Sensory Integration Approaches for Children and Youth in Occupational Therapy Practice

Definitions

The following definitions, presented in alphabetical order, are commonly used while discussing sensory-based and ASI interventions and will be used throughout this Position Statement:

▪ Ayres Sensory Integration (ASI): An evidence-based intervention provided by occupational therapy practitioners with advanced training after an evaluation is completed and the need for such an intervention is identified. ASI intervention follows a systematic approach and a set of fidelity principles (Parham et al., 2011; Schaaf & Mailloux, 2015), including

Importance and Significance of This Topic

Researchers have identified atypical sensory reactivity within the general U.S. population of between 5% and 16.5% (Ahn et al., 2004; Ben-Sasson et al., 2009; Jussila et al., 2020). The rates of sensory processing difficulties increase in neurodivergent children, autistic children, and children with developmental delays and disabilities (Kilroy et al., 2019; Little et al., 2018; Tomchek et al., 2015). In a study of children with prenatal alcohol exposure, approximately 73% of the sample demonstrated atypical sensory processing (Jirikowic et al., 2020). In studies of autistic children, 53% to 95% of the samples have demonstrated some degree of sensory processing difficulties (Jussila et al., 2020; Tomchek & Dunn, 2007). Children without co-occurring disabilities may also have sensory processing disorders characterized by sensory overresponsivity, sensory underresponsivity, and sensory seeking (Mulligan et al., 2021). At-risk children may also demonstrate unique sensory processing patterns (Reynolds et al., 2008). Some children who experience trauma may demonstrate sensory sensitivities and avoidance into adulthood (Engel-Yeger et al., 2015). The medical community recognizes the effect of a sensory processing disorder on children’s development and engagement in daily activities. Sensory processing disorder is included in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood—Revised (Egger & Emde, 2011) and the Interdisciplinary Council on Developmental and Learning Disorders’ Diagnostic Manual for Infants and Young Children (Greenspan & Wieder, 2008). Whereas the medical community may assign this diagnosis to a child, the role of the occupational therapist is to identify the occupational performance limitations through a comprehensive occupational therapy evaluation process with a thorough assessment of sensory discrimination, modulation, and integrative functioning. Altogether, this body of research suggests that sensory-based and ASI interventions may be necessary for some children to engage in everyday activities and participate at home, in school, and in the community.

The Occupational Therapy Process

As identified in the Occupational Therapy Practice Framework, Domain and Process, 4th Edition, occupational therapy practitioners are trained to consider occupation, context, performance patterns, performance skills, and client factors (AOTA, 2020c). Occupational therapists develop an occupational profile, identify a child’s strengths, and evaluate a child’s occupational performance by using a variety of assessment tools and strategies to gather relevant information. When referrals or observations suggest sensory-, motor-, and praxis-related performance limitations, the occupational therapy evaluation includes skilled assessment of these areas. Assessments may include an analysis of the child’s occupational performance during a variety of tasks to determine the demands of the activities (e.g., objects and their properties, space, sequencing, timing), social and physical characteristics of the environments, and effectiveness of the child’s performance skills and patterns in those activities and environments. The occupational therapist conducts assessments of sensory and neuromotor functions through observations in various environments and analyzes play performance and functional participation of the child in response to the setting’s demands (Bundy, 2020; Glod et al., 2015; Watling et al., 2018; Watts et al., 2014). A thorough evaluation of sensory functions must be completed before initiating sensory-based or ASI interventions (Gillen et al., 2019). Practitioners must ensure that the needs of the client that have been identified through the evaluation process are linked to sensory processing differences before implementing a sensory approach to intervention. Understanding differences in a client’s sensory preferences, thresholds, and sensory habituation should guide goal setting and intervention strategies, especially with autistic clients (Green et al., 2019; Jamal et al., 2021). Occupational therapists continue to reevaluate a child’s response to interventions throughout service delivery to ensure that the occupational therapy plan continues to be supportive of the child’s goals, sensory needs, and occupational performance.

The full scope of occupational therapy services expands far beyond the use of sensory-based and ASI interventions, if one or more type of sensory processing– or self-regulation–related deficits are revealed during the evaluation, the use of sensory-based or ASI interventions is appropriate; however, occupational therapy practitioners should combine interventions to address the full scope of occupational performance limitations across environments (Reynolds et al., 2017). Services may be provided individually (e.g., providing one-on-one intervention to remediate vestibular–ocular difficulties affecting visual tracking and handwriting), through consultation and collaboration with groups (e.g., establishing a movement break routine for whole classrooms), or through education and training (e.g., offering staff in- services on sensory regulatory strategies and awareness of sensory needs). When providing intervention services, occupational therapy practitioners consider occupational performance in all contexts and collaborate with the child’s family, teachers, and other service providers to facilitate carryover, generalization, and consistent use of strategies to support participation. The choice of interventions is guided by the best available research regarding the effectiveness of the intervention related to the identified occupation-based goals for the child.

Sensory-based interventions focus on how sensory input within the environment affects the child’s performance and participation. Occupational therapy practitioners use sensory-based interventions to address specific needs related to sensory modulation or sensory discrimination (Watling et al., 2018). Occupational therapy practitioners design multifaceted interventions that consider the sensory needs of the child within many ever-evolving contexts (i.e., authentic activity settings and routines; Reynolds et al., 2017). For example, interventions may include educating school personnel to consider sensory processing patterns or factors when addressing student concerns, implementing daily routines that incorporate sensory-based activities (Mills et al., 2016, 2021), or modifying the environment to match a child’s sensory needs and support participation (Piller & Pfeiffer, 2016). In addition, self- regulation and co-regulation skills may be taught to the child so that they are able to recognize when they are experiencing sensory processing challenges (e.g., reaching their sensory threshold) and begin to independently use strategies to manage emotions and behaviors in a manner that is effective within the activity or circumstance (Dunn et al., 2012; Watling & Hauer, 2015). Sensory-based strategies implemented without the assessment, planning, and oversight of an occupational therapist do not constitute occupational therapy.

The use of ASI interventions requires advanced training in evaluation and implementation following the ASI fidelity principles (Parham et al., 2011). Intervention is provided by a skilled occupational therapy practitioner who is guided by the interpretation of a thorough assessment and who provides services within a therapeutically designed setting with appropriate space and equipment. This method relies on interactions between the occupational therapy practitioner and child in a sensory-rich environment and uses a collaborative and playful approach, with attention to the child’s successful adaptation to a variety of novel challenges, including sensory modulation, sensory-based motor performance and postural skills, and praxis (Andelin et al., 2021; Kashefimehr et al., 2018; Omairi et al., 2022; Pfeiffer et al., 2011; Schaaf et al., 2014; Steinbrenner et al., 2020). Collaboration with caregivers is essential, as are the one-to-one interactions with the child (Dunn et al., 2012; Miller Kuhaneck & Watling, 2018; Parham et al., 2021; Reynolds et al., 2017).

Through the use of accurate functional baseline data, measurable goals, and data collection to monitor a child’s successful participation in the natural environment, occupational therapy practitioners provide accountability for a child’s progress based on occupational therapy intervention. Goal attainment scaling is one method often used to measure achievement toward customized, participation-based goals (Mailloux et al., 2007).

The occupational therapist and occupational therapy assistant collaborate to meet the needs of children and youth with occupational performance limitations related to differences in sensory processing patterns and sensory integration dysfunction. Under the direction and supervision of the occupational therapist to develop the occupational profile and evaluate a child’s occupational performance, the occupational therapy assistant may share skilled assessment data collected in the child’s natural environment or by implementing select assessment tools on which they have been trained (AOTA, 2020b). The occupational therapist and occupational therapy assistant may collaboratively develop, implement, and adjust the sensory-based interventions across a variety of settings, including, but not limited to, early intervention home visits, schools, inpatient hospitals, outpatient clinics, and community-based settings. Examples are provided in Case Studies 1 through 5.

Ethical, Legal, and Regulatory Considerations

Occupational therapy practitioners have a professional and ethical responsibility to provide services that are within their scope of practice and based on their individual level of competence. The AOTA 2020 Occupational Therapy Code of Ethics (AOTA, 2020a) establishes principles that guide safe and competent occupational therapy practice and must be applied when addressing sensory integrative dysfunction and sensory processing differences. Practitioners should ensure that they obtain an understanding of sensory integration theory, how to assess sensory processing and integration differences, and how the components of sensory integration influence success in occupation. Occupational therapy practitioners should be aware that some autistic people may camouflage or mask sensory symptoms as a means to avoid stigma and increase acceptance in certain environments (Corbett et al., 2021). Masking can cause exhaustion, trauma, and loss of self-identity (Miller et al., 2021). Practitioners should use a person-centered and strengths-based approach and educate team members that some autistic children may use certain behaviors for self-regulation, communication, or self-expression (Patten, 2022). Practitioners should refer to relevant principles in the Code of Ethics and comply with state and federal regulatory requirements.

There is emerging evidence of the prevalence of sensory challenges across a variety of marginalized populations with disparities in proper identification and intervention of sensory integration and praxis features. Non-White children, female children, and children whose mothers reported fewer years of education reported fewer sensory features associated with their autism diagnosis (Kirby et al., 2022). Many sensory features may be misidentified as problem behaviors or remain unidentified in certain underrepresented minority pediatric populations (Obeid et al., 2021). Because of this, it is imperative that occupational therapists and occupational therapy assistants demonstrate cultural humility and awareness of bias risks when conducting evaluations and interventions related to sensory processing and integration. Occupational therapists play a critical role with evaluation, educational, diagnostic clinic, and behavior analysis teams to offer skilled interpretation of contextualized behaviors that may be rooted in sensory processing or integration differences.

Funding and Reimbursement

Practitioners use sensory-based and ASI interventions with children with a variety of diagnoses across several practice settings, including, but not limited to, acute care, early intervention, schools, outpatient clinics, community, and mental health. Given the diverse use of sensory-based and ASI interventions, funding is contingent on diagnosis, practice setting, and geographic location. Practitioners must become familiar with relevant third-party payer policies in their state and may need to educate payers about the need for sensory-based and ASI interventions and the expected outcomes.

Conclusion

Sensory integration is one of several theories and methods used by occupational therapists and occupational therapy assistants working with children and youth. When children demonstrate limitations related to self-regulation, co-regulation, sensory registration and discrimination, sensory modulation, and sensory-based motor performance that interfere with their ability to perform everyday activities and participate in daily routines, occupational therapy using sensory-based interventions, or an ASI approach, can be used effectively to support occupation-based outcomes.