Research & Practice

From Sensory Ladders® to PEAR TREE™

…more than 25 years of noticing regulation differently

This new occupational therapy scoping review invites us to revisit an important question: what do we actually mean when we talk about “self-regulation”?

Cossart, Thomacos, Bhopti and Fossey’s 2026 review explores how occupational therapists understand self-regulation in mainstream primary schools. Despite self-regulation being widely discussed in occupational therapy, the authors found only 12 papers meeting their criteria, seven peer-reviewed studies and five dissertations. More importantly, they identified considerable uncertainty about how self-regulation is defined, understood and measured.

That conclusion resonates strongly with the history of Sensory Ladders® and with the more recently articulatoccupational therapistsed PEAR TREE™ Lens. The challenge may not simply be to help people become “better regulated”. It may be to understand regulation differently.

Across the literature reviewed by Cossart and colleagues, self-regulation was frequently understood as controlling or modulating thoughts, feelings, attention or behaviour. Different papers drew on overlapping concepts including executive functioning, emotional regulation, behavioural regulation and sensory processing. Yet the authors identify an important gap in occupational therapy. Self-regulation was not adequately operationalised in relation to occupational performance, engagement or participation.

That distinction matters.

For occupational therapists, the important question should surely not be whether somebody looks calm, still or socially expected. A person may look quiet while overwhelmed. Another person may move, rock, pace, hum, withdraw temporarily or seek intense sensory experiences and be doing exactly what their nervous system needs to remain available for participation. Behaviour alone tells us very little about what is happening.

We need to understand the Person, their body, their environment, what they are trying to do, who is alongside them, and what happens next.

This is familiar territory for Sensory Ladders®.

The first Sensory Ladders for self-regulation were developed in Cornwall in 2001, building on earlier “Sensory Levels” work from 1999. They grew out of occupational therapy practice with people whose participation could vary considerably depending on sensory experience, alertness, stress, environment, relationships, and occupational demands.

From the beginning, the idea was highly individual. A Sensory Ladder was never intended to tell somebody what a particular state should look like. It was designed to help make their experience more visible and understandable. What happens in my body? What might another person notice? What happens to my ability to think, communicate, move and do? What sensory experiences help? What makes things harder? What might I need other people to understand or change?

In this sense, Sensory Ladders have always been more than lists of sensory strategies. They provide a way to notice, communicate, reflect, and learn together.

The Cossart review makes this particularly interesting because none of the included peer-reviewed studies directly measured self-regulation itself. Instead, researchers measured related outcomes such as executive functioning, behaviour, self-efficacy, occupational performance and goal attainment. The authors conclude that occupational therapy still lacks a consistent, occupationally grounded way of conceptualising and measuring self-regulation.

That does not mean Sensory Ladders should become another standardised “regulation measure”. Quite the opposite. Their value may lie in preserving something that standardised measurement can easily lose: the Person’s own account of their embodied experience and how that experience changes according to context.

A Sensory Ladder can help us notice change – PEAR TREE™ helps us ask why.

The PEAR TREE™ Lens grew from many of these same clinical questions. Rather than locating regulation solely inside the Person, PEAR invites us to consider Person, Environment, Activity and Relational response together.

This changes the question significantly. Instead of asking, “Why can’t this Person regulate?”, we can ask what the Person is experiencing, what is happening in the environment, what the activity is asking of their body and nervous system, and what is happening within the relational response around them.

The same Person may be comfortably available in one situation and overwhelmed in another. The sensory environment may have changed. The activity may have become less predictable. Communication demands may have increased. Someone else’s tone, pace, expectations or proximity may be different. Fatigue, pain, hunger, anxiety, previous experience or movement needs may alter the body’s capacity to respond.

PEAR gives us somewhere to hold all of that.

The new review also reminds us that regulation develops relationally. Cossart et al. describe the movement towards greater self-regulation as occurring through experience and through warm, trusting interactions with others. Within school environments, responsive adults and teacher-child relationships can influence children’s participation and regulatory development.

This matters because self-regulation can too easily be framed as something the individual must learn to do alone.

PEAR TREE challenges that assumption.

Sometimes the most powerful intervention is not another strategy. It may be slowing down, reducing sensory load, offering predictability, changing the task, creating more time, listening differently, recognising communication in movement or behaviour, or being alongside rather than directing. Sometimes the Person needs co-regulation before independent self-regulation can reasonably be expected.

That is why Relational response sits explicitly within PEAR rather than being regarded simply as good interpersonal practice happening quietly in the background.

This relational and embodied way of thinking also has roots in our earlier work on adult mental health. Brown, Shankar, and Smith’s 2009 work explored possible connections between sensory processing differences and the experiences of adults receiving acute mental health care. The terminology and conceptual landscape have quite rightly moved on since then. Still, the clinical question underneath that work remains highly relevant: could behaviour interpreted primarily through a psychiatric or behavioural lens also tell us something about embodied sensory experience?

When we notice that experience differently, our response may change too.

This was part of the context in which Sensory Ladders developed. The Ladder helped move the conversation from “What is wrong with this behaviour?” towards “What might be happening for this person, and what might help?”

PEAR TREE now makes that question more explicit and more complete.

We can perhaps see the development as a widening lens. Sensory Ladders help us notice state changes. Sensory Spiders™ help us explore patterns across sensory experience. Sensory Grids™ help organise observations and interpretation. PEAR TREE helps us hold those observations within the wider reality of participation.

The TREE part of the Lens then supports the move from noticing into thoughtful clinical reasoning through Triage, Relational response, Evaluation and Ethics. This matters because noticing sensory experience should not automatically lead to prescribing a sensory strategy. We need to consider what needs attention first, understand the Person’s own priorities, assess risk without allowing risk management to silence agency, evaluate whether what we are doing actually helps, and ask whether our response is ethical, proportionate, and participation-focused.

PEAR TREE, therefore, does not replace Sensory Ladders. It helps us better understand what a Sensory Ladder may be showing us.

This longer developmental thread can also be seen in the more recent work led by Theoca Fredericks and colleagues in occupational therapy at Cygnet. Their sensory modulation quality improvement work within acute mental health services incorporated personalised sensory approaches, including Sensory Ladders® and Sensory Spiders™, as part of a wider package of support.

We need to be appropriately careful about what this tells us. It was a quality improvement project involving a package of interventions, not a controlled trial of Sensory Ladders, so changes in incidents cannot be attributed specifically to the Ladder.

But something else is interesting.

People talked about the Ladder. They used it to make sense of their experience and to understand changes in alertness and sensory state.

That begins to suggest a possible mechanism worthy of further research: shared understanding.

The most useful outcome may not simply be movement from one point on a Ladder to another. It may be the moment when a person can say, “This is what happens to me,” and another person can respond, “I can see that too. What would help?”

That shared language creates possibilities. It may support earlier communication, reduce misinterpretation, allow sensory support before distress escalates, help staff understand apparent behaviour differently, and enable environments and activities to be adapted. Importantly, it may return some power to the Person whose experience is being interpreted.

Within PEAR TREE, that conversation becomes richer still. A Sensory Ladder might help us recognise that a person is becoming less available. PEAR then asks whether something is changing within the Person, the Environment, the Activity or the Relational response. TREE asks what needs attention first, how we should respond relationally, how we will know whether the response helps, and whether what we are doing remains ethical, collaborative and proportionate.

This takes us well beyond “calming strategies.”

There is also an important neuroaffirming challenge within the literature. Some definitions of self-regulation identified by Cossart et al. include ideas of behaving appropriately or in accordance with social expectations. This deserves careful reflection.

A neuroaffirming sensory approach cannot have behavioural conformity as its destination.

Stillness is not automatically regulation. Eye contact is not evidence of participation. Compliance does not necessarily mean somebody feels safe. Movement is not automatically dysregulated. Withdrawal may sometimes be protective, and sensory seeking may be an intelligent response by a nervous system trying to find what it needs.

Our responsibility is not to teach people to look regulated. It is to support people in noticing their own experience, communicating what matters, accessing appropriate support, and participating in ways that are meaningful to them.

PEAR TREE makes this distinction clearer because participation always occurs in the interaction among Person, environment, activity, and relationship, not simply within the nervous system of a single individual.

Cossart and colleagues ultimately call for a more comprehensive, top-down and occupationally meaningful approach to self-regulation that explicitly considers participation. We agree with the need for occupationally meaningful practice, but perhaps the next development is not simply top-down or bottom-up.

It needs to move between them.

The body matters. Sensory registration, perception, reactivity and praxis matter. Thinking and meaning matter. Relationships matter. The physical and social environment matter. Occupation matters. Participation matters. And the Person’s own account of what is happening matters.

That movement between embodied experience and everyday participation is precisely the space Sensory Ladders have occupied since their earliest development, and it is the space PEAR TREE now helps us articulate more explicitly.

The next research question, therefore, perhaps should not simply be, “Do Sensory Ladders improve self-regulation?”

That risks returning us to the very conceptual difficulty identified in the new review.

More useful research might ask whether Sensory Ladders and PEAR TREE informed approaches help people recognise and communicate changing embodied states, strengthen agency and shared decision making, improve understanding between people and those supporting them, enable early regulation, change how distress and behaviour are interpreted, support adaptation of environments and activities, reduce escalation or reliance on restrictive responses, and ultimately improve occupational engagement and participation.

Cossart et al. specifically call for future research to examine how occupational performance, engagement, and participation are influenced by occupational therapy approaches to self-regulation.

That feels like exactly the right next question.

There is something powerful about seeing these threads come together across more than 25 years. What began as Sensory Levels in 1999 and Sensory Ladders in 2001 grew from clinical encounters with people whose experiences were not always adequately explained by the language available at the time. The Brown, Shankar and Smith work asked whether sensory experience might help us understand adult mental health presentations differently. Sensory Ladders continued to evolve through clinical practice, teaching, and co-production. The Cygnet work now offers another contemporary example of Sensory Ladders sitting within a wider sensory approach in acute mental health care.

And Cossart and colleagues’ 2026 review brings us back to a question that has been there all along.

How can occupational therapy understand regulation in a way that remains genuinely occupational?

Our answer continues to evolve.

Sensory Ladders help us notice the body and recognise change. PEAR helps us understand the Person within context and relationship. TREE helps us reason carefully about what we do next.

Participation remains the reason for doing any of it.

Perhaps that is the thread connecting more than 25 years of this work: not teaching people how to look regulated, but learning together what helps each Person be available for the people, places and occupations that matter to them.

Participation begins in the body.