From Sensory Regulation to Participation: A Clinical Reasoning Framework for Aquatic Therapy in Children with Autism Spectrum Disorder

Background and Objective: Research on aquatic interventions for children with autism spectrum disorder (ASD) has spanned over four decades, yet the field remains characterized by a fragmented evidence where therapeutic techniques often coexist without a unifying conceptual logic. This has led to a translational gap between research findings and clinical decision-making. This narrative review aimed to synthesize four decades of research into an evidence-informed clinical reasoning framework to capture the evolution of aquatic therapeutic practice and support clinical decision-making. Methods: Literature search was conducted in PubMed, Scopus, and Web of Science, covering publications from the earliest available records to May 2026. Studies were analysed according to their therapeutic concepts, clinical reasoning logic, and outcome domains. Results: A total of 30 studies met the inclusion criteria and were included in this review. The resulting synthesis enabled the derivation of an evidence-informed clinical reasoning framework representing five dominant therapeutic perspectives that characterize the development of aquatic clinical reasoning across the literature. By synthesizing peer-reviewed literature, we identified five dominant clinical reasoning paradigms that emerged across the development of the literature and continue to inform contemporary aquatic practice: (1) Exploratory and Sensory-Regulatory, (2) Skill- and Safety-Oriented, (3) Structured and Functional, (4) Participation- and Social-Oriented, and (5) Individualized and Outcome-Informed Practice. Conclusions: This conceptual roadmap may help clinicians align aquatic intervention strategies with individual therapeutic priorities, functional goals, and participation needs. The proposed framework provides a bridge between historical practice and contemporary evidence, supporting individualized and outcome-informed clinical reasoning in aquatic therapy for children with ASD. The five phases should be interpreted as dominant paradigms of clinical reasoning that may coexist within practice rather than as mutually exclusive or strictly chronological categories.