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Clinical trial

Does the Order of OT and ABA Therapy Matter?

Published 5 August 2026 · 5 min read

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Parents are often told to start occupational therapy (OT), which helps with everyday skills and the senses, before ABA, a therapy that teaches skills and behavior in structured steps. Some are told the opposite. No study has tested one order against the other. The best recent trial gave each therapy on its own and found both helped with daily living skills and personal goals. So the order seems to matter much less than two other things: the therapies working together, and fitting what your child needs most.

What this research found

  • No research has tested the order directly. OT is occupational therapy, which helps with everyday skills and the senses. ABA is applied behavior analysis, a therapy that teaches skills and works on behavior in structured steps. Advice about which comes first is often given with confidence. Yet no published trial compares "OT first, then ABA" with "ABA first, then OT". The question has not been answered because it has barely been asked.
  • When the two therapies were tested head to head, both worked. In one trial, children were put into groups by chance. Some had OT using Ayres Sensory Integration, a set method that works on how a child takes in and handles sensory input such as touch and sound. Some had ABA. Some had no treatment. Both therapy groups made gains too large to put down to chance, compared with the no-treatment group. The gains were on goals set for each child and on everyday activities.
  • That trial ran the therapies separately, not one after the other. Each child got one therapy or neither. So the results tell us whether each therapy helps. They say nothing about what order to put them in.
  • Professional writing argues for working together, not for a set order. A peer-reviewed paper (one checked by other experts before it was published) looked at how behavior analysts, the professionals who deliver ABA, and occupational therapists work together. It appeared in the journal Behavior Analysis in Practice. It says the central problem is the two professions working in isolation, and sometimes against each other. It calls for shared assessment and goals that line up.
  • The two fields truly disagree about sensory-based therapy. Behavior analysts have long questioned the evidence for sensory integration. That disagreement, not a settled rule about order, is behind much of the conflicting advice parents hear.
  • The usual reason for "OT first" is about readiness, not a proven order. The thinking goes like this. A child overwhelmed by sights, sounds and other sensory input cannot take part in structured learning. So helping the child feel calm and settled, which therapists call regulation, should come first. It is a reasonable clinical argument. But no controlled trial, meaning one with a comparison group, has tested it as a question of order.
  • The total amount of therapy is a real factor, and it can be measured. Research has looked at how many hours of therapy children get, and at caregiver stress. It shows that very stressed parents find it harder to carry out their child's behavior plans. So how much therapy your family can keep up is a practical limit on any plan.

What this means for caregivers

  • If a provider tells you there is one correct order, ask what that is based on. The honest answer from current research is that the order has not been studied. So a confident claim either way is a professional's opinion, not a research finding.
  • "Which comes first?" is hard to answer. "What is getting in the way right now?" is easier. If sensory distress is stopping your child from eating, sleeping, dressing or coping at school, that argues for giving OT priority. If the most pressing issue is communication, or a behavior that is unsafe, that argues for giving behavioral support priority.
  • Giving one therapy priority is not the same as putting them in order. Choosing where to put the most hours this term does not mean the other therapy has to wait until the first is "finished". Most children who get both have them at the same time.
  • Working together is the part the evidence actually supports. Whether the therapies run side by side or one leads, the advice that comes up again and again is the same. The OT and the behavior analyst should share goals and talk regularly. That way your child is not taught opposite things in two different rooms.
  • You are allowed to weigh what your family can manage. Waitlists, insurance coverage, travel, cost and how long a therapy week your child can handle are all fair things to consider. No order has been shown to be better. So starting with whichever good-quality service you can actually get is a reasonable choice.
  • Watch your own child rather than the schedule. The research cannot tell you the right order. So the most useful evidence is how your child responds over the first few months: what is improving, what is getting harder, and whether the total load is sustainable for your family.

Important caveats

  • This summary describes what the research does and does not show. It is not a recommendation about your child's therapy plan. It cannot replace an assessment by professionals who know your child.
  • Having no evidence about order is not the same as evidence that order never matters. Order may matter a great deal for some children, especially those with severe sensory distress. That possibility has not yet been tested.
  • The head-to-head trial is a single study, and its children were chosen because they had sensory differences. Its conclusions about ABA have been formally challenged in a commentary, a short published response, in the same journal. Treat it as one useful piece of evidence, not a final verdict.
  • "OT" and "ABA" are both broad labels that cover very different practices. Ayres Sensory Integration done the way a research study sets out is not the same as every service sold as sensory OT. ABA also varies widely in style, number of hours and quality.
  • Much of the easy-to-find material on this question comes from therapy providers who offer one or both services. Read it with that business interest in mind.
  • ABA itself remains disputed, especially by many autistic adults, for reasons that go beyond whether it works. Families weighing these therapies can reasonably take those concerns into account alongside the research.

The science behind it

This part is written for researchers, so it gets technical. Reading it anyway is what researchers do: checking how a finding was reached, not just what it says. It’s slow going at first and gets easier after your first few articles. Skipping it is fine too.

Parents are often told to start occupational therapy before ABA, or the other way round, but no study has actually tested one order against the other. The strongest recent evidence is a randomized trial that ran the two therapies separately and found both improved children's daily living skills and personal goals, which suggests the order matters far less than whether the therapies are coordinated and matched to your child's most pressing needs.

At a glance

Demographics: Autistic children with identified sensory differences
Key outcome: Both OT-ASI and ABA produced significant gains over no treatment on individualized goals (Goal Attainment Scaling, p < .001) and on daily activities scores, but because the trial never combined or sequenced the therapies it offers no evidence that either one has to come first.
Methodology: A parallel-arm comparative effectiveness trial randomized autistic children with sensory differences to occupational therapy using Ayres Sensory Integration (OT-ASI), to Applied Behavior Analysis (ABA), or to no treatment, with each therapy delivered as 30 one-hour sessions over 12-15 weeks. The two therapies were compared side by side, not one after the other.
Researchers: Roseann C. Schaaf
Institutes: Jefferson Autism Center of Excellence, Thomas Jefferson University

Limitations:

  • No published trial has directly compared starting with OT and then adding ABA against starting with ABA and then adding OT, so the ordering question itself is essentially unstudied.
  • The trial delivered each therapy on its own, which is not how most families receive services - in real life OT and ABA usually run at the same time.
  • Therapists and caregivers could not realistically be blinded to which therapy a child was receiving, which can inflate reported improvements.
  • A published commentary in the same journal has challenged how the trial characterized its ABA arm and how far its equivalence claims can be pushed.
  • The best dose, intensity and timing of sensory integration work are still unresolved, and the mechanisms behind any change are not established.

About this research

The strongest source here is a 2025 parallel-arm comparative effectiveness trial in Autism Research that randomized autistic children with sensory differences to OT using Ayres Sensory Integration, to ABA, or to no treatment - a design that compares the therapies but never sequences them. It is supported by a 2021 peer-reviewed paper in Behavior Analysis in Practice on collaboration between the two professions, and its claims about ABA have been challenged in a subsequent commentary in Autism Research. No systematic review or trial addressing therapy order was located, which is the central finding of this summary rather than a gap in the search: on the specific question of sequence, the evidence base is close to empty.

The research in its own terms. The findings above are written in plain words. Here are the terms the papers use, so you can match them up:

  • The trial's design: a randomized comparative trial; "gains too large to put down to chance" means statistically significant gains over no treatment on individualized goals and daily activities.
  • The collaboration paper: frames the central problem as behavior analysts and occupational therapists working in isolation and sometimes at cross purposes; calls for shared assessment and aligned goals.
  • Therapy load: the research cited is on intervention intensity and on caregiver stress; highly stressed parents have more difficulty implementing their children's behavior plans.

Sources

Related topics

This summary was prepared by the Curioler research agent. It is not medical advice. Always consult a qualified professional before making decisions about your child's care.

Reviewed by Bhavin Solanki, caregiver parent. This is informational content, not medical advice — see our disclaimer.