by computer-based or virtual reality interventions (n = 5), animal-assisted occupational therapy (n = 3), neurodevelopmental treatment (NDT; n = 3), health education or exercise (n = 3), visual-spatial interventions (n = 2), and play/leisure (n = 2), followed by additional interventions, each represented by one study: adapted equipment and oralmotor/feeding. Intervention durations varied widely, with two studies not specifying how long each session lasted (see Table 1 for more detailed information on session duration). The most common areas of occupation, as defined by the OTPF-4, addressed by the studies included: functional mobility (n = 14), play (n = 8), ADLs (n = 5), health management (n = 4), education (n = 4), leisure (n = 4), social participation (n = 3), IADLs (n = 3), work (n = 2), feeding/eating (n = 1), and sleep (n = 1). Formalized assessments were the most used outcome measure (n = 17) although eight studies used informal clinical observations or behavioral coding (see Table 1 for more detailed information on assessments used). The majority of studies reported significant results of their interventions (n = 12) versus mixed effects (n = 7) versus no effect (n = 2).

None of the 21 included studies met the NTACT's criteria for “High Quality” (meaning that a study meets 18 of 19 total criteria on the NTACT Quality Indicator Scale for group studies or 20 of 20 criteria for case studies) or “Acceptable Quality” (meaning that a group study meets 10 of 20 specific criteria such as having procedures to ensure participants were comparable across study groups or that the setting was described in replicable detail for a case study). These standards were quite stringent. However, a large majority of studies used a design characterized by NTACT as “rigorous” such as a pretest–posttest control group design or a multiple probe case study (n = 16) versus “weak” (e.g., one-group pretest–posttest design or AB case study design; n = 5). Because the quality indicator scales for case studies and group studies included different numbers of items, percent correct out of the total number of required items for “High Quality” designation was calculated (out of 18 items for studies comparing groups, and out of 20 items for case studies). Scores ranged from 33% to 89% of criteria met (mean = 63.62%; SD = 17.08%). Case studies lost quality points for features such as neglecting to measure treatment fidelity (n = 5), not overtly assessing social validity (n = 5), not noting whether an intervention was practice or cost-effective (n = 5), not reflecting on the social importance of the changes observed (n = 4), failing to include a baseline phase (n = 3), omitting measures of interobserver agreement (n = 3), or inadequately describing participant selection (n = 3). Group studies lost quality points due to the following errors: failing to formally assess treatment fidelity (n = 15), not measuring outcomes beyond an immediate posttest (n = 15), omitting interrater reliability (n = 12), omitting criterion and construct validity (n = 9), not having blind evaluators (n = 8), not having comparable conditions (n = 8), or not having comparable providers across conditions (n = 8).

After reviewing the studies included in this review using the NTACT Quality Indicator checklists, the first author compared the evidence base with the NTACT Criteria for Levels of Evidence, where interventions are categorized as “Evidence-Based Practice” for meeting the highest standards of research, “Research-Based Practice” for meeting high standards of research, or “Promising Practice” where research on the intervention is still emerging (National Technical Assistance Center on Transition, 2018). These designations rely heavily on the NTACT quality indicator checklists, prioritizing studies described as “methodologically sound” according to these checklists. For an intervention to be considered “Evidence-Based Practice,” it has to be positively supported by at least one group comparison study with random assignment to condition with at least 30 participants and three “methodologically sound” case studies and no “methodologically sound” studies showing negative effects and a ratio of 3:1 of “methodologically sound” studies showing positive effects to negative effects. For an intervention to be considered “Research-Based Practice” by NTACT, an intervention has to be positively supported by at least one “methodologically sound” group comparison study with random assignment to condition, one “methodologically sound” case study and one “methodologically sound” group comparison study without random assignment and studies must either calculate effect sizes or allow for such calculation. A practice is considered “Promising Practice” by NTACT if it is positively supported by two or more “methodologically weak” studies and the ratio of studies with positive to negative or neutral effects is less than 2:1.

Because none of the case studies or group comparison studies included in this review paper were considered “High Quality” according to the NTACT Quality Indicator Checklists and the ratio of studies with positive effects to neutral/negative effects is 12:9 which is less than 2:1, the provision of occupational therapy for individuals with Down syndrome is considered a “Promising Practice.”

Discussion

In this scoping review, we identified 21 articles in the occupational therapy literature addressing interventions for individuals with Down syndrome. While most included studies utilized study designs characterized as “rigorous” by the NTACT, none met NTACT criteria for “High Quality” or even “Acceptable Quality” due to multiple methodological flaws such as failure to randomly assign participants to treatment conditions, specifically outline participant selection, include reliability or validity of measures, and others. Sample sizes for included studies were quite small, reducing statistical power and reliability of results. Most studies in this review addressed pediatric populations, with relatively fewer studies addressing adults with Down syndrome. This pattern is concerning because individuals with Down syndrome often develop early-onset Alzheimer's disease, resulting in new occupational therapy treatment needs that may be unmet (Ptomey et al., 2018).

Surprisingly, most studies in this review originated from non-Westernized countries such as India, Taiwan, or Brazil, reflecting increased global awareness of the occupational therapy profession and of treatment options for individuals with Down syndrome. This global awareness is despite prevalent social stigma against people with Down syndrome (Jain et al., 2002). It is unexpected that there were so few studies from the United States, as the National Institutes of Health INCLUDE Project has allocated additional funding for Down syndrome research beginning in 2018 (National Institutes of Health, 2025). It may be difficult for occupational therapist researchers to access these funds, however (Bear-Lehman, 2011).

Limitations

A limitation of this review is that we adopted a strict operational definition of occupational therapy practice such that an occupational therapy practitioner had to conduct interventions according to the OTPF-4 for a study to be included in this review. It is true that interventions for Down syndrome that were within the scope of practice for an occupational therapist but conducted by another interventionist such as a physical therapist or behavioral therapist have been supported by higher-quality studies. For instance, resistance training, physical activity/adapted sports programs, treadmill training, virtual reality, and other interventions used by occupational therapy practitioners have been supported by systematic reviews, the highest level of research evidence (Kınacı-Biber et al., 2022; Muñoz-Llerena et al., 2024; Stander et al., 2021; Stojanović et al., 2025). Care for individuals with Down syndrome, much like the practice of occupational therapy, is an interdisciplinary endeavor. However, we assert the need for occupational therapy clinical expertise to inform clinical occupational therapy research to enhance the visibility of the profession as an evidence-based practice (Taylor & Kielhofner, 2017). Additionally, this review included a small number of studies with no limitation on publication date or study quality, meaning that several included studies are not current and may not reflect current best practices in the field. This finding may be especially relevant with interventions focusing on technological adaptations or virtual reality, as these fields evolve and may lose relevance quickly.

Future occupational therapy research in Down syndrome should emphasize improving methodological control of case studies, beginning with using multiple data collection points and evaluating of social validity for emerging treatments. These improved case studies should be followed by pretest–posttest studies with control groups with assessment of treatment fidelity and blinding of evaluators. Interventions for adults with Down syndrome experiencing functional declines in function are a priority for future research, as these individuals remain underrepresented in occupational therapy research. Studies including solely participants with Down syndrome instead of samples with multiple diagnoses are needed to ensure effective tailoring of interventions to their specific needs. Many included studies addressed sensory processing in Down syndrome while only one study addressed feeding, indicating that a greater variety of intervention research is needed to reflect the broad scope of occupational therapy practice.

Implications for Occupational Therapy Practice

While the evidence base for occupational therapy intervention for individuals with Down syndrome is limited, scholars and practitioners in occupational therapy a vital role in promoting evidence-based practice.

  • Clinicians should integrate data-driven decision making into their practice through application of theory, sound clinical judgment, and data collection, as this process enhances all clinical practice (Ayres, 1972; Schaaf, 2015).

  • Leaders in the profession should develop occupational therapy practice guidelines that are specific to Down syndrome, as they have done with other developmental conditions such as autism (Patten et al., 2024) or low vision (Kaldenberg & Smallfield, 2020).

  • Educators need to develop occupational therapy continuing education and academic training to inform practitioners on factors specific to Down syndrome beyond distinct clinical features in order to better reflect the complexity of the condition.

Conclusion

Due to the lack of high-quality studies on occupational therapy in Down syndrome, the provision of occupational therapy services for these individuals cannot be considered “Evidence-Based Practice” but is instead a “Promising Practice” under the rigorous standards of NTACT. For occupational therapy intervention to become an “Evidence-based Practice,” researchers will need to incorporate more rigorous research procedures into group study designs which include assessment of treatment fidelity, measuring outcomes at multiple time points, measuring interrater reliability, reporting criterion and construct validity for measures, using blind evaluators, and ensuring treatment conditions and providers are comparable across conditions. Scholars looking to improve research quality would benefit from using a quality indicator checklist such as those developed by NTACT for use when planning future studies. Due to the increase in funding opportunities for Down syndrome from the National Institutes of Health INCLUDE Project, now is the time for occupational therapy researchers to create high-quality methodologically sound research interventions tailored to the needs of children and adults with Down syndrome. Such interventions would greatly benefit practitioner continuing education, evidence-based interventions, and clinical outcomes for individuals with Down syndrome and their families.

Author biographies

Katherine L. Long, MS, MSOT, OTR/L, is PhD Candidate in Developmental Science and Graduate Assistant, Department of Psychology, Florida International University, Miami, FL.

Mario Sergio Barrios Lago is Lab Manager, Department of Psychology, Florida International University, Miami, FL and Board-Certified Behavior Analyst, Reflection Health Group, Inc., Miami, FL.

Eliza L. Nelson, PhD, is Associate Professor, Department of Psychology, Florida International University, Miami, FL.

Appendix 1

Database Key Search Terms
OTSeeker “Occupational therapy” AND “Down syndrome”
PubMed “down syndrome”[MeSH Terms] OR (“down”[All Fields] AND “syndrome”[All Fields]) OR “down syndrome” [All Fields] AND occupational therapy[MeSH Terms]
PsycINFO “Occupational therapy” AND “Down syndrome”
PEDro “Down syndrome”
CINAHL “occupational therapy or occupational therapist or OT or occupational therapy intervention AND Down syndrome”
Cochrane Library “occupational therapy AND down syndrome”
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Footnotes

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ORCID iDs: Katherine L. Long https://orcid.org/0000-0002-0957-1905

Mario Sergio Barrios Lago https://orcid.org/0009-0003-7148-2430

Eliza L. Nelson https://orcid.org/0000-0003-0058-8409

References

  1. American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process–fourth edition. American Journal of Occupational Therapy, 74, 1–87. 10.5014/ajot.2020.74S2001 [DOI] [PubMed] [Google Scholar]
  2. Arksey H., O'Malley L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. 10.1080/1364557032000119616 [DOI] [Google Scholar]
  3. Aromataris E., Lockwood C., Porritt K., Pilla B., Jordan Z. (2024). JBI manual for evidence synthesis. https://synthesismanual.jbi.global. https://doi.org/10.46658/JBIMES-24-01 [DOI] [PubMed]
  4. Ayres A. J. (1972). Sensory integration and learning disorders. Western Psychological Services. [Google Scholar]
  5. Baumer N. T., Hojlo M. A., Pawlowski K. G., Milliken A. L., Lombardo A. M., Sargado S., Soccorso C., Davidson E. J., Barbaresi W. J. (2023). Co-occurring conditions in Down syndrome: Findings from a clinical database. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 193, 10.1002/ajmg.c.32072 [DOI] [PubMed] [Google Scholar]
  6. Bear-Lehman J. (2011). The NIH roadmap: An opportunity for occupational therapy. Occupational Therapy Journal of Research, 31(3), 106–107. 10.3928/15394492-20110428-01 [DOI] [PubMed] [Google Scholar]
  7. Bruder M. B. (2010). Early childhood intervention: A promise to children and families for their future. Council for Exceptional Children, 76(3), 339–355. 10.1177/00144029100760030 [DOI] [Google Scholar]
  8. Champagne D., Dugas C. (2010). Improving gross motor function and postural control with hippotherapy in children with Down syndrome: Case reports. Physiotherapy Theory & Practice, 26(8), 564–571. 10.3109/09593981003623659 [DOI] [PubMed] [Google Scholar]
  9. Edwards S. J., Yuen H. K. (1990). An intervention program for a fraternal twin with Down syndrome. American Journal of Occupational Therapy, 44(5), 454–458. 10.5014/ajot.44.5.454 [DOI] [PubMed] [Google Scholar]
  10. Gibbons B. G., Williams K. E., Riegel K. E. (2007). Reducing tube feeds and tongue thrust: combining an oral-motor and behavioral approach to feeding. American Journal of Occupational Therapy, 61(4), 384–391. 10.5014/ajot.61.4.384 [DOI] [PubMed] [Google Scholar]
  11. Gawand N. S., Nandagaonkar M. H. (2014). To study the effectiveness of “D” chair on fine motor skills in children with Down's syndrome: A comparative study. Indian Journal of Occupational Therapy 46(3), 77–83. [Google Scholar]
  12. Gokhale P., Solanki P. V., Agarwal P. (2014). To study the effectiveness of play based therapy on play behaviour of children with Down’s Syndrome. Indian Journal of Occupational Therapy, 46, 41–48. [Google Scholar]
  13. Gomes C. M. S., Vasconcelos A. V. B., Santos A. M. C., Tokumaru R. S. (2024). Efficacy of an animal-assisted therapy program in the development of children with Down syndrome. Anthrozoös, 37(6), 1233–1252. 10.1080/08927936.2024.2406096 [DOI] [Google Scholar]
  14. Heller T., Hsieh K., Rimmer J. H. (2004). Attitudinal and psychosocial outcomes of a fitness and health education program on adults with Down syndrome. American Journal of Mental Retardation, 109(2), 175–185. [DOI] [PubMed] [Google Scholar]
  15. Jain R., Thomasma D. C., Ragas R. (2002). Down syndrome: Still a social stigma. American Journal of Perinatology, 19(2), 99–108. 10.1055/s-2002-23553 [DOI] [PubMed] [Google Scholar]
  16. Jenkins J. R., Fewell R. R., Harris S. R. (1983). Comparison of sensory integrative therapy and motor programming. American Journal of Mental Deficiency, 88(2), 221–224. [PubMed] [Google Scholar]
  17. Kaldenberg J., Smallfield S. (2020). Occupational therapy practice guidelines for older adults with low vision. American Journal of Occupational Therapy, 74(2), 1–24. 10.5014/ajot.2020.742003 [DOI] [PubMed] [Google Scholar]
  18. Karimi H., Nazi S., Sajedi F., Akbarfahimi N., Karimloo M. (2010). Comparison the effect of simultaneous sensory stimulation and current occupational therapy approaches on motor development of the infants with Down syndrome. Iranian Journal of Child Neurology, 4(3), 39–44. [Google Scholar]
  19. Kınacı-Biber E., Onerge K., Mutlu A. (2022). Gait characteristics and effects of early treadmill intervention in infants and toddlers with Down syndrome: A systematic review. Disability and Rehabilitation, 44(26), 8139–8148. 10.1080/09638288.2021.2010818 [DOI] [PubMed] [Google Scholar]
  20. Laverdure P., Beisbier S. (2021). Occupation- and activity-based interventions to improve performance of activities of daily living, play, and leisure for children and youth ages 5 to 21: A systematic review. The American Journal of Occupational Therapy, 75(1), 7501205050p1–7501205050p24. 10.5014/ajot.2021.039560 [DOI] [PubMed] [Google Scholar]
  21. Long K. L., Nelson E. L., Stephens D. P. (2025). Work as joy: Parental perspectives on factors affecting employment for emerging adults with Down syndrome . Disability and Rehabilitation, 1–8. 10.1080/09638288.2025.2527952 [DOI] [PubMed] [Google Scholar]
  22. Lin H.-C., Wuang Y.-P. (2012). Strength and agility training in adolescents with Down syndrome: A randomized controlled trial. Research in Developmental Disabilities, 33(6), 2236–2244. 10.1016/j.ridd.2012.06.017 [DOI] [PubMed] [Google Scholar]
  23. Mai C. T., Isenburg J. L., Canfield M. A., Meyer R. E., Correa A., Alverson C. J., Lupo P. J., Riehle-Colarusso T., Cho S. J., Aggarwal D., Kirby R. S. (2019). National population-based estimates for major birth defects, 2010–2014. Birth Defects Research, 111, 1420–1435. 10.1002/bdr2.1589 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. McGowan J., Straus S., Moher D., Langlois E. V., O'Brien K. K., Horsley T., Aldcroft A., Zarin W., Garitty C. M., Hempel S., Lillie E., Tuncalp O., Tricco A. C. (2020). Reporting scoping reviews—PRISMA ScR extension. Journal of Clinical Epidemiology, 123, 177–179. 10.1016/j.jclinepi.2020.03.016 [DOI] [PubMed] [Google Scholar]
  25. Muñoz-Llerena A., Ladrón-de-Guevara L., Medina-Rebollo D., Alcaraz-Rodríguez V. (2024). Impact of physical activity on autonomy and quality of life in individuals with Down syndrome: A systematic review. Healthcare, 12(181), 1–23. 10.3390/healthcare12020181 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Nadkarni S., S S, Ashok D. (2012). Enhancing eye-hand coordination with therapy intervention to improve visual-spatial abilities using ‘The Re-training Approach’ in children with Down syndrome: Three case studies. Disability , CBR & Inclusive Development, 23(2), 107–120. 10.5463/DCID.v23i2.87 [DOI] [Google Scholar]
  27. National Institutes of Health. (2025, July 16). INCLUDE Project. National Institutes of Health. Retrieved November 11, 2025 from https://www.nih.gov/include-project
  28. National Technical Assistance Center on Transition. (2016). QI checklist SINGLE Case [docx]. https://transitionta.org/quality-indicator-checklists/
  29. National Technical Assistance Center on Transition. (2018). NTACT criteria for levels of evidence. https://transitionta.org/wp-content/uploads/docs/criteria_NTACT-Levels-of-Evidence_2018.pdf
  30. National Technical Assistance Center on Transition. (2021). QI checklist GROUP [docx]. https://transitionta.org/quality-indicator-checklists/
  31. Novak I., Honan I. (2019). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Australian Occupational Therapy Journal, 66, 258–273. 10.1111/1440-1630.12573 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Patten K. K., Murthi K., Onwumere D. D., Skaletski E. C., Little L. M., Tomchek S. D. (2024). Occupational therapy practice guidelines for autistic people across the lifespan. American Journal of Occupational Therapy, 78(3), 1–53. 10.5014/ajot.2024.078301 [DOI] [PubMed] [Google Scholar]
  33. Pelosi M. B., de Oliveira Teixeira P., Santos Nascimento J. (2019). The use of interactive games by children with Down syndrome. Brazilian Journal of Occupational Therapy, 27(4), 718–733. 10.4322/2526-8910.ctoAO1869 [DOI] [Google Scholar]
  34. Ptomey L. T., Szabo A. N., Willis E. A., Gorczyca A. M., Greene J. L., Danon J. C., Donnelly J. E. (2018). Changes in cognitive function after a 12-week exercise intervention in adults with Down syndrome. Disability and Health Journal, 11(3), 486–490. 10.1016/j.dhjo.2018.02.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Ruiz-Gonzalez L., Lucena-Anton D., Salazar A., Martin-Valero R., Moral-Munoz J. A. (2019). Physical therapy in Down syndrome: Systematic review and meta-analysis [with consumer summary]. Journal of Intellectual Disability Research, 63(8), 1041–1067. 10.1111/jir.12606 [DOI] [PubMed] [Google Scholar]
  36. Reyneke L. K., Hoosain M. (2020). Dynamic seating in learners with Down's syndrome in South Africa. South African Journal of Occupational Therapy, 50(1), 20–27. 10.17159/2310-3833/2020/Vol50no1a4 [DOI] [Google Scholar]
  37. Raghupathy M. K., Divya M., Karthikbabu S. (2022). Effects of traditional Indian dance on motor skills and balance in children with Down syndrome. Journal of Motor Behavior, 54(2), 212–221. 10.1080/00222895.2021.1941736 [DOI] [PubMed] [Google Scholar]
  38. Satiansukpong N., Pongsaksri M., Sasat D. (2016). Thai Elephant-assisted therapy programme in children with Down syndrome. Occupational Therapy International, 23(2), 121–131. 10.1002/oti.1417 [DOI] [PubMed] [Google Scholar]
  39. Schaaf R. C. (2015). Creating evidence for practice using data-driven decision making. The American Journal of Occupational Therapy, 69(2), 1–6. 10.5014/ajot.2015.010561 [DOI] [PubMed] [Google Scholar]
  40. Silva L. M. T., Schalock M., Garberg J., Smith C. L. (2012). Qigong massage for motor skills in young children with cerebral palsy and Down syndrome. American Journal of Occupational Therapy, 66(3), 348–355. 10.5014/ajot.2012.003541 [DOI] [PubMed] [Google Scholar]
  41. Silva V., Campos C., Sa A., Cavadas M., Pinto J., Simoes P., Machado S., Murillo-Rodriguez E., Barbosa-Rocha N. (2017). Wii-based exercise program to improve physical fitness, motor proficiency and functional mobility in adults with Down syndrome. Journal of Intellectual Disability Research, 61(8), 755–765. https://www.doi.org/10.1111/jir.12384 [DOI] [PubMed] [Google Scholar]
  42. Stander J., du Preez J. C., Kritzinger C., Obermeyer N. M., Struwig S., van Wyk N., Zaayman J., Burger M. (2021). Effect of virtual reality therapy, combined with physiotherapy for improving motor proficiency in individuals with Down syndrome: a systematic review. South African Journal of Physiotherapy, 77(a1516). Epub. 10.4102/sajp.v77i1.1516 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Stojanović S., Rančić D., Ilić D., Aleksandrović M., Đorđević S., Hadžović M., Jorgić B. (2025). The effects of resistance training on health-related physical fitness of people with Down syndrome—a systematic review and meta-analysis. Disability and Rehabilitation, 47(13), 3214–3223. 10.1080/09638288.2024.2419421 [DOI] [PubMed] [Google Scholar]
  44. Taylor R. R., Kielhofner G. (2017). Kielhofner’s research in occupational therapy: Methods of inquiry for enhancing practice (2nd ed.). F. A. Davis Company. [Google Scholar]
  45. Tricco A. C., Lillie E., Zarin W., O'Brien K. K., Colquhoun H., Levac D., Moher D., Peters M. D. J., Horsley T., Weeks L., Hempel S., Akl E. A., Chang C., McGowan J., Stewart L., Hartling L., Aldcroft A., Wilson M. G., Garritty C., … Straus S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467–473. 10.7326/M18-0850 [DOI] [PubMed] [Google Scholar]
  46. Tsou A. Y., Bulova P., Capone G., Chicoine B., Gellaro B., Harville T. O., Martin B. A., McGuire D. E., McKelvey K. D., Peterson M., Tyler C., Wells M., Whitten M. S. (2020). Medical care of adults with Down syndrome: A clinical guideline. Journal of the American Medical Association, 324(15), 1543–1556. 10.1001/jama.2020.17024 [DOI] [PubMed] [Google Scholar]
  47. Uyanik M., Bumin G., Kayihan H. (2003). Comparison of different therapy approaches in children with Down syndrome. Pediatrics International, 45(1), 68–73. 10.1046/j.1442-200x.2003.01670.x [DOI] [PubMed] [Google Scholar]
  48. Udiaver D. V. (2020). The effect of balance and coordination rehabilitation exercises on serving skills of students with special needs undergoing vocational training in hospitality and catering department: A prospective one-arm interventional study. Indian Journal of Occupational Therapy, 52(2), 37–42. 10.4103/ijoth.ijoth_9_20 [DOI] [Google Scholar]
  49. Veritas Health Innovation. (2025). Covidence. https://www.covidence.org/ [Google Scholar]
  50. Wan Y.-T., Chiang C.-S., Chen S. C.-J., Wuang Y.-P. (2017). The effectiveness of the computerized visual perceptual training program on individuals with Down syndrome: An fMRI study. Research in Developmental Disabilities, 66, 1–15. 10.1016/j.ridd.2017.04.015 [DOI] [PubMed] [Google Scholar]
  51. White A. N., Chevette M., Hillerstrom H., Esbensen A. (2021). Parental perspectives on research for Down syndrome. Journal of Applied Research in Intellectual Disabilities, 1–9. 10.1111/jar.12937 [DOI] [PubMed] [Google Scholar]
  52. Wuang Y.-P., Chiang C.-S., Su C.-Y., Wang C.-C. (2011). Effectiveness of virtual reality using Wii gaming technology in children with Down syndrome. Research in Developmental Disabilities, 32(1), 312–321. 10.1016/j.ridd.2010.10.002 [DOI] [PubMed] [Google Scholar]

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