Ayres Sensory Integration^® Intervention for Autistic Children: A Telehealth Adaptation

Autism spectrum disorder is a neurodevelopmental disorder characterized by social communication impairments, restricted and repetitive behaviors, and atypical responses to sensory experiences (Centers for Disease Control and Prevention, 2022). Up to 90% of autistic children demonstrate sensory features, which may negatively affect participation in daily routines and occupations (Ben-Sasson et al., 2019; Lin, 2020; Schaaf et al., 2015; Yela-González et al., 2021).

Schaaf and Mailloux (2015) created and tested a manualized protocol of occupational therapy based on the principles of Ayres Sensory Integration^® (OT–ASI). The manual is based on the principles of ASI (Ayres, 1979, 2005; Parham et al., 2011) and uses a data-driven, decision-making process to guide the clinical reasoning process. Assessment data are analyzed and used to develop hypotheses regarding the underlying sensory–motor factors affecting participation in activities and tasks, intervention activities, and outcome measurement. The active ingredients of the intervention are individually tailored, active, sensory–motor activities, contextualized in play at the just right challenge to facilitate adaptive responses for participation in activities, tasks, and occupations. The in-person manualized OT–ASI protocol has been tested and shown to be effective in improving individualized goals and socialization among autistic children (Omairi et al., 2022,; Schaaf et al., 2015); moreover, it is recognized as an evidence-based intervention for autistic children (Hume et al., 2021; Omairi et al., 2022; Schaaf et al., 2014; Schoen et al., 2019; Steinbrenner et al., 2020; Watling & Hauer, 2015).

During the coronavirus disease 2019 (COVID-19) pandemic, therapeutic services for autistic children were disrupted, leading to decreases in adaptive functioning and occupational participation (Amaral & de Vries, 2020; Chung, 2020). Telehealth emerged as an alternative service delivery method enabling clinicians to provide needed services while respecting pandemic guidelines. Moreover, telehealth provided a means to overcome logistical challenges, including cost, travel time, and extensive wait lists (Alfuraydan et al., 2020; Simacek et al., 2021). However, many therapists do not have the advanced skills and competencies needed to effectively implement telehealth services (Gabellone et al., 2022; Wittmeier et al., 2022), and training and procedural guidelines may be necessary (Ashburner et al., 2016).

Currently, no manualized protocols are available to guide telehealth implementation of OT–ASI interventions, a highly requested and valued intervention by autistic families. Thus, the purpose of this study is to adapt the in-person, manualized, evidence-based protocol of OT–ASI for autistic children for telehealth intervention and report on expert and clinician review of and rating of the adapted protocol. Findings from this project set the foundation for later feasibility and effectiveness testing.

This project was deemed exempt by the ethics board of Thomas Jefferson University. The study procedures (Figure 1) began with the research team synthesizing the literature on best practices in telehealth and adapting the manual accordingly. Next, the adapted manual was reviewed and rated by telehealth experts who provided suggestions for additional adaptations. Lastly, occupational therapy clinicians reviewed the adapted manual and provided suggestions that were integrated into a final version.

Two groups of participants were included: telehealth experts (n = 2) and occupational therapy clinicians providing services to autistic children (n = 6). Participants were sent a description of the study procedures and links to the online survey and manual via email. Completing the survey served as consent to participate in the study.

Telehealth experts were included if they were a licensed rehabilitation health care provider with ≥5 yr of experience using telehealth in the field of autism. Experience in pediatric occupational therapy was encouraged but not required. Participants were recruited from professional networks, including membership rosters from the American Academy for Cerebral Palsy and Developmental Medicine, the American Occupational Therapy Association, and the International Society for Autism Research.

Occupational therapy clinicians were included if they had ≥5 yr of experience working with autistic children. Participants were recruited from professional networks in the New York and New Jersey areas. These clinicians were certified in ASI and had experience implementing the original OT–ASI protocol and advanced training in telehealth procedures.

Two Qualtrics surveys (available online with this article at https://research.aota.org/ajot) were developed to obtain input from telehealth experts and occupational therapy clinicians, respectively. A survey expert reviewed both surveys to ensure clarity, jargon-free language, and relevance. Each item used a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree), followed by an open-ended question for further elaboration.

The telehealth expert survey consisted of seven questions assessing feasibility of remote implementation, appropriateness of provided resources, and clarity of intervention instructions (e.g., “The manual is easy to follow”). The clinician survey consisted of 11 questions covering similar concepts and specific OT–ASI principles as well as a single question rated on a 5-point Likert scale item ranging from 1 (extremely inadequate) to 5 (extremely adequate) because of the nature of the question (i.e., “The manual adequately details how this intervention will address common challenging areas of telehealth interventions”).

Frequencies, means, and standard deviations were calculated in Qualtrics for each survey question. A mean of ≥3 was needed to indicate agreement with any given item. Questions that did not meet this minimum level were reviewed by the research team and recorded in a table of revisions that detailed areas of concern and listed suggested revisions and rationales.

Responses to open-ended questions were compiled and stored in a password-protected electronic platform. These data were then reviewed and rated as “no action needed” or “reject/accept this recommendation” by the research team’s consensus. Solutions were generated by the team and reviewed by the senior investigator (Roseann Schaaf) to ensure that they addressed the reviewers’ concerns and were appropriate for inclusion.

On the basis of telehealth best practices, the following enhancements were made to the existing OT–ASI manualized protocol before expert review: (1) recommendations for web conferencing applications that were compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub. L. 104-191) as well as suitable device and environmental setup, provided to the family before the session (Kalvin et al., 2021; Loman et al., 2021), and (2) emphasis on cultural sensitivity, humility, nonjudgmental approach, relationship building, and family privacy (Alkhalifah & Aldhalaan, 2018).

All survey questions received appropriate levels of agreement (Figure 2), with the highest being Question 1 (M = 3.50, SD = 0.71), Question 2 (M = 4.00, SD = 0.00), Question 5 (M = 3.50, SD = 0.71), and Question 7 (M = 3.50, SD = 0.71). Telehealth experts found the manual logically structured, inclusive of telehealth best practices, and feasible for implementation. Although all questions met the acceptance threshold, the research team reviewed items with a mean of 3.00 to determine whether revisions needed to be considered. These items included Question 3 (M = 3.00, SD = 1.41), Question 4 (M = 3.00, SD = 1.41), and Question 6 (M = 3.00, SD = 0.00). Accordingly, the research team recommended adding additional resources for guiding parent interactions, providing clearer technology troubleshooting guidelines, clarifying the assessment process, and adding information to encourage active parent participation.

All questions received appropriate levels of agreement (Figure 3), with the highest being Question 5 (M = 4.00, SD = 0.00), Question 6 (M = 4.00, SD = 0.00), Question 8 (M = 4.00, SD = 0.00), Question 10 (M = 4.00, SD = 0.00), and Question 12 (M = 4.00, SD = 0.00). Occupational therapy clinicians felt that the manual integrated the essential principles and components of the OT–ASI approach, provided useful guidance on intervention planning using a telehealth format, and seemed feasible to implement.

Although all questions met the acceptance threshold, the research team gave particular attention to items with lower agreement levels, namely, Question 2 (M = 3.33, SD = 0.82) and Question 11 (M = 3.33, SD = 0.52). In response, the team improved figure resolution and specified how household materials can be used therapeutically without the need for families to purchase additional resources.

Open-ended comments from both reviewer groups revealed the need to add strategies to guide family interaction, clarify the intervention flow and terminology, specify training requirements, provide more detailed guidance on the assessment protocol, enhance document formatting and layout, offer additional technology troubleshooting resources, and clarify how to use household materials therapeutically.

On the basis of the reviewer feedback and appraisal, the research team completed revisions to increase stakeholder support and to improve comprehensiveness of written directions (Table 1).

The purpose of this study was to adapt the evidence-based, manualized protocol of OT–ASI for telehealth delivery. Findings highlighted the adapted manual’s strengths in ease of use, adherence to best practices, and feasibility for implementation by trained clinicians. Reviewer feedback suggested the need for specific enhancements, which were incorporated into the final version of the manual.

Notably, open-ended responses revealed the need for greater detail in the assessment process, which is pivotal in informing the overall intervention process. Although it was not possible to conduct a full standardized assessment of sensory integration, we created a more detailed assessment guide and a clinical impression tool to guide data interpretation. Although the research team recognizes the need to standardize and obtain psychometric data on any new assessments, the current version provides preliminary guidance on assessment of sensory integration functions via telehealth and helps to organize assessment data and guide intervention planning.

Findings also indicated a potential need for increased resources to support clinician–family interactions. Subsequently, a coaching skills self-assessment, links to external trainings, specific open-ended questioning techniques, and flowcharts demonstrating how to situate basic coaching strategies within each session component were included.

Finally, findings were consistent with prior research in noting that additional training is useful to competently use a telehealth delivery model (Ashburner et al., 2016). We identified two existing telehealth trainings for OT–ASI (Collaborative for Leadership in Ayres Sensory Integration, n.d.; Sensory Processing Institute for Research and Learning Foundation, 2020) that provide needed skills to supplement the manual.

When interpreting the study findings, several limitations should be considered. Because we used a small sample of urban clinicians and telehealth experts in this study, generalization of findings may be limited to those working in rural areas. Moreover, the incremental improvements made during the iterative editing process may have positively biased the reviewers’ perceptions of the manual’s feasibility.

In this study, we report on the successful telehealth adaptation of an evidence-based, manualized occupational therapy intervention. It is now ready for a feasibility trial to evaluate its acceptability, satisfaction, and preliminary outcomes as well as to identify specific areas of challenge within the protocol’s implementation.

The results of this study have the following implications for occupational therapy practice:

• ▪ This study enhances the repertoire of resources available to support clinicians in delivering sensory integration interventions for autistic children.

• ▪ The comprehensive training and resources provided in the manual are valuable tools for bolstering clinician competence in delivering telehealth-based interventions.

• ▪ The manual will be available to clinicians after feasibility and pilot testing.

In this study, we adapted a manualized intervention of OT–ASI for telehealth delivery that was well-received by all reviewers. The successful adaptation of the manual holds promise for increasing access to specialized occupational therapy services for autistic children who would traditionally face barriers to accessing such services. By leveraging telehealth, practitioners have the potential to expand the scope of established interventions, thereby ensuring access to services for autistic children with sensory challenges who live in underserved areas or who are unable to access in-person clinics.

Funding for this project was provided by C-Progress, the National Institutes of Health–funded National Pediatric Rehabilitation Resource Center. Thank you to the clinicians who reviewed the manual and provided input and the many occupational therapy doctoral students who were involved with this project.