Occupational Therapy Interventions Using Ayres Sensory Integration ® for Children and Youth (May 2015–January 2024)

Full Systematic Review Question

This systematic review addressed the question, “What is the effectiveness of interventions using Ayres Sensory Integration^® to support functioning and participation for children and youth (0–21 yr of age) with challenges in processing and integrating sensory information that interferes with everyday life participation?”

Current Theme Reported

The main theme of the studies included in this systematic review brief includes Ayres Sensory Integration^® (ASI) interventions for children and youth with sensory processing differences. The following subthemes were identified:

▪ ASI for individual goal attainment.

Clinical Scenario

ASI theory is based on decades of research, rooted in principles of neuroscience, emphasizing the importance of sensory-motor experiences in shaping early childhood development and participation in daily activities (Ayres, 1975). Research suggests that approximately 5%–25% of children in the United States have sensory differences (Ben-Sasson et al., 2009; Jussila et al., 2020), with higher rates reported among clinical populations (Kilroy et al., 2019; Little et al., 2018; Tomchek et al., 2015) such as children with autism, attention deficit hyperactivity disorder, or other developmental delays. Children with sensory integration and processing differences experience challenges engaging in daily occupations, impacting quality of life (Chien et al., 2015; Costa-López et al., 2021; Little et al., 2015; Schaaf et al., 2011). Occupational therapy using ASI is a warranted intervention approach when assessment results identify sensory integration differences that impact the child’s engagement and participation in everyday activities (American Occupational Therapy Association [AOTA], 2023).

Based on the original theory developed by A. Jean Ayres, ASI has evolved into a manualized, evidence-informed intervention approach (Schaaf & Mailloux, 2015). This approach, with its key ingredients of individually tailored, sensory-rich activities situated in the context of play, and presented at the just-right challenge, can transform the lives of children with sensory integration differences. Occupational therapy practitioners (OTPs) using ASI focus on the child’s intrinsic strengths, using skilled techniques to build upon these strengths and preferences to support participation. ASI intervention is designed to comprehensively address clients’ individual needs based on a therapeutic relationship and data-driven decision-making (Schaaf & Mailloux, 2015). To ensure fidelity, the intervention follows a systematic approach and a defined set of structural and process elements that are essential to this practice, described in the ASI Fidelity Measure (ASIFM) (Parham et al., 2011; Schaaf & Mailloux, 2015). Structural elements include specifications for evaluation, therapist training, and clinical equipment while process elements emphasize core features of the contextual elements (e.g., therapist–child collaboration, the context of play, just-right challenge) and sensory-motor factors (e.g., provision of sensory-rich activities, providing opportunities to integrate sensory information, addressing postural-ocular-bilateral integration challenges and praxis) (Parham et al., 2011; Schaaf & Mailloux, 2015).

The ability to clearly define features of ASI from other sensory-based intervention approaches has bolstered research in this area. Since Watling and Hauer’s (2015) systematic review, there has been increased awareness and use of the ASIFM (Parham et al., 2011), and the intervention was manualized to enhance replicability for research and best practice (Schaaf & Mailloux, 2015). These tools laid the groundwork for how to provide and measure the effectiveness of ASI intervention, thus driving increased rigor in research of ASI intervention. Therefore, this systematic review aimed to examine the research since 2015 regarding the effectiveness of ASI in the treatment of children and youth with sensory integration and processing differences.

Summary of Key Findings

This systematic review included quantitative evidence at Level 1 and Level 2 based on Nursing-Johns Hopkins Evidence-Based Practice Model (Dang et al., 2022), including single-subject designs at Logan Level 4 or higher (Logan et al., 2008) that used ASI interventions. Twelve articles were reviewed, four at Hopkins Level 1 and eight at Hopkins Level 2, including four single-subject designs at Logan Level 2. The strength of evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018) grade definitions. The risk of bias for most studies was low to moderate. Study participants represented children aged 0–12 yr; diagnoses included autism spectrum disorder, sensory processing differences/disorder, developmental delay, Rett syndrome, lack of coordination, and preterm infants. Most studies occurred in a clinic setting (10), and two occurred in schools.

ASI was found to be effective for children with sensory integration and processing differences when addressing goal attainment, occupational performance, daily living skills/self-care skills, social participation, communication, and playfulness.

Bottom Line for Occupational Therapy Practice

This systematic review revealed several strong studies in support of ASI as an intervention for children and youth with sensory integration and processing differences, with or without other diagnoses. The studies used a variety of outcome measures and varied greatly in the area of occupation they assessed. This created challenges when attempting to draw a cohesive, unified conclusion from the outcome evidence. However, as a core principle of ASI, which focuses on each client’s strengths, preferences, and individualism rather than a set of previously determined outcomes, using a variety of outcome measures is congruent with the theory. There is strong evidence to support the use of ASI intervention for improvements in participation-based outcomes in many populations.

Many articles in this systematic review used ASI with other interventions (e.g., STAR approach, parent education, usual care, etc.), making it difficult to definitively state that ASI was the determinative intervention within those studies. Parent education and incorporating multiple intervention strategies within occupational therapy practice, particularly in pediatrics, is typical. Pediatric occupational therapy clients often present with complex needs requiring interventions that use multiple frames of reference and multiple occupational theories and models to adequately address all of their occupational challenges and improve participation. This systematic review supports ASI as one of the essential ingredients in occupational therapy interventions for children and youth with sensory processing differences.

While most of the studies occurred in a clinic setting, studies performed in the school setting demonstrated emerging and positive signs of effectiveness if the studies were conducted per ASIFM. OTPs can advocate for equipment and training to meet the requirements of the ASIFM in settings, such as schools, to address occupational performance related to that context. ASI performed with good fidelity and in accordance with manualization is an evidence-based intervention that can be effective across any setting as long as the required equipment is available and professional training of the OTP is completed. OTPs have access to strong evidence to support ASI as a necessary intervention for children with sensory integration and processing differences, thus substantiating that children should have access to ASI through a variety of funding sources (e.g., IDEA and insurance).

The studies in this systematic review focused on ASI for children and youth from birth through age 12 yr. There is a lack of evidence for ASI in the population older than 12 yr. This does not mean that ASI is ineffective after this age, but it points to future research direction. Service frequencies also varied between studies, representing interventions provided for several weeks to several months, for various durations, without a clear indication of whether the duration of treatment impacted outcomes. The dosage and frequency of interventions are important in pediatric therapy, especially for reimbursement of services. Therefore, as evidence of the effectiveness of ASI continues to grow, further attention to dosage and frequency should be given. It will also be important to investigate the most effective dosage and frequency for clients of various needs and of various ages.

Overall, this systematic review provides support for the effectiveness of ASI when performed with good fidelity, making it an important intervention in occupational therapy for children and youth with sensory processing differences. Current research supports OTPs confidently using ASI as part of the complex intervention processes of pediatric occupational therapy and thus justifies access to and reimbursement for ASI intervention. However, continued research is needed to examine the effectiveness across settings and ideal dosage and frequency.