Abstract
This study developed the Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice.
School-based occupational therapy practitioners are charged with holistically supporting students in their occupational endeavors in the school setting. The Individuals with Disabilities Education Improvement Act of 2004 (IDEA; Pub. L. 108-446) and the Every Student Succeeds Act of 2015 (ESSA; Pub. L. 114-95) direct practice, establishing occupational therapy practitioners as related service providers and ensuring that services support challenges faced by students accessing their education, are delivered in the least restrictive environment, and are evidence based (ESSA, 2015; IDEA, 2004). A student’s sensory integration and processing is one facet that has been shown to affect their access to, and participation in, school occupations (Gonçalves & Abreu, 2023). School-based occupational therapy practitioners report that sensory-related issues are frequently or always the reason for a referral (Bolton & Plattner, 2020). Therefore, the evaluation of and interventions to address sensory functions are important aspects of school-based occupational therapy, as acknowledged by the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2020). School-based occupational therapy practitioners are recognized as lead team members when sensory integration and processing challenges are suspected to be influencing a student’s function.
Given the growing sensory integration and processing challenges among school-age children (Iimura, 2022), there is an increased emphasis on providing support for sensory functions through intervention guided by Ayres Sensory Integration® (ASI) within a multitiered system of supports (MTSS; ESSA, 2015; Whiting et al., 2022, 2025). Occupational therapy using ASI is a manualized, evidence-based intervention designed to address sensory integration and processing challenges that affect occupational performance and participation (Schaaf et al., 2014; Steinbrenner et al., 2020). ASI is distinct from protocolized sensory-based strategies, which are commonly used in schools, in that it is an active process that uses specifically designed activities with a just-right challenge to support physical and social engagement across contexts (Case-Smith et al., 2015). AOTA’s (2023) Position Statement “Sensory Integration Approaches for Children and Youth in Occupational Therapy Practice” acknowledges the relevance of ASI in schools, and a recent study demonstrated the feasibility and effectiveness of ASI in the school setting (Whiting et al., 2023).
Occupational therapy practitioners working within the school setting can use their knowledge of ASI theory and intervention principles to apply this frame of reference across all tiers of an MTSS, including Tier 1 (universal supports), Tier 2 (small-group supports), and Tier 3 (individualized support; Whiting et al., 2022, 2025). In this approach, school-based occupational therapy practitioners work with caregivers, teachers, and students to create support plans that allow increased access for all, thereby upholding the principles of occupational justice. However, school-based occupational therapists report several barriers to applying ASI principles, including a lack of resources available to guide ASI implementation specifically in the school setting (Cerase, 2023). Existing resources for the implementation of ASI have all been designed to guide application of ASI principles in clinic settings (Parham et al., 2011; Schaaf & Mailloux, 2015). The ASI Fidelity Measure (ASIFM; Parham et al., 2011) in particular has most often been used in research to determine whether an intervention examined in an individual treatment study is consistent with the principles of ASI. The ASIFM describes the structural and process elements that are necessary for implementing occupational therapy using the principles of ASI (Parham et al., 2011). However, the ASIFM in its current form is of limited usefulness to school-based practice because it does not include guidelines for support across the school or within the classroom, and it requires specific equipment not available in many schools.
Consistent with next-step recommendations for the use of ASI in schools (Whiting et al., 2025), we sought to develop guidelines that operationalize the principles and practices of ASI for school-based practice across the MTSS tiers. These guidelines, which are based on the ASIFM, adapt and extend the ASIFM to provide school-based occupational therapy practitioners with a tool that details the implementation of ASI to support the participation and performance of students but is adjustable for use within the parameters of their setting. Moreover, the guidelines are intended to support progression along a continuum of ASI use and to discriminate ASI from the use of sensory-based approaches, as well as to encourage practitioners to use any or all the principles, even if they cannot apply the entirety of the guidelines.
Establishing face validity and content validity is important when developing a new instrument (Beck, 1999; Connell et al., 2018). Face validity, though subjective, helps determine whether an instrument’s content is suitable for its stated purpose. A survey of potential users—in this case, school-based occupational therapists—is also important to ensure its usefulness (Connell et al., 2018). In addition, content validity more objectively quantifies the clarity and relevance of the instrument when expert raters share both quantitative and qualitative feedback. Content validity ensures that the instrument and its items sufficiently represent the key features within the construct of interest. Thus, the three primary aims of this study were to (1) develop guidelines that describe the implementation of ASI in the school setting across the tiers; (2) determine whether the guidelines are useful, feasible, and representative of ASI intervention for the schools (face validity); and (3) ensure that the guidelines are clear, relevant, and comprehensive (content validity).
This study had a descriptive survey research design and took place across three phases. The guidelines were developed in Phase 1. In Phase 2, we explored their face validity, and in Phase 3 we explored their content validity. In Phases 2 and 3, voluntary feedback was gathered anonymously via surveys on an online platform distributed to purposively recruited samples. All procedures were approved by the Johnson & Wales University Institutional Review Board.
Phase 1: Guideline Development
Method
The recommended five-step process for creating a new tool was guided by Shekelle et al.’s (1999) suggestions and is outlined in the Procedures section that follows: (1) defining the subject area for which the guidelines are being developed, (2) gathering a group of individuals who can serve in different roles, (3) assessing the current evidence in the literature, (4) developing the guidelines, and (5) performing an external review of the guidelines.
Participants
Five occupational therapists, all members of the research team and authors of this article, and who have expertise in sensory integration and knowledge of school-based practice, participated in Phase 1. Overall, they had between 10 and 49 yrs experience as occupational therapists and sensory integration researchers/clinicians. Three of the participants served as experts in school-based practice, and two served as experts in research methodology.
Procedures
Phase 1 began with a discussion of the subject area of concern: the need for the guidelines for implementing ASI in schools and what those guidelines should encompass given the challenges that therapists report (Cerase, 2023). The research team, upholding their relative roles, decided to use the ASIFM, a well- established, valid, and reliable tool that describes ASI implementation in settings other than schools as a starting point (May-Benson et al., 2014; Parham et al., 2011). Selected items that the research team determined could be adapted to the school setting formed the basis of item generation and construction of the preliminary guidelines. After an extensive review of the literature regarding the use of ASI in schools, and relevant laws and policies, the research team adapted the ASIFM to include the use of ASI and its principles in each tier and specific to the unique context of the school. In addition, the team made adjustments to the structural elements of the ASIFM for Tier 3; these are described in the Results section, next. Finally, a plan was made for the external review of the guidelines to establish face and content validity.
Results
Phase 1 resulted in the initial version of the Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice. This version included scoring procedures, similar to those for the ASIFM, that allow the practitioner to rate whether a particular sensory integration principle was intentionally included within and across the tiers of practice. The guidelines outlined the principles of ASI intervention with a focused goal of improvement in participation and performance in the school setting. The guidelines were broken down into five primary sections and included a total of 58 items. The primary sections were as follows: (1) Recommendations, (2) Tier 1: Universal Support, (3) Tier 2: Small-Group Intervention in Natural Environments, (4) Tier 3: Individualized Intervention, and (5) Tier 3: Structural Elements. A detailed description and examples were provided for each item. The first section recommended the type and amount of training and mentorship needed to use ASI at the entry level. The Tier 1 section highlighted how school-based occupational therapy practitioners can work to provide universal support for the entire school for sensory integration and processing using the principles of ASI. One aspect of universal support described was education and training for staff and caregivers about sensory integration and processing theory to ensure a supportive and inclusive school climate. Next, the Tier 2 section broke down each ASI principle from the ASIFM and discussed how school-based practitioners can enact them in natural settings with a small group or through consultation with the teacher. It is important to note that the guidelines differentiate ASI from sensory-based interventions; using ASI principles requires collaboration, motivation, and active participation on the part of the student (Whiting et al., 2025). The Tier 3 section parallels the organization of the ASIFM with a focus on the individual student (Parham et al., 2011). The guidelines described the necessary components of a comprehensive occupational therapy evaluation; strategies for consultation with the teacher or direct, in-class support by the therapist; and how to address each ASI principle for pull-out direct service delivery. They also provided clarification to help therapists determine when a student should be considered for Tier 3 pull-out service delivery. This included a requirement for data demonstrating that Tier 1, Tier 2, and Tier 3 embedded supports provided in general education settings were not sufficient in remediating a particular student’s occupational performance difficulties and that evaluation data demonstrated that sensory integration and processing challenges are affecting the student’s access to education (Whiting et al., 2022). Finally, the structural elements section of Tier 3 specified the space and equipment guidelines to meet the criteria for ASI intervention. Thus, the guidelines were ready for the next stage of tool development: external review.
Phase 2: Exploring Face Validity
Method
Face validity was guided by the procedures recommended by Allen et al. (2023), which suggest inviting prospective consumers to rate each item. Revisions were made on the basis of respondents’ feedback to ensure that the guidelines were understood by and useful to potential users. In this phase, we explored whether ASI in the school setting is reflected in the Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice that were developed in Phase 1.
Participants
Fifteen school-based occupational therapy practitioners were invited via email to assess the face validity of the guidelines document. Purposive sampling based on names generated by the research team described in Phase 1 was used. The three inclusion criteria were as follows: (1) occupational therapist who (2) had worked in United States schools for at least 3 yr within the past 10 yr and (3) had completed advanced training in sensory integration theory and intervention. Nine practitioners completed the consent process. Research suggests that a minimum of five raters provides an acceptable level of control for chance agreement for projects such as this one (Lynn, 1986). The participants were between ages 30 and 72 yr, had spent 16 yr on average in the school setting, and worked in six different states.
Procedures
The survey was launched using Qualtrics, an online survey platform (https://www.qualtrics.com). After providing informed consent, the nine school-based practitioner raters were provided with introductory information needed to complete the study: definitions of ASI and an MTSS, an explanation of the study’s purpose, the guidelines document, and directions for how to review the guidelines. Participants were given 3 wk to provide their feedback and were allocated space to offer narrative feedback in each section to discuss its usefulness and feasibility, suggest alternative wording, and offer overall impressions of whether the instrument adequately represents the use of ASI in the schools.
Results
Face validity was established by examining the participants’ narrative comments. Overall, school-based practitioner participants endorsed the guidelines’ feasibility and usefulness. The research team collectively reviewed the results and came to a consensus regarding needed changes. Commonalities of participants’ comments emerged around clarification of how the guidelines will be used, with comments such as “There are many limitations that therapists do not have control over,” “[Occupational therapists] may feel pressed to provide a certain [score],” and “It would be helpful to describe different ways to [implement each of the items].” On the basis of input from the school-based practitioners, the research team recommended removing the scoring portion of the questionnaire, adding a statement about the guidelines’ purpose, providing examples of what is expected at each tier, and making minor wording revisions.
Phase 3: Exploring Content Validity
Method
The content validity phase adhered to the recommended procedures for quantitative methods that follow classical test theory by quantifying how the items represent the attribute of interest, with the option to provide narrative feedback (Cappelleri et al., 2014; Polit et al., 2007). This methodology provided a systematic, quantitative assessment of the guidelines’ items relative to clarity, relevance, and comprehensiveness.
Participants
Purposive sampling from a list collectively generated by the research team was used to identify 25 occupational therapists who were invited, via email, to review the revised version of the Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice from Phase 2. The five inclusion criteria for participation were (1) being an occupational therapist who (2) had worked in a school setting, collaborated with, or supervised a school-based occupational therapist within the past 10 yr; (3) completed advanced training in sensory integration theory and intervention; (4) been recognized as an expert in sensory integration as evidenced by peer-reviewed publications and presentations; and (5) completed at least 10 yr of practice. Fourteen participants agreed to partake in evaluating the revised guidelines. The participants were ages 30–74 yr, had an average of 29 yr of experience as an occupational therapist, and practiced in 14 different states.
Procedures
Using Qualtrics, the participants completed their informed consent and were given access to the revised guidelines and a survey. The survey contained definitions of ASI and an MTSS, a description of the guidelines, and specific instructions on how to complete the survey. The participants were asked to rate the relevance and clarity of the items as well as the comprehensiveness of each section (Recommendations; Tier 1, Tier 2, and Tier 3 intervention; and Tier 3 structural elements). A 4-point ordinal rating scale was used to rate relevance (1 = not relevant, 2 = minimally relevant, 3 = moderately relevant, 4 = highly relevant) and clarity (1 = not clear, 2 = minimally clear, 3 = moderately clear, 4 = very clear), and comprehensiveness was rated globally as either “yes” or “no” for each section. Participants also provided narrative feedback at the end of the survey. They were allotted 3 wk to respond to the survey.
Data Analysis
We analyzed the quantitative data using Microsoft Excel. The statistical measures used were content validity indexes (CVIs), which calculate the degree to which individual items (item-level CVI score [I-CVI]) or the whole scale (scale-level CVI score) are considered relevant and clear by content experts. An I-CVI score was calculated by providing a sum of ratings that were either highly relevant (rating of 4) or moderately relevant (rating of 3) and dividing the summated ratings by the number of content experts (Polit et al., 2007). The same process was used to calculate an I-CVI for clarity. In addition, scale-level CVI averages (S-CVI/Aves) were calculated using the average I-CVI across items for relevance and clarity (Polit et al., 2007; Polit & Beck, 2006). An I-CVI ≥.79 (Zamanzadeh et al., 2015) or an S-CVI/Ave ≥.90 (Polit et al., 2007) is considered “excellent” content validity. A modified κ statistic was not run on the data because the literature indicates that this statistic is not necessary when the number of raters exceeds 10 (Wynd et al., 2003). The proportion of agreement among the experts who scored the instrument’s comprehensiveness for each section of the guidelines was also calculated. Because no criteria have been established in the literature, the research team had predetermined that sections with >79% rater agreement would be considered comprehensive on the basis of the accepted agreement percentages for I-CVIs (Zamanzadeh et al., 2015). Finally, four research team members reviewed the qualitative data from the anonymous comments to establish a consensus on which items needed revision and the nature of those revisions.
Results
All guideline items and the total instrument scored above the threshold for a determination of excellent content validity according to guidelines offered by Polit et al. (2007) and Zamanzadeh et al. (2015; Table 1). All items had an I-CVI ≥.86, with a range of .86–1.0 with respect to both relevance and clarity. Scale-level relevance and clarity (S-CVI/Ave) values were .98 and .97, respectively. Over 79% of the raters agreed that all the sections were comprehensive, except for Tier 1, which had 50% endorsement.
Results of the Content Validity Analysis of the Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice
Note. ADLs = activities of daily living; ASIFM = Ayres Sensory Integration Fidelity Measure; I-CVI = item-level content validity index; OTP = occupational therapy practitioner; PE = Process Element; S-CVI/Ave = averaged scale-level content validity index.
Agreement comprehensiveness: 93%.
Agreement comprehensiveness: 50%.
Agreement comprehensiveness: 79%.
Agreement comprehensiveness: 86%.
Four research team members independently came to 86% agreement on revisions needed according to participant feedback (one research team member was unavailable to participate) and then came to a consensus on the remaining revisions. Thus, minor changes were made to address participant suggestions, and a final version of the guidelines was produced. Participants had asked that more examples be added on how, where, and when interventions would be provided at each tier and to have a greater representation of caregivers and praxis in Tier 1 to enhance comprehensiveness. In addition, participants had suggested some minor word changes/additions, such as changing sensory “tools” to “experiences” and adding “how practice improves performance.”
Discussion
The three phases of this study answered our three aims, guided by procedures that had been validated in previous studies. Guidelines for the adaptation of ASI for use by school-based occupational therapists were developed, and their face and content validity were established. The resulting tool is entitled “Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice.” Their development and the establishment of their preliminary psychometrics respond to a call to action to develop guidelines for implementing ASI in school-based practice that can be applied across an MTSS (Whiting et al., 2025).
The final version of the guidelines has 58 items across five main sections. It adapts and extends the ASIFM (Parham et al., 2011) to be consistent with ASI theory and intervention but to better match the unique features of a school context. For example, the guidelines outline the importance of working with administrators to provide education specific to sensory integration theory and ASI-informed support across the entire school. In addition, to recognize the school setting’s financial and space limitations, equipment and space requirements were modified to allow practitioners to consider existing space and equipment that could be used in a new way. A focus on equipment affordance was included rather than recommendations for specific pieces of equipment.
The guidelines further clarify how sensory integration and processing can be effectively supported across the tiers to improve students’ access to their education (Whiting et al., 2022, 2023). The guidelines use the structure of an MTSS and then provide details and examples for each item in the three tiers to help the user operationalize ASI implementation in a school setting. The guidelines also honor the value of Tier 2 and Tier 3 teacher consultation and in-class support of sensory integration and processing (Frolek Clark et al., 2019) while sharing how ASI principles can be applied. This is consistent with Reynolds et al.’s (2017) recommendation for a multifaceted occupational therapy intervention approach that is focused on participation. Most important, it fills the gap that has been identified for a tool specific to the school setting that guides occupational therapy practitioners in the use of ASI and its principles.
Future Directions
More research is needed to fully realize the implementation of the guidelines for school-based practice. Planned next steps include development of a full training and manual that uses the guidelines as the outline, a pilot study to determine the feasibility of using the guidelines in practice that includes novice and expert school-based occupational therapy practitioners, and a cross-sectional survey that explores to what degree school-based occupational therapy practitioners are implementing various aspects of ASI in practice according to the guidelines document.
Implications for Occupational Therapy Practice
There has been an increasing amount of discussion surrounding the importance of using ASI in the school setting to support occupational performance and participation. School-based occupational therapy practitioners interested in using ASI and its principles in the school setting can use the Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice to evaluate and improve their practice after the completion of advanced training. School-based practitioners can use these guidelines for several purposes: ▪ to advocate for consultation, training, supervision, and mentoring of occupational therapy practitioners to foster use of ASI in school-based practice; ▪ to guide communication, consultation, training, and education on sensory integration and processing to school staff, students, and caregivers; ▪ to establish programs for Tier 1, Tier 2, and Tier 3 support, making both in-class and pull-out services align with ASI principles; ▪ to determine the space, equipment, and other resources needed across the tiers and to consider how to use existing equipment and space; ▪ to differentiate treatment that meets the criteria for ASI from other school-based interventions; and to serve as a resource to help school-based practitioners advocate for themselves as leaders in the field of sensory integration and processing.
Conclusion
The Guidelines for Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice were developed to support the use of ASI in schools. They are a response to a call to action by Whiting and colleagues (2025) and are intended to remove some of the barriers, such as lack of resources and knowledge, that have been identified by school-based occupational therapy practitioners (Cerase, 2023). The face validity and content validity of these guidelines are strong, and they will help guide school-based occupational therapy practitioners in how to adapt ASI across the tiers in their school setting.