Evaluation in Ayres Sensory Integration® (EASI) Tactile Perception Tests: Construct Validity and Internal Reliability.

IMPORTANCE: Assessment of tactile perception is foundational for addressing aspects of occupational performance. OBJECTIVE: To evaluate the construct validity and internal reliability of four new tactile perception tests. DESIGN: Causal comparative groups design. SETTINGS: Homes, schools, and therapy practices across the United States. PARTICIPANTS: Children ages 3 to 12 yr: typically developing (n = 174) and those with sensory integration concerns (n = 153). OUTCOMES AND MEASURES: Rasch analyses to evaluate construct validity; analysis of covariance to evaluate group differences. RESULTS: The Rasch model confirmed evidence of construct validity for each of the four tests. The typically developing group scored significantly higher than the clinical group on all tests (η2p = .040-.105, p < .001). Person reliability indices and strata indicated moderate to strong internal reliability (Rasch person reliability indices = .69-.87; strata = 2.33-3.82). CONCLUSIONS AND RELEVANCE: The Evaluation in Ayres Sensory Integration® (EASI) Tactile Perception Tests are reliable and valid measures for assessing tactile perception in children ages 3 to 12 yr. Findings suggest that these tests are likely to be clinically useful and appropriate for children in this age range and may provide critical information regarding underlying sensory functions necessary for optimal occupational performance. What This Article Adds: This article provides data supporting the reliability and validity of the EASI Tactile Perception Tests in a U.S. SAMPLE: These assessments can be used by therapists trained in their administration to assess tactile functions that may affect participation in activities, tasks, and occupations.

Evaluation in Ayres Sensory Integration® Praxis Tests: Construct Validity and Internal Reliability.

IMPORTANCE: Assessment of praxis using valid and reliable measures is important for understanding factors affecting occupational participation. OBJECTIVE: To evaluate evidence of construct validity and internal reliability of data gathered with four newly developed praxis tests. DESIGN: Comparative descriptive design. SETTING: Homes, schools, and therapy practices across the United States. PARTICIPANTS: A control group consisting of 163 children without any concerns or diagnoses and a case group of 145 children with sensory integration difficulties, ages 3 to 12 yr. OUTCOMES AND MEASURES: Rasch analyses to evaluate construct validity, and Student's t tests to evaluate group differences. RESULTS: Total test scores and most item scores conformed to Rasch model expectations. Group differences were significant; the control group scored higher. Internal reliability was strong. CONCLUSIONS AND RELEVANCE: Findings support the validity and internal reliability of the four praxis tests. What This Article Adds: This study adds to the growing body of evidence for validity and reliability of the Evaluation in Ayres Sensory Integration® tests.

Evaluation of MealSense©: A Sensory Integration-Based Feeding Support Program for Parents.

IMPORTANCE: Children with autism spectrum disorder (ASD) often experience feeding challenges related to difficulties with sensory integration. OBJECTIVE: To evaluate the content, acceptability, and usefulness of MealSense©, an online parent education program for children with ASD who have feeding challenges related to poor sensory integration. DESIGN: A descriptive study in which experts reviewed and rated MealSense content for consistency with Ayres Sensory Integration® (ASI) principles and evidence-based practices in feeding. PARTICIPANTS: A convenience sample of expert reviewers (n = 5) and parents of children with ASD and feeding challenges (n = 5). RESULTS: Expert ratings (n = 5) met criteria showing that MealSense is consistent with ASI and evidence-based practices in feeding. Parent ratings (n = 5) met criteria showing that MealSense is acceptable and useful. CONCLUSIONS AND RELEVANCE: MealSense is acceptable and useful to parents of children with ASD and is consistent with ASI and evidence-based practices in feeding. What This Article Adds: This study provides preliminary support for MealSense as an evidence-based tool to supplement direct intervention for children with ASD and feeding difficulties. Further research is needed to determine its efficacy in improving the transfer of feeding skills into the home environment.

Occupational Therapy Using Ayres Sensory Integration®: A Randomized Controlled Trial in Brazil.

IMPORTANCE: Research conducted in the United States has found that occupational therapy using Ayres Sensory Integration® is an effective evidence-based intervention for children with autism spectrum disorder (ASD). Replication of this research in other cultures is needed. OBJECTIVE: To evaluate the outcomes of occupational therapy using Ayres Sensory Integration in a sample of Brazilian children with ASD. DESIGN: Prospective randomized controlled trial. SETTING: Occupational therapy clinic. PARTICIPANTS: Seventeen children with ASD ages 5-8 yr (n = 9 in the intervention group, n = 8 in the usual-care control group) recruited from a local hospital via flyers and word-of-mouth. Completed pretreatment characterization and baseline measurement. INTERVENTIONS: The intervention group received occupational therapy using Ayres Sensory Integration, and the control group received usual therapeutic and educational services only. OUTCOMES AND MEASURES: We conducted a pre-post assessment of self-care and socialization using the Pediatric Evaluation of Disability Inventory and individualized goal ratings. RESULTS: Participants in the intervention group scored significantly higher on outcome measures of self-care (p = .046, rb = .57), social function (p = .036, rb = .61), and parent-identified goal attainment (p < .001, rb = .94) compared with the control group. CONCLUSIONS AND RELEVANCE: Occupational therapy using Ayres Sensory Integration was effective in enhancing self-care, socialization, and goal attainment for children with ASD in a Brazilian cohort. What This Article Adds: This study contributes further support from outside the United States that occupational therapy using Ayres Sensory Integration is an effective evidence-based intervention to improve self-care, socialization, and parent-identified goal attainment in children with ASD.

A Parent Guidebook for Occupational Therapy Using Ayres Sensory Integration®.

IMPORTANCE: Occupational therapy using Ayres Sensory Integration® (ASI) is an evidence-based intervention that includes parent education and participation to support outcomes. However, guidelines for this parent component have not been published. OBJECTIVE: To obtain input from stakeholders on a revised guidebook for parent education during ASI intervention. DESIGN: Cross-sectional survey design. SETTING: Online surveys. PARTICIPANTS: Experts in ASI, occupational therapy practitioners who use this approach, and parents of children with autism who received occupational therapy using this intervention. OUTCOMES AND MEASURES: Surveys designed and vetted to obtain input on content and usability. RESULTS: Experts rated the guidebook as consistent with ASI principles, practitioners rated it as clinically useful, and parents rated it as useful and clear. CONCLUSIONS AND RELEVANCE: The parent guidebook for ASI is ready for further testing and use. What This Article Adds: This report adds knowledge translation and best practice strategies in parent education to the parent guidebook for ASI and provides evidence that it is acceptable by experts, parents, and clinicians.

EASI Praxis Tests: Age Trends and Internal Consistency.

IMPORTANCE: Ayres Sensory Integration® is an evidence-based practice that requires a comprehensive assessment before intervention. The Evaluation in Ayres Sensory Integration (EASI) is intended for this purpose, and psychometric data are needed to determine its validity and reliability. OBJECTIVE: To evaluate the internal consistency of four EASI Praxis tests and their validity as developmental measures. DESIGN: Cross-sectional developmental design. SETTING: Participants' homes. PARTICIPANTS: Typically developing children and young adolescents, ages 6 to 12 yr (N = 234). Outcomes and Measures: We analyzed four EASI Praxis tests using Cronbach's α, Pearson correlation coefficients, and one-way analysis of variance to explore internal consistency and developmental trends. RESULTS: The findings indicate moderate to high internal consistency for all tests. Significant correlations between age and praxis scores indicate that the EASI Praxis tests are sensitive to developmental changes. CONCLUSIONS AND RELEVANCE: Occupational therapists can have confidence in the internal consistency and sensitivity to developmental changes of these praxis scores through early adolescence. What This Article Adds: Occupational therapists administering EASI Praxis tests can have confidence that they consistently measure praxis ability and are sensitive to developmental changes across ages 6 to 12 yr. The results suggest that praxis continues to develop into early adolescence, and adolescents may benefit from assessment and intervention targeting praxis ability.

Evaluation in Ayres Sensory Integration® (EASI) Vestibular and Proprioceptive Tests: Construct Validity and Internal Reliability.

IMPORTANCE: Vestibular and proprioceptive functions play a critical role in occupational performance and participation. Assessment of these functions in a reliable and valid manner is part of a comprehensive assessment in the Ayres Sensory Integration® frame of reference, commonly applied in pediatric occupational therapy. OBJECTIVE: To report on reliability and validity of six tests of vestibular and proprioceptive functions of the Evaluation in Ayres Sensory Integration (EASI). DESIGN: We used Rasch analyses to examine and modify the number of items and scoring categories on the six tests and known-groups analysis to examine group differences. We evaluated internal consistency using Cronbach's α and Rasch person reliability. PARTICIPANTS: The sample contained typically developing children (n = 150) and children with sensory integration concerns (n = 84); all participated voluntarily. Outcomes and Measures: The EASI is used to measure sensory and motor functions in children ages 3 to 12 yr. The six tests of vestibular and proprioceptive functions were analyzed in this study. RESULTS: Data from >96% of items conformed to the expectations of the model. We found statistically significant group differences (ps < .001-.128; ds = 0.20-1.31), with the typically developing children group scoring significantly higher on all but one test, and moderate to strong evidence of internal consistency (Rasch person-reliability indices ≥ 0.80; strata > 3) for five of six tests. CONCLUSIONS AND RELEVANCE: The EASI vestibular and proprioceptive tests have strong construct validity and internal reliability, indicating that they are psychometrically sound clinical measures. What This Article Adds: The development of occupational therapy assessments with strong psychometric properties, such as the EASI tests of vestibular and proprioceptive functions, enhances clinical practice and research by elucidating the factors affecting participation in accurate and dependable ways so that occupational therapy interventions can be focused and effective.

Cultural Adaptation of the Evaluation in Ayres Sensory Integration® (EASI) for Spanish-Speaking Populations.

IMPORTANCE: Spanish-speaking populations represent a significant percentage of occupational therapy clientele globally. Culturally appropriate Spanish translations of assessments are therefore imperative. This study describes the process of a culturally adapted translation of a set of tests for use with Spanish-speaking pediatric populations. OBJECTIVE: To produce a culturally adapted Spanish translation of the Evaluation in Ayres Sensory Integration® (EASI) for international use. METHOD: We used cultural adaptation methodology that included direct and back translations of the EASI by bilingual translators and interviews with pediatric occupational therapists and children ages 3-6 yr from Spain. Linguistic experts helped revise the translations, and pediatric occupational therapy leaders in five Spanish-speaking North and South American countries reviewed the translations for comprehensibility and cultural appropriateness. RESULTS: Back translations demonstrated equivalence with the original EASI tests except for a few test instructions and scoring criteria. Interviews with occupational therapists and children in Spain revealed some comprehension difficulties for several tests, which were revised in consultation with a linguistic expert. Additional adaptations were made on the basis of recommendations to address cultural differences by occupational therapy leaders from five North and South American countries. Most changes in wording were made in one EASI test (Praxis: Following Directions) that is heavily dependent on language comprehension. CONCLUSIONS AND RELEVANCE: We used currently recommended methodologies to develop and adapt a Spanish translation of the EASI for use across diverse cultures. What This Article Adds: A Spanish translation of the EASI has been developed for use in culturally diverse Spanish-speaking countries around the world.

Introduction to the Evaluation in Ayres Sensory Integration® (EASI).

Comprehensive, reliable, and valid assessment is essential for individually tailored, appropriate, and effective intervention planning and implementation. Research, education, and practice using an Ayres Sensory Integration® (ASI) approach have a long history of prioritizing comprehensive assessment. To meet the need for a set of tests that will fully evaluate the constructs of ASI with psychometrically strong, internationally appropriate, and easily accessible measurement tools, the development of the Evaluation in Ayres Sensory Integration® (EASI) has been initiated. This article introduces the EASI, describes the overarching plan for its development, and reports the results of promising preliminary analyses of discriminative validity data.

Application of Data-Driven Decision Making Using Ayres Sensory Integration(®) With a Child With Autism.

Health care and educational legislation and policy require that clinicians demonstrate, using measurement and report of outcomes, accountability for services rendered. Clinical algorithms have been developed and are used by various health care professionals to assist with hypothesis generation and systematic clinical reasoning; however, they do not explicitly guide measurement of outcomes as part of the reasoning process. Schaaf and colleagues developed the Data-Driven Decision Making (DDDM) process to address the greater need for outcome measurement, systematically support decision making, target intervention more precisely, and measure and document outcomes. This article describes the application of the DDDM process with a child with ASD who received occupational therapy using Ayres Sensory Integration(®).

State of the Science: A Roadmap for Research in Sensory Integration.

This article builds on the work of Case-Smith and colleagues and proposes a roadmap to guide future research in occupational therapy. To foster best practice in the application of principles and practices of sensory integration (SI), the pillars of practice, advocacy, and education are identified as elements that provide the foundation for research. Each pillar ensures that SI research is conducted in a rigorous and relevant manner. To this end, achievements to date are discussed, with proposed goals presented for each pillar. Finally, the roadmap builds on the pillars and outlines implications for occupational therapy with the overarching theme that a wide array of scientists, educators, therapists, and service recipients will be needed to ensure that those who may benefit most have access to intervention that is evidence based, theory driven, and provided within the highest standards of service delivery.

Interrater reliability and discriminative validity of the structural elements of the Ayres Sensory Integration Fidelity Measure.

This study examined the reliability and validity of the structural section of the Ayres Sensory Integration® Fidelity Measure© (ASIFM), which provides a method for monitoring the extent to which an intervention was implemented as conceptualized in studies of occupational therapy using sensory integration intervention methods (OT-SI). We examined the structural elements of the measure, including content of assessment reports, availability of specific equipment and adequate space, safety monitoring, and integration of communication with parents and other team members, such as collaborative goal setting with parents or family and teacher education, into the intervention program. Analysis of self-report ratings by 259 occupational therapists from 185 different facilities indicated that the structural section of the ASIFM has acceptable interrater reliability (r ≥ .82) and significantly differentiates between settings in which therapists reportedly do and do not practice OT-SI (p < .001).

Modification of the postrotary nystagmus test for evaluating young children.

This article explores the use of the postrotary nystagmus (PRN) test for children younger than current norms (children 4.0 yr-8.11 yr). In the first study, 37 children ages 4-9 yr were examined in the standard testing position and in an adult-held adapted position to determine whether holding a child affected the reflex. Because the position did not affect the reflex, in the second study, PRN in 44 children ages 2 mo-47 mo was compared with published normative mean raw scores for 44 children age 5 yr to determine whether norms for older children were applicable to younger children. No statistically significant differences were found between <4-yr-old and 5-yr-old children, suggesting that the PRN test can be used in infants and toddlers with valid comparison to current norms for 4-yr-olds on the Sensory Integration and Praxis Tests (4.0 yr-8.11 yr). Future research exploring the predictive value of this measure is warranted.

Sensory integration functions of children with cochlear implants.

OBJECTIVE. We investigated sensory integration (SI) function in children with cochlear implants (CIs). METHOD. We analyzed deidentified records from 49 children ages 7 mo to 83 mo with CIs. Records included Sensory Integration and Praxis Tests (SIPT), Sensory Processing Measure (SPM), Sensory Profile (SP), Developmental Profile 3 (DP-3), and Peabody Developmental Motor Scales (PDMS), with scores depending on participants' ages. We compared scores with normative population mean scores and with previously identified patterns of SI dysfunction. RESULTS. One-sample t tests revealed significant differences between children with CIs and the normative population on the majority of the SIPT items associated with the vestibular and proprioceptive bilateral integration and sequencing (VPBIS) pattern. Available scores for children with CIs on the SPM, SP, DP-3, and PDMS indicated generally typical ratings. CONCLUSION. SIPT scores in a sample of children with CIs reflected the VPBIS pattern of SI dysfunction, demonstrating the need for further examination of SI functions in children with CIs during occupational therapy assessment and intervention planning.

State of measurement in occupational therapy using sensory integration.

This article presents the current state of measurement in the area of sensory integration within the field of occupational therapy in three areas: (1) phenotypic characterization, (2) intervention adherence and dosage, and (3) outcome measurement. The need for additional measurement tools in all three areas is addressed. In regard to outcome measurement of occupational therapy using sensory integration, the use of both qualitative and quantitative methods to obtain outcome data is recommended. Further, a strategy is recommended for obtaining outcome data from direct report from the child or other stakeholder.

Sensory Phenotypes in Autism: Making a Case for the Inclusion of Sensory Integration Functions.

Sensory features are part of the diagnostic criteria for autism and include sensory hypo/hyper reactivity and unusual sensory interest; however, additional sensory differences, namely differences in sensory integration, have not been routinely explored. This study characterized sensory integration differences in a cohort of children (n = 93) with a confirmed diagnosis of autism (5-9 years) using a standardized, norm-referenced battery. Mean z scores, autism diagnostic scores, and IQ are reported. Participants showed substantial deficits in tactile perception, praxis, balance, visual perception, and visual-motor skills. Relationship with autism diagnostic test scores were weak or absent. Findings suggest additional sensory difficulties that are not typically assessed or considered when characterizing sensory features in autism. These data have implications for a greater understanding of the sensory features in the autism phenotype and the development of personalized treatments.

Examining the Latent Structure and Correlates of Sensory Reactivity in Autism: A Multi-site Integrative Data Analysis by the Autism Sensory Research Consortium.

Background Differences in responding to sensory stimuli, including sensory hyperreactivity (HYPER), hyporeactivity (HYPO), and sensory seeking (SEEK) have been observed in autistic individuals across sensory modalities, but few studies have examined the structure of these "supra-modal" traits in the autistic population. Methods Leveraging a combined sample of 3,868 autistic youth drawn from 12 distinct data sources (ages 3-18 years and representing the full range of cognitive ability), the current study used modern psychometric and meta-analytic techniques to interrogate the latent structure and correlates of caregiver-reported HYPER, HYPO, and SEEK within and across sensory modalities. Bifactor statistical indices were used to both evaluate the strength of a "general response pattern" factor for each supra-modal construct and determine the added value of "modality-specific response pattern" scores (e.g., Visual HYPER). Bayesian random-effects integrative data analysis models were used to examine the clinical and demographic correlates of all interpretable HYPER, HYPO and SEEK (sub)constructs. Results All modality-specific HYPER subconstructs could be reliably and validly measured, whereas certain modality-specific HYPO and SEEK subconstructs were psychometrically inadequate when measured using existing items. Bifactor analyses unambiguously supported the validity of a supra-modal HYPER construct (ω H = .800), whereas a coherent supra-modal HYPO construct was not supported (ω H = .611), and supra-modal SEEK models suggested a more limited version of the construct that excluded some sensory modalities (ω H = .799; 4/7 modalities). Within each sensory construct, modality-specific subscales demonstrated substantial added value beyond the supra-modal score. Meta-analytic correlations varied by construct, although sensory features tended to correlate most strongly with other domains of core autism features and co-occurring psychiatric symptoms. Certain subconstructs within the HYPO and SEEK domains were also associated with lower adaptive behavior scores. Limitations: Conclusions may not be generalizable beyond the specific pool of items used in the current study, which was limited to parent-report of observable behaviors and excluded multisensory items that reflect many "real-world" sensory experiences. Conclusion Psychometric issues may limit the degree to which some measures of supra-modal HYPO/SEEK can be interpreted. Depending on the research question at hand, modality-specific response pattern scores may represent a valid alternative method of characterizing sensory reactivity in autism.

Examining the latent structure and correlates of sensory reactivity in autism: a multi-site integrative data analysis by the autism sensory research consortium.

BACKGROUND: Differences in responding to sensory stimuli, including sensory hyperreactivity (HYPER), hyporeactivity (HYPO), and sensory seeking (SEEK) have been observed in autistic individuals across sensory modalities, but few studies have examined the structure of these "supra-modal" traits in the autistic population. METHODS: Leveraging a combined sample of 3868 autistic youth drawn from 12 distinct data sources (ages 3-18 years and representing the full range of cognitive ability), the current study used modern psychometric and meta-analytic techniques to interrogate the latent structure and correlates of caregiver-reported HYPER, HYPO, and SEEK within and across sensory modalities. Bifactor statistical indices were used to both evaluate the strength of a "general response pattern" factor for each supra-modal construct and determine the added value of "modality-specific response pattern" scores (e.g., Visual HYPER). Bayesian random-effects integrative data analysis models were used to examine the clinical and demographic correlates of all interpretable HYPER, HYPO, and SEEK (sub)constructs. RESULTS: All modality-specific HYPER subconstructs could be reliably and validly measured, whereas certain modality-specific HYPO and SEEK subconstructs were psychometrically inadequate when measured using existing items. Bifactor analyses supported the validity of a supra-modal HYPER construct (ωH = .800) but not a supra-modal HYPO construct (ωH = .653), and supra-modal SEEK models suggested a more limited version of the construct that excluded some sensory modalities (ωH = .800; 4/7 modalities). Modality-specific subscales demonstrated significant added value for all response patterns. Meta-analytic correlations varied by construct, although sensory features tended to correlate most with other domains of core autism features and co-occurring psychiatric symptoms (with general HYPER and speech HYPO demonstrating the largest numbers of practically significant correlations). LIMITATIONS: Conclusions may not be generalizable beyond the specific pool of items used in the current study, which was limited to caregiver report of observable behaviors and excluded multisensory items that reflect many "real-world" sensory experiences. CONCLUSION: Of the three sensory response patterns, only HYPER demonstrated sufficient evidence for valid interpretation at the supra-modal level, whereas supra-modal HYPO/SEEK constructs demonstrated substantial psychometric limitations. For clinicians and researchers seeking to characterize sensory reactivity in autism, modality-specific response pattern scores may represent viable alternatives that overcome many of these limitations.

Verification and clarification of patterns of sensory integrative dysfunction.

Building on established relationships between the constructs of sensory integration in typical and special needs populations, in this retrospective study we examined patterns of sensory integrative dysfunction in 273 children ages 4-9 who had received occupational therapy evaluations in two private practice settings. Test results on the Sensory Integration and Praxis Tests, portions of the Sensory Processing Measure representing tactile overresponsiveness, and parent report of attention and activity level were included in the analyses. Exploratory factor analysis identified patterns similar to those found in early studies by Ayres (1965, 1966a, 1966b, 1969, 1972b, 1977, & 1989), namely Visuodyspraxia and Somatodyspraxia, Vestibular and Proprioceptive Bilateral Integration and Sequencing, Tactile and Visual Discrimination, and Tactile Defensiveness and Attention. Findings reinforce associations between constructs of sensory integration and assist with understanding sensory integration disorders that may affect childhood occupation. Limitations include the potential for subjective interpretation in factor analysis and inability to adjust measures available in charts in a retrospective research.

Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration intervention.

OBJECTIVE: We developed a reliable and valid fidelity measure for use in research on Ayres Sensory Integration (ASI) intervention. METHOD: We designed a fidelity instrument to measure structural and process aspects of ASI intervention. Because scoring of process involves subjectivity, we conducted a series of reliability and validity studies on the process section. Raters were trained to score therapist strategies observed in video recordings of adult-child dyads. We examined content validity through expert ratings. RESULTS: Reliability of the process section was strong for total fidelity score (ICC = .99, Cronbach's alpha = .99) and acceptable for most items. Total score significantly differentiated ASI from four alternative interventions. Expert ratings indicated strong agreement that items in the structural and process sections represent ASI intervention. CONCLUSION. The Ayres Sensory Integration Fidelity Measure has strong content validity. The process section is reliable and valid when scored by trained raters with expertise in ASI.