Occupational Therapy Using Ayres Sensory Integration^® in School-Based Practice: A Call to Action

An increasing number of children demonstrate challenges processing and integrating sensations that affect their successful participation at school (Iimura, 2022). Sixty-five percent of school-based occupational therapy practitioners report that sensory-related issues are frequently or always the reason for occupational therapy referrals (Bolton & Plattner, 2020). Children’s sensory integration and processing challenges inherently affect their abilities to access educational programming and participate in a variety of activities, tasks, and occupations (Gonçalves & Abreu, 2023). The ability to sustain an upright position for sitting at a desk; to coordinate head and eye movements for activities such as writing or cutting; or to organize multistep activities, such as completing a science project, fundamentally require underlying aspects of sensory integration and processing, including sensory perception, postural functions, and praxis. When evidence shows that a child struggles with tasks that require efficient sensory integration, successful participation is hampered, compromised and, possibly, unattainable. Yet historically, the inclusion of sensory integration as part of the scope of practice of school-based occupational therapy has been limited. This has led to many children not receiving adequate school-based evaluations or interventions to address the negative impacts of sensory integration and processing challenges on occupational engagement in school. When occupational therapy using Ayres Sensory Integration^® (ASI) is needed but not included as a school-based publicly funded intervention, disparities between privileged and marginalized/disadvantaged children become magnified, and occupational injustices procreate (Kirby et al., 2022).

ASI is an evidence-based manualized intervention in which practitioners use individually tailored, purposeful, playful, sensory-rich activities to promote adaptive behaviors and provide a foundation for growth and development (Parham et al., 2011). Unlike sensory-based strategies, the principles that underlie ASI require collaboration, motivation, and active participation (Case-Smith et al., 2015). The American Occupational Therapy Association’s (AOTA’s; 2023) Position Statement on Sensory Integration Approaches for Children and Youth Within Occupational Therapy Practice acknowledges that

Increasing evidence for the effectiveness of ASI has resulted in its recognition as an evidence-based practice for autistic children ages 5–12 yr (Schaaf et al., 2014; Steinbrenner et al., 2020). More recently, researchers have demonstrated emerging and promising evidence of the effectiveness of ASI with other populations (Andelin et al., 2021; Whiting et al., 2023) and within the school setting (Whiting et al., 2023).

Paired with recent changes in education legislation that highlight the importance of prevention and the promotion of physical and mental health, the occupational therapy profession needs to reassess best practices for use of ASI in the school setting. As outlined in the Every Student Succeeds Act of 2015 (ESSA; Pub. L. 114-95) and its multitiered system of supports (MTSS), school-based occupational therapy practitioners are now called on to address prevention and promotion of health proactively and support all students to engage at school (ESSA, 2015; Whiting et al., 2021). ASI’s guiding principles should be used to create sensory-rich activities and environments in the school setting that produce adaptive responses and support functioning across each of the tiers: Tier 1, whole school or whole classroom; Tier 2, targeted small groups; and Tier 3, individualized. More than 80% of school-based occupational therapy practitioners report interest in applying ASI in school-based practice and find it relevant (Cerase, 2023) because of the observed impact of sensory integration on students’ educational participation. However, ASI is not uniformly used as an option in school settings.

We are issuing a call to action for occupational therapy practitioners to provide students with the support they deserve by recognizing, responding to, and evolving school-based practice to include ASI and ASI principles in all tiers. In answering the following questions, we address underlying philosophical and ethical concerns. First, is ASI a necessary, essential, and inherently appropriate intervention for school settings? Second, does ASI align with education laws and mandates? After addressing these questions, in the “Next Steps” section we provide a perspective on best practices for implementing ASI in schools and address the feasibility of using ASI in school-based practice given the existing systemic and logistical barriers. With the growing recognition of the impact of sensory integration and processing challenges on engagement in school (Gonçalves & Abreu, 2023) and the importance of building environments that help neurodivergent students flourish (Dallman et al., 2022), now is the time to reevaluate the use of ASI in occupational therapy school-based practice.

Within the profession, the question of whether ASI is a medical model–based intervention that is not appropriate for school-based practice has been raised among clinicians. However, because sensation affects everything we do and underlies how we understand ourselves and the world, every occupation is embedded in taking in, processing, and integrating sensation. When challenges with sensory integration and processing occur, we have an ethical obligation to explore their impact on educational performance and access to educational programming as well as to identify evidence-based methodology that can remove barriers. It is important to note that ASI addresses both proximal and distal areas of performance concurrently (May-Benson et al., 2018). Proximal outcomes reflect the foundational areas of concern, such as sensory perception, reactivity, and praxis, whereas distal outcomes reflect the child’s successful occupational engagement in the school setting.

Sensory integration theory and the current literature clearly articulate how proximal outcomes of improvement connect to distal outcomes of performance (May-Benson et al., 2018; Schaaf, 2015; Whiting et al., 2023), such as increased regulation during academic tasks, greater independence in classroom routines, and enhanced participation in play with friends during recess. When a comprehensive occupational therapy evaluation shows that difficulty with sensory integration and processing is affecting occupational performance in the school setting, the occupational therapy practitioner should consider using evidence-informed, theory-driven ASI (AOTA, 2023).

To use this potentially meaningful intervention, it is imperative that occupational therapy practitioners receive the necessary knowledge and training to implement the principles of ASI across all the tiers of school-based interventions. ASI can be used more broadly than its traditional application solely as an individualized, manualized approach by expanding on the teacher consultation and communication that are already intrinsic to the ASI Fidelity Measure (Parham et al., 2011) and applying ASI principles for embedded support.

Tier 1 offers education and training for staff and administrators about sensory integration theory and its applications to the school environment. This helps develop a collective knowledge base and the creation of sensory environments that support the broad sensory needs and preferences of children across multiple school contexts. In addition, Tier 1 interventions delivered across multiple classrooms can help students better understand how their own sensory preferences and differences play a role in their success in school.

Tier 2 interventions, at the small-group level and involving teacher consultation, can align with ASI principles such as providing sensory opportunities that address constructs related to functioning in the classroom (e.g., alertness, postural control, praxis), designing just-right challenges, and supporting intrinsic motivation. In Tier 2, small groups of students can benefit from carefully planned sensory experiences and sensory adaptations that support success, as well as activity modifications.

Finally, Tier 3 interventions, using a push-in or pull-out model, focus on sensory integration and processing challenges that are interfering with an individual’s ability to access the educational environment. In order to align interventions with the educational model and ASI principles, combining the provision of Tier 3 direct pull-out ASI for individual children with teacher consultation encourages carryover, generalization, and the appropriate use of strategies (Whiting et al., 2023). Occupational therapy practitioners who use Tier 3 ASI also play a critical role in supporting the education-related goals of the student’s team, recognizing the importance of investigating the desire for change on the part of the student and their family (Dallman et al., 2022). This multifaceted approach, implemented in a publicly funded setting, is encouraged in the literature (Reynolds et al., 2017) and supports access to educational programming while reducing disparities.

Providing MTSS (ESSA, 2015) allows occupational therapy practitioners to offer integrated support at the whole-school and small-group levels before considering a more restrictive pull-out model (Whiting et al., 2021). Tiers 1 and 2 interventions are always implemented first. If it is necessary to move to Tier 3, consultation with school personnel and interventions in the classroom or other school settings can be an effective approach to meet the goals specified in individualized education programs (Frolek Clark et al., 2019). However, full inclusion does not fit every student, and the general education classroom is not always the least restrictive environment. The mandate for the least restrictive environment asks that occupational therapy practitioners provide services in general education settings only when they can ensure a student’s success in that setting. Service providers always must base decisions on the individual student’s strengths, needs, and goals (Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446 [IDEA], 2004).

Occupational therapy practitioners need to consider the full array of service delivery options for supporting students with sensory integration and processing challenges that affect their access to the education program. When support in the general education setting does not result in satisfactory change in participation in the classroom and occupational engagement, as demonstrated by progress-monitoring data, the law supports the consideration of services in a more restrictive setting, such as direct, pull-out ASI (IDEA, 2004; No Child Left Behind Act of 2001, Pub. L. 107-110). Whiting et al. (2023) provided a road map for navigating decision-making across tiers. They also gave an example of pull-out service delivery for effective Tier 3 school-based ASI that demonstrated meaningful educational outcomes (i.e., improved functional regulation, increased participation, and occupational engagement) that maximized each student’s performance in the education setting.

School-based occupational therapy practitioners must feel empowered to advocate for ASI and its principles across all three tiers of school-based services. Occupational therapy practitioners should note that access to training, high caseloads, time constraints, and short staffing can make tiered service delivery challenging and that context limitations (e.g., space and equipment, limited teacher and administrator knowledge) may affect their ability to implement ASI (Cerase, 2023). Therefore, practice, advocacy, and education must evolve to remove barriers and provide support for school-based occupational therapy practitioners. Although all three areas have improved since Schaaf et al. (2015) addressed these issues, there is still work to be done. Next, we outline some key action items needed to support this advancement.

• ▪ Design guidelines that elucidate essential ASI principles and structural elements of space and equipment, adapted for school settings and applied across the tiers.

• ▪ Develop a manual that outlines decision-making for student-centered, strengths-based occupational therapy using ASI across the tiers and focuses on school-related and academic, occupation-based outcomes.

• ▪ Provide support for further research in school settings to build evidence for the effectiveness of ASI across student populations and all tiers. Occupational therapy practitioners should partner with researchers and mentors to design and implement rigorous studies to demonstrate the applicability, feasibility, and value of ASI and identify sensitive outcome measures of participation and engagement in school occupations.

• ▪ Collaborate with educators and administrators to determine the best fit of multitiered ASI within the context of their schools, and help build an understanding of sensation, the impact of sensation on participation, and how supports for sensory integration and processing can help maximize the accomplishment of education-related goals.

• ▪ Consider that front-loading an intensive short-term model of direct pull-out ASI may take less time and be more effective than seeing a student year after year with an inclusive model.

• ▪ Campaign for training, assessment tools, equipment, and space in school districts for the delivery of ASI-based interventions.

• ▪ Advocate for a broader scope of school-based service delivery that includes ASI and its principles across all tiers.

• ▪ Develop specific ASI continuing education opportunities for school-based occupational therapy practitioners that are accessible, affordable, and delivered within a time frame that matches their availability. Schools also need to support this type of training for their occupational therapy practitioners given that implementing ASI requires advanced training.

• ▪ Ensure the consistent administration of a comprehensive evaluation that explicitly links sensory integration and processing to occupational performance and participation in school as advocated in AOTA’s best practice recommendations (AOTA, 2021). In addition to occupation-focused assessments, occupational therapy practitioners should include performance-based assessments and teacher- and parent-report measures specific to sensory integration and processing, along with structured and unstructured clinical observations and observations in the natural environment, all of which are critical to targeting appropriate areas for intervention success.

• ▪ Encourage occupational therapy graduate school programs to add content to their basic coursework to cover ASI principles and intervention.

• ▪ Urge AOTA to develop mechanisms to disseminate information to school-based practitioners regarding the application of ASI in school settings and differentiate it from sensory-based interventions.

This call to action necessitates a change in the occupational therapy profession’s approach to sensory integration and processing challenges in the school-based setting. Administrators, educators, and school-based practitioners need to recognize that sensory integration and processing functions are inherently linked to participation in a wide range of school-related domains (e.g., social participation, education, play, activities of daily living, health management; AOTA, 2020). School-based occupational therapy practitioners are urged to use the whole scope of practice and align with AOTA’s Position Statement and practice framework by consistently supporting sensory integrative functions in all tiers using ASI and its principles (AOTA, 2020, 2023). Equity and occupational justice require that these services be available to all students. Educational success is a right; thus, school-based occupational therapy practitioners must be empowered with the knowledge and skills to use ASI principles in interventions across the tiers.