Differentiating Sensory, Executive Function, and Behavioral Challenges

Dominique Blanche Kiefer, OTD, OTR/L, BCP
Therapy West 2, Orlando

Introduction

Children frequently present in clinical and educational settings with behaviors described as disruptive, avoidant, inattentive, or emotionally reactive. These behaviors are often addressed through generalized behavior management strategies; however, such approaches may overlook the diverse mechanisms contributing to observable performance. Sensory processing challenges, executive function (EF) deficits, and learned behavioral patterns can present with similar outward characteristics despite reflecting fundamentally different developmental processes. Inaccurate attribution may therefore result in interventions that are poorly aligned with a child’s actual needs.

This article presents the Integrative Model of Development to clarify these relationships. Using a developmental framework, it emphasizes the role of comprehensive evaluation and clinical reasoning in guiding targeted interventions that support meaningful functional participation.

Difficulties with participation in daily living, academic tasks, play, and social interaction remain among the most common reasons for referral to occupational therapy services (American Occupational Therapy Association, 2020). During evaluation, observable behavior is often the primary concern; however, behavior alone does not explain the mechanisms underlying participation challenges. Similar presentations may arise from sensory processing differences, executive dysfunction, skill-based limitations, or learned responses shaped by environmental contingencies. Evaluation must therefore move beyond description of behavior to identify the developmental systems influencing participation.

Model Overview: The Integrative Model of Development

The Integrative Model of Development (Figure 1) conceptualizes functional participation as the observable outcome of nested developmental domains. The model is represented as embedded rings in which inner domains provide the foundation for outer domains. The outermost ring represents functional participation—performance within daily routines and environmental contexts—and is consistent with participation as defined within the International Classification of Functioning, Disability and Health (World Health Organization, 2001).

Participation is influenced by three primary domains: skills, executive functions, and sensory processing/sensory integration. Skills include foundational motor, perceptual, and praxis-based abilities that support task execution. Executive functions reflect cognitive processes required for goal-directed behavior, including inhibition, working memory, planning, organization, cognitive flexibility, and self-monitoring (Diamond, 2013). Sensory processing represents the innermost domain and provides the neurological foundation for regulation, attention, motor coordination, and adaptive engagement (Ayres, 1972; Dunn, 1997).

The nested structure emphasizes that inefficiencies within inner domains may influence the development and performance of outer domains. For example, sensory processing challenges may compromise regulation and attention, interfering with executive functioning and skill acquisition (Brown et al., 2021). In contrast, executive function deficits or skill limitations do not alter sensory processing capacities. This distinction supports differential clinical reasoning regarding whether participation challenges reflect primary sensory dysfunction, executive dysfunction, skill-based limitations, learned behavior, or interaction among domains.

Functional participation is also influenced by contextual variables, including environmental demands, cultural expectations, health, and physiological factors. These contextual influences interact with developmental capacities and may support or constrain performance (WHO, 2001). The model therefore provides a framework for evaluation that integrates internal developmental systems with external task demands.

Applying the Model to Evaluation

During evaluation, clinicians must determine whether functional difficulties reflect deficits in sensory processing, executive functioning, skill development, behavioral learning, or a combination of factors. The model supports differentiation between capacity-based limitations and adaptive responses to contextual demands.

Sensory processing supports self-regulation, attention, and higher-level executive functioning by enabling the nervous system to register and modulate sensory input (Ayres, 1972; Blanche et al., 2025). When inefficient, children may demonstrate difficulty maintaining regulation, filtering information, sustaining attention, and coordinating movement, which may affect participation. Emerging evidence supports meaningful associations between sensory processing and executive functioning in children, reinforcing the importance of differential assessment across these domains (Brown et al., 2021; Li et al., 2023).

Executive functions support goal-directed behavior. When compromised, children may present as disorganized, inattentive, emotionally reactive, or noncompliant. These behaviors should be interpreted as indicators of developmental limitations rather than intentional misconduct (Diamond, 2013). Further, executive function interventions must be selected carefully, as not all approaches demonstrate consistent evidence for generalized EF improvement (Diamond & Ling, 2016).

Skill development supports successful task engagement. Inefficiencies in visual perception, motor coordination, praxis, or handwriting may increase cognitive load and frustration, contributing to dysregulation. In such cases, behavior may reflect task difficulty rooted in skill-based limitations.

Behavior is best understood as the observable outcome of interactions among sensory processing, executive functions, skills, and environmental context. Differentiation among these influences is essential for selecting interventions that address underlying mechanisms rather than surface-level behavior.

Evaluation Priorities and Clinical Reasoning: A Differential Framework

Figure 2 outlines a structured evaluation process for determining whether participation challenges are primarily related to sensory processing, executive function deficits, behavioral learning patterns, or interaction among domains.

Evaluation begins with determining whether referral concerns may be associated with sensory processing differences. If sensory challenges can be identified, further assessment of executive functioning, skill development, and behavioral manifestations is warranted to clarify primary and secondary influences. If sensory processing is within expected limits, evaluation shifts toward examining executive functioning and its impact on skills and participation.

When executive function deficits are identified and linked to referral concerns, intervention planning should integrate executive supports with behavioral strategies. If executive functioning is not implicated, behavioral approaches may be emphasized.

This structured reasoning process strengthens problem identification and guides targeted intervention planning aligned with the child’s developmental profile.

Intervention: Thoughtful Integration of Approaches

Intervention should target the developmental domain(s) most strongly contributing to participation challenges. Within the Integrative Model of Development, intervention is most effective when aligned with underlying mechanisms rather than observable behavior alone.

When sensory processing challenges are primary, sensory integration approaches should support regulation and adaptive engagement (Ayres, 1972; Blanche et al., 2025). When executive dysfunction is primary, intervention should incorporate executive supports such as strategy instruction, structure, and coaching, often alongside behavioral strategies. When skill-based limitations are primary, intervention should emphasize skill development, task adaptation, and environmental modification. When behaviors reflect learned patterns, behavioral approaches and contextual restructuring are indicated.

Many children present with overlapping challenges; coordinated intervention across domains may therefore be necessary. Effectiveness depends not on the number of approaches used, but on alignment with evaluation findings. Evidence supports combining sensory integration with complementary intervention approaches when clinically indicated (Blanche et al., 2022).

Conclusion

Children’s behaviors provide meaningful information about underlying developmental capacities. When interpreted through the Integrative Model of Development, evaluation can differentiate sensory processing challenges, executive dysfunction, skill limitations, and learned behavior patterns. Such differentiation allows occupational therapy practitioners to move beyond generalized intervention toward targeted approaches that support sustained participation and functional success.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Ayres, A. J. (1972). Sensory integration and learning disorders. Western Psychological Services.

Blanche, E. I., Giuffrida, C., Hallway, M., Edwards, B., & Test, L. A. (Eds.). (2022). An evidence-based guide to combining interventions with sensory integration in pediatric practice. Routledge.

Blanche, E. I., Kiefer, D. B., & Test, L. (2025). Sensory Integration Theory. In Routledge Companion to Occupational Therapy (pp. 377-388). Routledge.

Brown, T., Swayn, E., & Pérez Mármol, J. M. (2021). The relationship between children’s sensory processing and executive functions: An exploratory study. Journal of Occupational Therapy, Schools, & Early Intervention, 14(3), 307–324. https://doi.org/10.1080/19411243.2021.1875386

Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64, 135–168. https://doi.org/10.1146/annurev-psych-113011-143750

Diamond, A., & Ling, D. S. (2016). Conclusions about interventions, programs, and approaches for improving executive functions that appear justified and those that, despite much hype, do not. Developmental Cognitive Neuroscience, 18, 34–48. https://doi.org/10.1016/j.dcn.2015.11.005

Dunn, W. (1997). The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model. Infants & Young Children, 9(4), 23–35.

Dunn, W. (2001). The sensations of everyday life: Empirical, theoretical, and pragmatic considerations. American Journal of Occupational Therapy, 55(6), 608–620. https://doi.org/10.5014/ajot.55.6.608

Li, J., Wang, W., Cheng, J., Li, H., Feng, L., Ren, Y., et al. (2023). Relationships between sensory integration and the core symptoms of attention-deficit/hyperactivity disorder: The mediating effect of executive function. European Child & Adolescent Psychiatry, 32(11), 2235–2246.

World Health Organization. (2001). International classification of functioning, disability and health (ICF). Author.

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