Response to Whiting et al. (2025), “Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice: A Call to Action”

This Letter to the Editor is a response to Whiting et al.’s (2025) article “Occupational Therapy Using Ayres Sensory Integration® in School-Based Practice: A Call to Action.” We want to address issues that arise from this call to action.The primary purpose of school-based occupational therapy is to facilitate children’s access to and participation in their educational program. Occupational therapy ethics and competency documents provide guidance on what comprises best and competent practice, with occupation-based interventions central to both (American Occupational Therapy Association, 2017). Occupation-based interventions are top-down approaches that leverage the dynamic interaction among person, occupation, and environment to support daily occupations.The Ayres Sensory Integration® (ASI) framework is a top-to-bottom-up approach (see Dancza & Rodger, 2018) that requires its practitioners to ask about occupational goals; however, ASI uses impairment-based intervention theory (Novak & Honan, 2019). To be specific, the main focus of ASI intervention is on improving the child’s perceived dysfunctional sensory system with the goal of normalizing that system and the child, not on developing functional skills that can be transferred to their academic setting. Strong, replicated evidence supports the mandate of occupational therapy practitioners to use top-down occupation-based approaches (Laverdure & Beisbier, 2021).Adaptive skills emerge from self-organized strategies formed through contextual skill experience and are specific to the demands of the task. In fact, the consistency and strength of the evidence support the use of task-specific training, metacognitive problem-solving approaches, and coaching models (Novak & Honan, 2019). These approaches have been derived from dynamic systems and contemporary motor control theories. In contrast to ASI, one significant feature of top-down approaches is that the occupation is both the focus and the outcome of the intervention; that is, there are no degrees of separation between the intervention content and the intended outcomes (Polatajko & Davis, 2019). Thus, the occupation is an integral part of the process used by the client and family to identify the most effective solution for themselves.Although ASI intervention allocates most of its dose to sensory activities, it also requires intervention activities that target therapist–child communication, task-specific training (e.g., play practice), and parent education to bridge to performance and participation (Camarata et al., 2020). These specific intervention activities confound which ingredients are effective, putting into question what Whiting et al. (2025) attributed to ASI. In addition, the evidence does not support critical tenets of ASI theory (Spencer et al., 2011); thus, occupational therapy practitioners need to consider empirically supported theories and effective interventions, especially when addressing emotion regulation (e.g., Pandey et al., 2018).The multitiered system of supports (MTSS) framework is designed to build the capacity of teams to increase all children’s outcomes through the implementation of proven practices (Every Student Succeeds Act of 2015, Pub. L. 114-95). Whiting et al. (2025) suggested that ASI should be provided as part of the MTSS framework; however, their position is contradictory to this framework in several ways. ▪ ASI must be provided by highly trained occupational therapy practitioners; thus, it does not support capacity building of the educational team.▪ ASI requires a high dose of 3 hr/wk for ≥8 wk. As such, children would miss significant instruction and opportunities to learn, which are the leading causes of poor educational outcomes (Marcotte & Hemelt, 2008).▪ Promotion of ASI as a preferred school-based intervention has the potential to intensify and increase stakeholder expectations to receive pull-out services that use impairment-based, bottom-up approaches (Wintle et al., 2017).▪ ASI is provided outside of the classroom in specialized gyms, although legislation and evidence-based practice call for contextualized service delivery (Individuals With Disabilities Education Improvement Act of 2004 [Pub. L. 108-446]; Wintle et al., 2017).▪ ASI assumes that learning is readily transferred and generalized to new contexts and new occupations, respectively. The evidence for transfer/generalization to increase academic skills (i.e., distal skills as defined in the Every Student Succeeds Act of 2015 [Pub. L. 114-95]) remains sparse (Novak & Honan, 2019; Schaaf et al., 2018). According to Schaaf et al.’s (2018) systematic review, ASI transfer/generalization to proximal skills (i.e., self-care, play, reported goal attainment scaling goals) has been shown to be weak and rarely demonstrated without caveats (Ouellet et al., 2021).Because Whiting et al. (2025) advocated the use of a specific intervention, it is critically important that the authors report their personal and financial interests. Each of the coauthors is a strong advocate of ASI, which may result in impartiality and lack of objectivity on its use in schools, especially because several of the article’s authors have reported extensive conflicts of interest in other journals (e.g., Frontiers in Integrative Neuroscience; Schoen et al., 2022). At a minimum, Whiting et al. (2025) must add a statement noting their conflict of interest.

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