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Manualization of Occupational Therapy Using Ayres Sensory Integration® for

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Article

OTJR: Occupation, Participation and

Manualization of Occupational
Health
2017, Vol. 37(3) 141­–148
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Integration® for Autism DOI: 10.1177/1539449217697044

https://doi.org/10.1177/1539449217697044
journals.sagepub.com/home/otj

Joanne Hunt1, Elke van Hooydonk2, Patricia Faller2,

Zoe Mailloux3, and Roseann Schaaf3

Abstract
This article reports on the development of a Stage 3 manual (following pilot effectiveness study) for implementing occupational
therapy using Ayres Sensory Integration® (OT/ASI) for children with autism spectrum disorders to enhance participation in
daily occupations. Three stakeholder groups were surveyed to aid in translation of manual from research to practice (i.e.,
Stage 3 manual) and an expert consensus meeting was held to finalize recommendations. Data indicated that the manuals
usability could be improved by including a section on frequently encountered problems and solutions, and by including video
case examples. Also recommended were greater chapter uniformity, improved clarity of forms and charts, and inclusion of a
glossary. Changes were made and subject to expert review and consensus using modified Delphi process. The Stage 3 manual
has been rigorously vetted and is ready for practice and research replication.

Keywords
sensory integration, knowledge translation, autism

Introduction Occupational therapy using the principles of Ayres Sensory

Translation of research evidence to clinical practice is
urgently needed to promote evidence-based practice (Clark,
Park, & Burke, 2013; Forsyth, Summerfield-Mann, &
Kielhofner, 2005; Murphy & Gutman, 2012; Schaaf, 2015),
and one important way to bridge this gap is the translation of
research intervention manuals and protocols to clinical prac-
tice (Blanche, Fogelberg, Diaz, Carlson, & Clark, 2011;
Lopata, Thomeer, Volker, Nida, & Lee, 2008; Schnyer &
Allen, 2002). Manuals that provide guidelines for practice
and research also assure that interventions can be replicated
and utilized with high fidelity (Carroll & Nuro, 2002). To
translate an evidence-based, manualized intervention from
research to clinical practice, Carroll and Nuro (2002) pro-
posed a three-stage progression in which a Stage 1 manual
tests the feasibility of implementation of the intervention, a
Stage 2 manual evaluates efficacy of the intervention, and a
Stage 3 manual translates the intervention for clinical use
with the potential to evaluate its efficacy with diverse popu-
lations. As the level of complexity evolves through each
stage of testing an intervention, a more explicit framework to
guide clinical practice is achieved (Des Jarlais, Lyles, Crepaz,
& TREND Group, 2004). Westen (2002) advised that seek-
ing input from clinicians during the development of a Stage
3 manual is important to ensure clinical utility and applica-
bility of the intervention for practice.
Integration® (OT/ASI) is a frequently utilized and requested
intervention for children with autism spectrum disorders
(ASDs) to facilitate the child’s participation in activities and
improve the quality of life (QoL) for the family. More than
95% of occupational therapists (OTs) working in pediatrics
report using this approach as part of their practice (Mailloux
& Smith Roley, 2010), and it is one of the most utilized ser-
vices by parents of children with ASD (Goin-Kochel,
Mackintosh, & Myers, 2009; Green et al., 2006; Mandell,
Novak, & Levy, 2005). OT/ASI is a complex intervention that
utilizes individually tailored sensory motor activities to facili-
tate participation and QoL. The intervention activities are
based on the child’s unique needs, which are identified in the
assessment data. The intervention involves active participa-
tion of the child, with the therapist guiding the process by
facilitating therapeutic activities in the context of play. The
1
Children’s Specialized Hospital, Mountainside, NJ, USA
2
Children’s Specialized Hospital, Toms River, NJ, USA
3
Thomas Jefferson University, Philadelphia, PA, USA
Corresponding Author:
Roseann Schaaf, Department of Occupational Therapy, Jefferson School
of Health Professions, and Faculty, Farber Institute of Neuroscience,
Thomas Jefferson University, 901 Walnut Street, Suite 605, Philadelphia,
PA 19107, USA.
Email: roseann.schaaf@jefferson.edu
142
therapeutic activities involve sensory motor experiences
aimed at a level of challenge that is considered “just-right” for
the child, and that produce an “adaptive response” as a basis
for enhancing the child’s participation in play, activities of
daily living, learning and social activities in the home, school,
and community (Ayres, 2005; Parham & Mailloux, 2015).
Outcomes of this approach are measured at the proximal (sen-
sory) and distal (participation/occupation-based) levels. The
core principles of the intervention are described elsewhere
(Parham et al., 2011; Schaaf & Mailloux, 2015).
Although OT/ASI is frequently utilized as an intervention
for children with conditions such as ASD and is highly
requested by parents, a manual that systematically describes
the procedures of this approach has not been published prior
to the effort explained in this article. The lack of a manual
has resulted in the identification of research studies that
claim to be using an ASI approach but are, in fact, not consis-
tent with the principles of this approach (Clark, 2012; Schaaf
& Case-Smith, 2014). The publication of a manual on this
approach will help eliminate this confusion.
The American Occupational Therapy Association
(AOTA) published practice guidelines for OT using sensory
integration (Watling, Koenig, Davies, & Schaaf, 2011), and
although this document presents the evidence available at the
time, as well as general guidelines for practice, it was not
intended to provide specific step-by-step procedures to
assure the intervention is replicable, systematic, and focuses
on occupation-based outcomes. Thus, more specific guide-
lines were needed for implementing OT/ASI in clinical prac-
tice and research in a consistent, replicable manner with high
fidelity (May-Benson & Koomar, 2010; Miller, Coll, &
Schoen, 2007; Parham et al., 2007; Pfeiffer, Koenig,
Kinnealey, Sheppard, & Henderson, 2011).
To meet this need, a Stage 1 manual that operationalized
the principles of OT/ASI into clinical guidelines was devel-
oped (The Sensory Integration Research Collaborative,
2011) and tested in a feasibility study. Findings showed that
the OT/ASI was safe and feasible to deliver and that parents
and therapists rated the intervention as acceptable (Schaaf,
Benevides, Kelly, & Mailloux-Maggio, 2012). Revisions to
the Stage 1 manual were made to help clarify and guide the
interventionist’s clinical reasoning.
These substantial revisions included the use of a prelimi-
nary version of the data-driven decision-making process
(Schaaf, 2015) as the organizing framework to guide the OT
process during ASI to ensure that the manual was contextual-
ized within occupation and participation, and that outcome
measurement was an integral part of the approach. This Stage
2 manual was tested in a randomized control trial (RCT) for
children with ASD (Schaaf et al., 2014). This study found
that children who received OT/ASI using the manualized
intervention scored significantly better on individual goals,
t(23) = −3.23, p = .003, ES = 1.2. In addition, using the
Pediatric Evaluation of Disability Inventory as a second
OTJR: Occupation, Participation and Health 37(3)
Figure 1. Steps in the study process.
Note. This figure illustrates the survey methodology and consensus group
processes used in this study. OTP = occupational therapy practitioners;
OTI = occupational therapy interventionists; OTE = occupational therapy
experts in Ayres’ sensory integration.
outcome measure (Haley, Coster, Ludlow, Haltiwanger, &
Andrellos, 1992), we found that caregivers rated children in
the treatment group as needing less assistance for participa-
tion in the occupations of daily living skills (p = .008, ES =
0.9) and socialization (p = .04, ES = 0.7). With the Stage 1
manual tested for feasibility and the Stage 2 manual tested in
an RCT, the next stage for development of this manualized
intervention is to gather data from key stakeholders to facili-
tate translation of the manual from research to clinical prac-
tice (Stage 3). Therefore, the purpose of the study reported
here was to gather and analyze data that informed the
advancement of the Stage 2 manual to a Stage 3 manual.
Method
Overview: The study was approved by the University institu-
tional review board of the fourth and fifth authors. Participants:
Three groups of key stakeholders were included in the study:
occupational therapy practitioners (OTP) who used OT/ASI
in their clinical practice (n = 25), occupational therapy inter-
ventionists (OTI) who used the Stage 2 manual during the
Schaaf et al.’s (2014) RCT (n = 4), and a group of occupa-
tional therapy experts (OTE) on OT/ASI (n = 10). We sur-
veyed each group of participants to obtain the data using a
step-by-step process, and then, as a final step, a modified
Delphi process was used with the OTEs to reach consensus.
The participants, methods, and findings for each step are
shown in Figure 1 and described below.
Step 1: Survey of OTPs and OTIs
Participants
OTPs. The OTPs consisted of a convenience sample of
25 OTs from central and northern New Jersey. They were
surveyed to obtain recommendations for the type of infor-
mation they perceived would be useful for an OT/ASI
intervention manual. Experience ranged from 1 to 25 years
with nine (56%) practicing for 1 to 5 years, one (6%) for
7 years, four (25%) for 16 to 20 years, and two (13%) for
Hunt et al.
more than 25 years. Twelve were educated at the master’s
degree level and four at the bachelor’s degree level. Six
completed Certification in Sensory Integration via a 60-hr
program offered by the University of Southern California
and Western Psychological Services® (2015). All the OTPs
reported using sensory integration theory frequently and
four reported using it always, within their practices.
OTIs. A second group of participants in step 1 were the
therapists who participated in the Schaaf et al. (2014) RCT
of OT/ASI (n = 4). These therapists were surveyed to gather
their recommendations for the Stage 3 manual. The OTIs
had an average of 22 years of experience, and all completed
Certification in Sensory Integration via the University of
Southern California and Western Psychological Services®
(2015) program. Two were educated at the master’s level
and two were educated at the bachelor’s level.
Instruments. Separate online surveys for the OTP and the
OTI groups consisted of targeted, forced-choice questions,
using a Likert-type scale, and open-ended questions.
Response options for the OTP survey were always, fre-
quently, occasionally, seldom, and never for the forced-
choice questions. An example question from the OTP survey
was, “I would benefit from a treatment manual that would
guide clinical reasoning of OT/ASI.” Open-ended questions
then queried the participants about the content that would be
helpful in such a manual.
The response options for the OTI survey were strongly
agree, agree, disagree, and strongly disagree for the forced-
choice questions. An example question from the OTI survey
was, “Using the manual provided structure in the evaluation
process,” and open-ended questions provided an opportunity
for respondents to indicate specific content they felt would
be useful in a manualized protocol. An expert in survey
development reviewed the surveys and made recommenda-
tions to improve clarity and to ensure that the items were
clear and relevant to the research area.
Data analysis. Summary statistics were compiled and
responses were calculated and reported as a percentage.
Qualitative data from the open-ended questions were ana-
lyzed using an inductive reasoning process.
Results of Step 1
Findings from OTP survey. Sixteen of the 25 OTPs (64%)
returned the survey. One hundred percent of survey respon-
dents indicated that a manual for ASI would always or fre-
quently aid with consistency in practice, including guiding
clinical reasoning for assessment and intervention. They rec-
ommended that the Stage 3 manual include case examples
to exemplify the treatment process, and description of fre-
quently encountered problems with suggested solutions to
guide clinical reasoning.
143
Findings from the OTI survey: One hundred percent of
the OTIs returned their surveys. The data showed that (a)
75% recommended greater organization and uniformity in
chapters; (b) 50% recommended greater clarity in the Goal
Attainment Scale (GAS) forms, tables, and charts; and (c)
100% recommended consistent terminology throughout the
manual using a glossary of terms.
Step 2: Revisions Based on Survey Findings From
OTP and OTI
The five main suggestions from the survey data, namely, (a)
video case examples, (b) frequently encountered problems
and suggested solutions, (c) greater uniformity in chapters,
(d) greater clarity in GAS forms and tables, and (e) a glos-
sary of terms were considered for revision in the Stage 3
manual as described below.
To address the recommendation for frequently encoun-
tered problems and suggested solutions, reflective questions
and tips were developed for each of the main treatment areas
of the manual. Adult learning theory supports the use of strat-
egies such as self-reflection questions and tips to enhance
clinical reasoning and to facilitate transformational learning
in which critical reflection is central to the learning process
(Merriam, 2001), and thus adult learning guided the develop-
ment of these.
To address the recommendation for consistent terminology,
a glossary of terms was developed by identifying terms in the
Stage 2 manual that were specific to ASI and not part of the
usual English lexicon. For example, terms such as sensory per-
ception, sensory reactivity, and praxis were identified, and
then, classic literature on sensory integration and neuroscience
was used to define these (e.g., Bundy, Lane, & Murray, 2002;
Kandel, Schwartz, & Jessell, 2000; Parham & Faxio, 1997).
To address the recommendation for greater clarity of
forms and charts, revisions were made to the organizational
structure of the GAS quick tips check sheet, the GAS techni-
cal checklist, and the parent interview template for GAS.
Research by Beaumont and Russell (2012); Casati and Bjugn
(2012); Kerber, Hofer, Meurer, Fendrick, and Morgenstern
(2011); Mason (2012); and Haynes and colleagues (2009)
reported that templates and checklists have good utility in
standardizing patient care processes and optimizing clinical
assessment by cueing important elements. They also show
that templates and checklists are useful strategies for stan-
dardizing patient care and promoting completeness of
documentation. Thus, recommendations regarding clarity
and organizational structure from this literature guided revi-
sions of these forms.
The suggestions to include video case examples and
greater organization and uniformity of chapters deferred as
it was decided that these enhancement would be better
addressed in concert with a publisher and copy editor in the
development and production of a published manual.
144
Step 3: Review of Revised Documents by the
OTE
Participants. The OTE group was comprised of twelve
experts in OT/ASI who were recruited to review the addi-
tions and revisions to the manual. These individuals were
chosen because of their expertise in ASI and OT. Experience
ranged from 11 years to more than 25 years in practice, with
70% currently practicing in the area of pediatrics for more
than 25 years in a variety of settings, including private prac-
tice, academia, hospital-based setting and schools. All the
OTEs were educated at the doctoral level and had completed
Certification in Sensory Integration in a recognized program.
Within the group of experts, 60% were involved in teaching
continuing education courses in sensory integration, and
85% had authored or coauthored in publications on the topic
of sensory integration.
Instruments. An online survey was developed and was sub-
ject to expert validation as described previously. The OTE
survey consisted of targeted forced-choice questions using a
4-point Likert-type scale with responses of strongly agree,
agree, disagree, and strongly disagree, as well as open-ended
questions. Responses of strongly disagree or disagree trig-
gered an open-ended question for responders to provide sug-
gestions for improvement. Following are examples of OTE
survey questions: “The Goal Attainment Scale technical
checklist template provides sufficient structure to guide the
technical assessment of the goal attainment scales” and “The
reflective questions and tips section address useful areas to
guide clinical reasoning of the therapist in providing Ayres
Sensory Integration.” The criterion for acceptance of manual
revision was set as a rating of agree or strongly agree by 90%
of expert participants.
Data analysis. Frequency distribution of all responses were
analyzed and described with the percentage of total response
to each of the Likert-type scale answers.
Results. Eleven of the 12 (92%) OTEs reached consensus on
the revised reflective questions and tips; thus, this section
reached acceptable criterion. An example of the final reflec-
tive questions and tips is shown in Table 1.
The OTE group also reached consensus on 24 of the 37
glossary of terms. For those that did not reach consensus, the
OTEs suggested greater clarity in definitions using literature
in neuroscience and ASI. The terms were revised accord-
ingly and then subject to re-review at the Delphi meeting as
described below:
Two forms did not meet the 90% consensus criterion by
the OTEs, namely, the GAS quick tips form and GAS techni-
cal quality checklist. Specific suggestions for greater clarity
and organization of these forms to provide systematic guid-
ance in developing and rating the GAS goals were made. The
forms were revised accordingly.
OTJR: Occupation, Participation and Health 37(3)
Step 4: Modified Delphi Meeting With OTE
Participants. A Delphi meeting with the OTEs was held to
gain consensus on the manual revisions. Seven of the origi-
nal 12 OTEs accepted the invitation to participate in the Del-
phi meeting. One of the seven members was not able to join
the meeting in person, but participated remotely.
Procedures. Delphi methodology was used to consider the
revised items (Hartnett, n.d.). The modified Delphi method-
ology was utilized because this final step necessitated a
methodology that allowed for determination of the extent to
which the OTEs agreed with the revisions. Following this
methodology, the Delphi meeting had an established time
frame; a facilitator, note taker, and time keeper; rules regard-
ing time for each item and the entire meeting; rules for facili-
tating consensus; and strategies for resolution of items that
did not achieve consensus as described below. In keeping
with Delphi methodology, the OTEs were asked to maintain
mutual respect, be open to suggestions, and build on ideas.
The procedures are outlined below:
•• Total time for the meeting was set at 90 min.
•• Time for each topic was 2 min.
•• A time keeper tracked the discussion time and called
for a vote at the 2 min mark.
•• When 100% consensus was not reached, another
round of discussion (2 min) occurred followed by a
second vote.
•• Items that reach consensus were considered resolved,
while unresolved items were deferred.
•• Unresolved items were given to a designated expert
from the group who made the final recommendation.
Results. Of the thirteen revised glossary terms presented for
review, discussion, and vote, consensus was reached on
eight. Five glossary terms were deferred (sensory discrimi-
nation, bilateral integration, arousal, self-regulation, and sen-
sory reactivity), and one of the OTEs was chosen by the
group to make the final revision based on the panel’s conver-
sation and their own expert opinion. A sample of glossary
terms and definitions is shown in Table 2. The entire glossary
can be found in the Stage 3 manual publication (Schaaf &
Mailloux, 2015).
Discussion
Manualization of an intervention is an important part of evi-
dence-based practice. Manualization provides a systematic
description of an intervention so that it can be replicated in
future studies and utilized in clinical practice. A crucial step
in the manualization process is obtaining input from key
stakeholders (Westen, 2002). In this study, key stakeholders
were represented by the OTPs, OTIs, and OTEs who
reviewed and contributed input for manual revisions.
Hunt et al. 145

Table 1. Examples of Reflective Questions and Tips.

Reflective questions for sensory perception Tips

Did I provide sensory opportunities (tactile, vestibular, and
proprioception) that address the child’s participation-based
challenges?
In what ways did I provide opportunities tailored to the child’s
needs?
Did the child respond to the therapeutic activities with
appropriate adaptive responses?
What can I do differently next session to assure that the
sensory activities are matched to the child’s needs?
Choose activities that are rich in total body sensory experiences
that are consistent with the child’s interests and needs.
Reflect on the child’s assessment data and assure the activities
are targeted toward the identified areas.
Identify the adaptive responses and assure they are consistent
with the stated goals for intervention.
Review the assessment data with an eye toward the sensory and
motor factors that are affecting the child’s participation and
choose activities that are a good match with these.

Praxis
Were the activities utilized rich in somatosensory experiences
and require that the child plan and execute purposeful
movements as a basis for participation?
In what ways did I support and present challenges to the
child’s ability to conceptualize and plan novel motor
activities, and to organize his or her own behavior in time
and space?
What amount and type of structure did I need to provide for
the child to execute and/or create new action ideas for play
and other activities?
What changes did the child exhibit related to organized
behavior for participation?
Assure that the environment contains a variety of materials and
props to allow for total body somatosensory experience and
that facilitates praxis through play.
Tap into the child’s interest and then gradually expand their
praxis and play repertoire.
Provide a model play for the child if needed.
Beware of being too directive; instead, offer opportunities and
wait for child to respond.
Be mindful of collaborating with the child on activity choices.
Consider phrasing verbal cues in form of questions, for
example, “What could we use this for?”
Allow children time to process and figure things out by
themselves.

Table 2. Sample Terms From Glossary.

Adaptive response
“An appropriate action to an environmental demand. Adaptive responses require good sensory integration, and they also further the
sensory integrative process” (Ayres, 1979, p. 181).
Body awareness (body perception)
A person’s perception of his own body, consisting of sensory pictures or “maps” of the body stored in the brain, may also be called
body scheme, body image, or neuronal model of the body (Ayres, 1979).
GAS
Setting up a measurable scale for goals (Kiresuk & Sherman, 1968); a means of individualized, criterion-referenced, quantifiable
measurement of change across time that involves defining a unique set of goals for each child based on their functional needs
(Mailloux et al., 2007); a method of goal setting and objective measurement of individualized functional responses to therapeutic
interventions (Kiresuk, Smith, & Cardillo, 1994).
Gravitational insecurity
A type of sensory hyperreactivity that involves signs of distress in response to movement or change of head position or center of
gravity that is greater than would be expected; anxiety and distress when head position is changed or movement occurs (Ayres, 1979).

Note. GAS = Goal Attainment Scale.

Carroll and Nuro (2002) suggested that a manual’s util-
ity can be increased by anticipating and acknowledging
challenging clients and problem areas. They also recom-
mended strategies such as trouble shooting guidelines,
templates for organizing complex treatments, brief session
summaries, and outlines to direct clinicians to the key
points of the intervention. Consistent with this literature,
our survey data showed that the OTPs and the OTIs recom-
mended the use of self-reflective questions and tips to elu-
cidate specific intervention principles and solutions. In
keeping with Carroll and Nuro (2002), they also indicated
that such strategies would enhance the clinician’s clinical
reasoning process and assure adherence to the interven-
tion. Adult learning theory also supports the use of strate-
gies such as self-reflection questions and tips to enhance
clinical reasoning and to facilitate transformational learn-
ing in which critical reflection is central to the learning
process (Merriam, 2001) and guided the development of
these. Thus, the use of reflective questions and tips for
each intervention area in the Stage 3 manual may be useful
strategies to shape clinical reasoning and decision making.
In particular, these reflective questions help tailor the
146
intervention to the child’s unique participation-based or
occupation-oriented outcomes.
Regarding the finding that the inclusion of a glossary
with consistent and well-defined terminology would
improve usability, Schnyer and Allen (2002) promoted the
use of standard terminology in manual development as a
basis for ensuring replicability, adherence, and internal
validity of an intervention. They recommend that terminol-
ogy be housed in the conceptual framework of the interven-
tion and promote understanding of the intervention by both
clinicians and researchers. Schnyer and Allen (2002) rec-
ommended the following terminology guidelines when
developing manuals: (a) defining terms used, (b) providing
a substantive term list, (c) stating the sources used, and (d)
establishing agreement among clinicians about the use and
meaning of the terms (Schnyer & Allen, 2002). We fol-
lowed these guidelines when identifying and defining ASI
terms. Although the glossary of terminology was challeng-
ing due to varying definitions of some of the terms, the use
of consensus group methodology was particularly useful as
it provided the mechanics to facilitate decision making
among experts. This was especially important because we
found inconsistent terminology in the literature, use of pro-
fessional jargon rather than lay terminology, and that the
same term was attributed to different concepts. This lack of
consistent terminology is one factor contributing to unclear
practice standards for ASI (Smith Roley, Mailloux, Miller-
Kuhaneck, & Glennon, 2007), may affect clear articulation
of the scope and domain of ASI, and contributes to ASI
being misunderstood and mislabeled (Case-Smith, Weaver,
& Fristad, 2015). Thus, the development of a glossary of
terms and the use of OTE via the modified Delphi process
is an important contribution. Given that the glossary of
terms was subject to rigorous review and consensus, it has
the potential to serve as a guiding document to assure that
terms used are universally understood and communicated
within and among professionals and parents.
Schnyer and Allen (2002) reported that case examples
help to shape and tailor clinical reasoning as well as provide
strategies for handling unique clinical situations. Because the
literature on manualized interventions also provides support
for our finding regarding use of systematic case examples to
illustrate the assessment and intervention process, this rec-
ommendation was considered as highly important. The sug-
gestion for video case examples was deferred so that it could
be addressed more comprehensively in concert with a pub-
lisher and copy editor. Dimeff et al. (2009) showed that ther-
apists learning a dialectical behavior therapy preferred
multimedia on-line training to a written treatment manual.
Thus, online video segments illustrating treatment concepts
are a useful consideration for presentation of case material in
conjunction with the Stage 3 manual. Similarly, the continu-
ity of chapters in terms of organization, as suggested by the
OTEs, was addressed by the copy editor in the published ver-
sion of the manual.
OTJR: Occupation, Participation and Health 37(3)
Conclusion
Manualization of OT interventions, using the rigorous
methodologies such as those described in this study, is
essential to intervention development to provide standard
procedures for research and clinical practice. Not only do
manualized intervention protocols establish fidelity to
intervention principles, but they also assist in developing
the therapists’ clinical reasoning and facilitating the trans-
lation of research findings to the clinical setting. The meth-
odologies outlined by Carroll and Nuro (2002), which
supported the translation of a Stage 2 to a Stage 3 manual
for clinical practice, can serve as a model for developing
Stage 3 manuals for other areas of OT practice and research.
Clinician input for the Stage 3 manual helped bridge the
divide between research and practice.
The process used in the development of the Stage 3 man-
ual complied with literature that recommends clinician
involvement in the early stages of manual development as
essential for the translation of research to practice (Carroll &
Nuro, 2002). Thus, the Stage 3 manual for OT/ASI offers a
detailed, tested protocol to guide research and practice for
children with ASDs, thus facilitating evidence-based prac-
tice. Although the manual was specifically tested for children
with ASDs, it is also easily translatable to other clinical pop-
ulations that may have participation challenges related to dif-
ficulty processing and integration sensation. Furthermore,
the manual describes the use of occupation-based outcomes
as part of the OT/ASI approach, and clinicians and research-
ers may want to consider inclusion of such measures in their
work. Of note, it is recommended that those utilizing the
manual supplement their knowledge and skills by obtaining
certification in the ASI approach by attending a recognized
certification program
Authors’ Note
This research was approved by the Thomas Jefferson University
Ethics Committee/Institutional Review Board (phone: 215-503-
8966). This work was completed by the first three authors in partial
fulfillment of an occupational therapy doctoral degree at Thomas
Jefferson University, Department of Occupational Therapy, College
of Health Professions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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