Response: Commentary: Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis

1 STAR Institute for Sensory Processing, Centennial, CO, United States, 2 Rocky Mountain University of Health Professions, Provo, UT, United States, 3 Jefferson Autism Center of Excellence, Thomas Jefferson University School of Rehabilitation Sciences and Department of Occupational Therapy, Philadelphia, PA, United States, Department of Occupational Therapy, Colorado State University College of Health and Human Sciences, Fort Collins, CO, United States, 5 TMB Education, LLC, Norristown, PA, United States, 6 Institute of Occupational Therapy Education, Widener University, Chester, PA, United States, University of New Mexico, Albuquerque, NM, United States, Collaborative for Leadership in Ayres Sensory Integration, Aliso Viejo, CA, United States


INTRODUCTION
As experts in the field of sensory integration, we were eager to read Camarata et al.'s paper Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis. Accurate representation of sensory integration and its effectiveness are essential for consumers and researchers, as this will provide a clear and useful path forward. Unfortunately, this manuscript misrepresents current evidence, which will add confusion, rather than clarity to the science. The authors have inaccurately characterized the intervention components, employed language not used in the field, and proposed an inappropriate framework for systematic testing. They advocate for fair trials that are inconsistent with the theory of change presented and include outcomes irrelevant to the intervention. Below, we highlight some of the main areas in which Camarata et al.'s review falls short of an accurate analysis and why their suggested next steps neglect to build on the existing evidence base.

EVALUATION OF THE EVIDENCE
Ayres Sensory Integration R (ASI) is a multifaceted, complex theory and intervention approach. The core elements of ASI are active engagement of the child in individually tailored sensory motor activities, contextualized in play, at the "just right" challenge in a therapeutic alliance. The desired outcomes of ASI are improved processing and integration of sensation to enable adaptive responses that support meaningful engagement in everyday life activities.
The term Ayres Sensory Integration R was registered specifically to distinguish it from other sensory-based protocols/ procedures or intervention (SBIs) (Smith Roley et al., 2007). Unfortunately, Camarata and colleagues inappropriately combined evidence for ASI R with that of other sensory-based interventions such as sensory diets, and single domain sensory protocols. These sensory-based interventions are restricted protocols conducted by caregivers or school personnel designed to target specific sensory symptoms (Case-Smith et al., 2015). While they utilize sensory input, the application of these interventions is inconsistent with the core elements of ASI.
Importantly, the ASI R Fidelity Measure (Parham et al., 2007(Parham et al., , 2011May-Benson et al., 2014) details the core elements of ASI and explicates the essential features of this approach. This validated tool guides clinicians and researchers to distinguish ASI from sensory-based protocols. When evaluating the evidence from individual studies or systematic reviews, the ASI Fidelity Measure (Case-Smith et al., 2015;Bundy and Lane, 2020) should be used to distinguish studies of ASI intervention from other sensory interventions. Failure to use this tool to distinguish studies is a major flaw in Camarata et al.'s paper. In short, their finding of "mixed results" for sensory integration interventions does not reflect the current state of knowledge/evidence about ASI (Schaaf et al., 2018;Schoen et al., 2019;Steinbrenner et al., 2020;Hume et al., 2021). Rather, current evidence, including randomized controlled trials and single subject case studies, supports the effectiveness of ASI Pfeiffer et al., 2011;Schaaf et al., 2014;Kashefimehr et al., 2018;Schoen et al., 2018Schoen et al., , 2019Andelin et al., 2021;Omairi et al., 2022Omairi et al., , 2022.

THEORY OF CHANGE
In their discussion of theory of change as it applies to ASI, Camarata and colleagues again inaccurately represented the literature. Their models presented in Figures 1 and 3 suggest a linear progression from sensory to motor to social to behavior and from tactile stimulation to improved play to increased social learning. This is a vastly over-simplified depiction of dysfunction and intervention and an inaccurate portrayal of the processes described in ASI. ASI theory considers the complex, dynamic, multidirectional nature of sensory reception, integration, analysis and output (Schaaf and Mailloux, 2015 Chapter 1;Bundy and Lane, 2020) and is based on developmental theory of sensorimotor functions and principles of neuroplasticity.
The theory of change underpinning ASI considers the ability of the central nervous system to change, the role of active participation, interdependency of the body-centered senses and the integration of sensation from movement and the environment, all of which support planning and organizing of behavior. Engagement in a trusting/safe relationship (i.e., a therapeutic alliance) is critical to the theory of change in ASI (Lane and Schaaf, 2010;Reynolds et al., 2010;Kilroy et al., 2019;Lane et al., 2019).
In short, ASI involves active engagement of child and therapist in a therapeutic relationship. The interactive social components of this alliance require collaboration and communication that are essential to the intervention. Separating these therapeutic components from the sensorymotor activities, as Camarata et al. suggested, is not possible in the ASI approach. While, it is possible to deliver sensorybased activities without verbal/nonverbal transactions, this type of modification is inconsistent with the active ingredients of ASI. Nonetheless, a randomized controlled trial comparing conversational recasting to ASI might be a viable means of examining differences in outcomes between these differing approaches.

OUTCOMES: CONDUCTING FAIR TRIALS
ASI is a well-established, complex, sensory motor intervention that is individually tailored to the needs of each child and family . The content of intervention is based on a comprehensive assessment of sensory integration and the outcomes are improved participation in daily life activities and tasks. The ultimate goal is improved quality of life of children and their families characterized by improved function and participation in daily activities, roles, and routines (Schaaf et al., 2011Ismael et al., 2018;Schaaf and Mailloux in Bundy and Lane, 2020). A professional, most commonly an occupational therapist, with advanced training in the theory and approach is the interventionist (Steinbrenner et al., 2020).
Implementation of ASI considers both proximal and distal outcomes. Distal outcomes are skills, abilities and behaviors expected to change as a result of intervention often without being directly targeted, while proximal outcomes are the underlying sensory-motor factors hypothesized to impact distal outcomes (Melnyk and Morrison-Beedy, 2012;. With its focus on function, distal outcomes of ASI reflect improvements in participation/functioning in daily life (e.g., completing family chores or independently performing a bath-time or bedtime routine). Proximal markers reflect change in sensory and motor factors hypothesized to underlie participation/functional challenges (e.g., improved posture, balance, sensory perception and praxis; Schaaf, 2015). The link between proximal and distal outcomes is key in ASI. Camarata and colleagues missed this important point when discussing outcome measures. They proposed multisensory integration (MSI) as a measure but failed to link this proximal outcomes to distal, participation-based outcomes. While changes in MSI might be an appropriate proximal marker for some children, the MSI measure of auditory-visual integration is not appropriate. Tactile, vestibular and proprioceptive sensory perception and integration, rather than visual and auditory perception and integration, have always been the focus of ASI (Ayres, 1972). A fair trial would include the primary sensory domains addressed within ASI, with both proximal (sensory-motor or MSI) and distal (function and participationbased) outcomes.

DISCUSSION
ASI is an evidence-based intervention comprising elements specified in the fidelity measure and effectiveness determined through measurable distal outcomes (Steinbrenner et al., 2020). We agree with the call for more research into ASI and assert there is a solid foundation of evidence upon which to build. We further suggest that the research community spend less time deconstructing existing evidence and more time conducting new research that builds on ASI's existing foundation.
As with any intervention, continued research is needed to identify the mechanisms of action, the markers of change and the populations for which the intervention is effective. However, this work must utilize appropriate interpretations of existing literature, particularly the rigorous studies published in the last decade. The literature is fraught with inaccuracies, discrepancies in terminology and misrepresentations of sensory integration as a therapeutic practice. A sophisticated analysis is needed to assure that conclusions are accurate and scientifically sound. We contend that the Camarata et al. review failed to provide an accurate representation of ASI; failed to appreciate the complex nature of the theory and intervention approach; and proposed a strategy for evaluating change that is not consistent with the theoretical tenants of ASI. Our response to this article is provided in the spirit of clarification. Our intent is to challenge scientists and clinicians to be thoughtful and systematic when designing future studies and evaluating interventions addressing sensory differences that impact function and participation.

AUTHOR CONTRIBUTIONS
SS, RS, and ZM provided substantial contributions to the conception or design of the work, or the acquisition, and analysis or interpretation of data for the work. AB, SL, TM-B, LP, and SR assisted in drafting the work or revising it critically for important intellectual content as well as providing approval for publication of the content. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.