Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

ORIGINAL ARTICLE

Adherence to the Ayres Sensory Integration® Fidelity Measures:

Malaysian Occupational Therapists’ Practices
Farah Samsu Rahman, Masne Kadar, Dzalani Harun
Centre for Rehabilitation & Special Needs Studies, Occupational Therapy Programme, Faculty of Health Sciences, Universiti
Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Wilayah Persekutuan Kuala Lumpur, Malaysia.

ABSTRACT

Introduction: A popular intervention for paediatric clients, Ayres Sensory Integration® (ASI) must adhere to sensory
integration (SI) fidelity. This study describes fidelity adherence in ASI intervention by occupational therapy practi-
tioners in Malaysia. Methods: A questionnaire on ASI fidelity was developed before being tested for its validity by sev-
en experts and for its internal consistency and test-retest reliability by 30 occupational therapists. The questionnaire
was then used nationally to collect data on ASI practitioners. Data were collected from 161 occupational therapists
working in various settings. Results: The mean of the sub-scales I-CVI was excellent, ranging between 0.97 and 1.00.
The total S-CVI/Ave of the form was also reported as excellent, at 0.98, with subscales S-CVI ranging between 0.75
and 1.00. Cronbach’s alpha was 0.80 for the questionnaire’s internal consistency and the ICC for test-retest reliability
ranged from 0.80 to 0.95. The survey received 161 responses, indicating that most respondents perceived themselves
as having ‘moderate competence’ and showing ‘high interest’ in ASI implementation. Most fidelity aspects were
addressed in their practices. Majority of the respondents adhered to the process elements. It was indicated that three
aspects of physical space under the structural elements could not be provided by most occupational therapists in the
study. Conclusion: To implement evidence-based practice, adherence to fidelity when providing ASI is important to
ascertain its effectiveness. Improvements to ensure optimal space, ASI certification, and more related training are the
first steps that can be taken by the related agencies to ensure effective ASI intervention could be delivered.
Malaysian Journal of Medicine and Health Sciences (2023) 19(2):76-85. doi:10.47836/mjmhs19.2.13

Keywords: Ayres sensory integration®, Fidelity measures, Sensory processing issues, Occupational therapy interven-
tion

Corresponding Author: the years, many research studies have contributed

Masne Kadar, PhD evidence of this intervention’s effectiveness (1, 4-8),
Email: masne_kadar@ukm.edu.my especially for those with sensory processing issues and
Tel: +603-92897628 ASD. ASI is often used in occupational therapy practices,
and the increasing number of studies on this approach
INTRODUCTION since 2004 have established strong evidence for its use
in clinical practice (9).
Occupational therapy is one of the paediatric healthcare
services (1) in which sensory integration is a popularly Sensory integration theory postulates that the ability
requested intervention; this is widely used for children of the brain to process and integrate various sensory
with Autism Spectrum Disorder (ASD) (2). The sensory stimuli effectively is the foundation for successful
integration approach refers to the concept and theory adaptive behaviour (3, 10). The study by Schaaf and
developed by Dr A. Jean Ayres (3). Dr Ayres (18 July 1920 Mailloux (11) explained the sensory integration process
to 16 December 1988) was an occupational therapist as the coordinated interaction of various sensory
and neuropsychologist involved in numerous research systems, such as the vestibular (balance and movement),
projects throughout her career (3). She conducted proprioceptive (joint sense), tactile (touch), visual (sight),
various studies pertaining to sensory integration, and she auditory (hearing), gustatory (taste), and olfactory (smell)
developed sensory integration theory and various related systems. The sensory integration approach focuses on
assessment tools (i.e., the Southern California Sensory the sensory-motor functions that affect one’s behaviours,
Integration Tests (SCSIT) in 1975, the Sensory Integration developmental and learning skills, and engagement and
Praxis Test (SIPT) in 1989 (3), and the sensory integration active participation in activities.
intervention in 1972, which is now trademarked as the
Ayres Sensory Integration® (ASI) intervention (4). Over The sensory integration approach differs from

Mal J Med Health Sci 19(2): 76-85, March 2023 76

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

intervention using sensory-based approaches as it must ASI intervention adhere to the structural and process
adhere strictly to its core principles, i.e., the process and elements to provide comprehensive evaluations,
structural elements (12). These elements are the essential deliver intervention safely in an adequately equipped
features of the fidelity tool, demonstrating its adherence space, and collaborate actively with family and other
to the theory and practice of ASI (11). During sensory professionals (13). Compliance to ASI intervention
integration sessions, the process elements ensure that fidelity measures should ensure accurate documentation
the important aspects of therapist–child interaction and monitoring of the deliverables; enable duplication of
are present, such as 1) ensuring physical safety, 2) the intervention, especially in a randomised controlled
presenting sensory opportunities, 3) maintaining trial (RCT) study; and identify the intervention as ASI,
appropriate levels of alertness, 4) challenging postural, as opposed to other types of intervention that might
ocular, oral, or bilateral motor control, 5) challenging seem similar (12). However, as with any intervention,
praxis and organisation of behaviour, 6) collaborating ASI intervention also has been criticised over the years
in activity choices, 7) tailoring activity to the present for its lack of evidence. These controversial claims can
just-right challenge, 8) ensuring that activities are only be resolved through accurate conformity to the
successful, 9) supporting the child’s intrinsic motivation properly documented ASI intervention process, which
to play, and 10) establishing a therapeutic alliance occupational therapists must take seriously. This may
(12). In comparison, the structural elements address assist in establishing evidence-based practice, based on
the intervention setting, including the qualifications of the effectiveness of the interventions.
the therapist(s) involved; the physical elements of the
environment in which intervention is provided; and the A descriptive study undertaken in 2007 found that SI
assessment process, goal setting, and interaction with intervention practised by Malaysian occupational therapy
parents (13). Implementing ASI requires a qualification practitioners in clinical settings contained elements of
following formal post-professional SI training and both the structural element of ASI intervention and the
guidance from a therapist who is trained and skilled in sensory-based intervention approach (16). However, no
SI (13). Without these two criteria, any results obtained further information from the 2007 study was available
from the Ayres Sensory Integration Fidelity Measure on the nature of the intervention delivery, such as
(ASIFM) might be compromised. However, the process the degree of adherence to the core principles of ASI
and structural elements can be used as guidance for ASI intervention practised by those practitioners and their
intervention in a clinical setting (11). challenges in practice (16). However, a more recent
study conducted by Wan Yunus et al. in 2020 provided
The sensory integration approach is highly utilised clearer guidelines on the sensory integration protocol
in occupational therapy intervention worldwide, (15). These were valuable guidelines for those in practice.
including in Malaysia (14). However, the nature or Therefore, there is a need to examine the current status
degree of adherence to the fundamental principles of SI intervention practice in the country and study its
of ASI intervention practised by those practitioners effectiveness as reported by the practitioners. Hence,
was not clearly understood. Limited published data the objective of this study was to report on the current
exist on the practice of providing sensory integration profile of adherence to ASI fidelity among occupational
intervention by occupational therapists in Malaysia. therapists in Malaysia, i.e., on the structural and
One Malaysian study indicates that the rigorousness of process elements, which are both essential in providing
the sensory integration intervention protocol might be ASI intervention. Such information could benefit the
further improved if the fidelity measurement was closely occupational therapy profession in Malaysia, especially
observed (15). However, the authors only touched in planning for services, staff training, as well as suitable
briefly on how fidelity could be ascertained. During equipment and facilities.
their occupational therapy training, occupational
therapy students/trainees in Malaysia are exposed to and MATERIALS AND METHODS
taught about the theory, frame of reference, and basic
principles of sensory intervention through a minimum Study design
of a two-credit course. This is equivalent to 80 hours This study utilised a descriptive survey methodology
of learning, that may consisting of 28 hours of direct and consisted of two phases. Phase 1 involved the
lectures, with the remaining hours used for independent development of the questionnaire used in the study
learning and assessments. Additionally, several qualified and the process of testing its validity and reliability. The
occupational therapists attend the course to gain a questionnaire was updated from a previous study (16)
deeper knowledge of this form of intervention, either and the ASI Fidelity Measure (12, 13, 17). The newly
locally or abroad. Some even take further courses to developed questionnaire was then used in Phase 2 of the
become certified trainers so they can train and counsel study to survey occupational therapists about their ASI
other professionals who wish to be trained in the field. intervention practices. These two phases are explained
accordingly.
It is important that occupational therapists who practise

77 Mal J Med Health Sci 19(2): xxxxxxx, March 2023

Phase 1 using convenience sampling. The inclusion criteria
included those who had had experience of working or
Development process of the survey instrument were currently working with a paediatric population
A new questionnaire was specifically developed for using the sensory integration approach for one year or
the current study, entitled ‘the Sensory Integration more. Those working outside Malaysia and those who
Intervention Practice Questionnaire Survey’. This was had never used the approach were excluded. Their
adapted and updated from the Sensory Integration academic qualifications were to include a diploma, a
Survey Form (an unpublished tool), originally developed bachelor’s degree, or a master’s degree in occupational
by Harun (16); it was also based on the Fidelity Measure therapy. Data were collected physically using pen
of Ayres Sensory Integration® Intervention (12, 13, 17). and paper, which was completed in a day for each
The newly developed questionnaire includes currently participant. This process provided reliability data with
used assessment tools and updated ASI intervention which to assess the internal consistency and test-retest
elements. reliability of the questionnaire, with a ten-day interval
between the first and second administration for each
The validity process of the developed questionnaire participant (20). The internal consistency data were
Validity and reliability processes were followed to only analysed based on the first administration of the
ensure the usability of the developed questionnaire. questionnaire as this was considered sufficient for the
As part of the validity process, the questionnaire was intended purpose.
first sent to seven experts. These experts included
five SI-certified occupational therapists with either Phase 2
diploma, bachelor’s, or master’s qualifications in the
occupational therapy field; one language expert with a Respondents
bachelor’s degree; and one clinical psychologist with a Using the questionnaire developed in Phase 1, a cross-
master’s degree qualification in their respective fields. sectional study was conducted to investigate the extent
The aims of sending the newly developed questionnaire to which ASI intervention practices in Malaysia adhered
to the experts were to ensure that the questionnaire’s to the fidelity measures. To be eligible for this study,
design worked in practice; to detect and modify the respondents were required to have at least one year
problematic questions; and identify issues relating to of work experience with children and/or adolescents
the layout, wording, content, length, or instructions in the provision of occupational therapy services while
in the questionnaire; this would further refine the working in government or private settings (hospitals,
questionnaire. The experts were invited to review the clinics, higher institutions, school-based) or non-
questionnaire and give their feedback, either verbal or government organisations, as well as having experience
written, on the new questionnaire. in implementing ASI. Those who were not Malaysian
citizens, were working outside Malaysia, and/or had
After improvements had been made to the questionnaire never practised ASI were ineligible for the study.
based on the experts’ recommendations and suggestions,
the questionnaire was sent to the same experts, this time A total of 550 occupational therapists were identified
for rating purposes. The experts were asked to give a as potential respondents for the study. These potential
rating to enable an evaluation of the Content Validity respondents were recruited from centres identified
Index (CVI), both on each item (I-CVI) and the scale as providing ASI services. Information about the
(S-CVI) (18) of the questionnaire in regard to three potential respondents was obtained by contacting
aspects: (1) the relevance of each question, (2) the clarity the administration officers/ managers and/or heads of
of each question, and (3) unambiguity in the intent and departments of these centres.
meaning of each question.
Data collection process
To assist with the rating process, the experts were given The data collection process started in November 2018
a form and requested to give responses based on a and ended in March 2019. Packets containing survey
four-point Likert scale from 1 (very weak/not suitable) invitation letters, information about the study, consent
to 4 (very strong/suitable) (19). The form and a copy forms, copies of the questionnaire, and stamped self-
of the developed questionnaire were distributed to the addressed return envelopes were mailed to the heads of
experts to facilitate the rating process. The experts were department/managers of the relevant centres, according
also given the option to convey their opinions or make to the number of staff available at those centres. The
suggestions regarding the developed questionnaire by heads of department/managers at the study centres were
completing the open-ended questions at the end of the asked to deliver information about the study to their
rating form. staff, as well as distribute and collect the completed
questionnaires to be returned to the researchers.
The reliability process of the questionnaire Through their head of department/manager, the
The questionnaire was then further tested on 30 occupational therapists were informed to take ample
occupational therapy practitioners, who were recruited time when considering the decision to participate in the

Mal J Med Health Sci 19(2): 76-85, March 2023 78

Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

Table III: Comparison between the demographics, laboratory param- were made to the initial questionnaire, including the
eters and clinical phenotypes of JAK2V617F, CALR and patients nega- layout of the table format, as some experts suggested
tive for both JAK2V617F and CALR mutations in this study.
that certain questions were too long and repetitive.
Parameters JAK2 Mutations JAK2/CALR neg-
(n=21) CALR (n=6) ative (n =53) Besides that, some wordings were amended to ensure
better understanding and grammatical mistakes were
Mean Hb (g/dL) 13.2 11.5 15.4
corrected. During the review process, no suggestions
Mean Haematocrit (%) 41.6 36.6 47.0 were made by the experts to omit any sub-scales or
Mean WCC (109/uL) 18.1 18.1 14.5 items in the initial questionnaire.
Mean Platelets (109/uL) 655 856 374
Gender 7 Females 5 Females 11 Females Finding from the CVI process
14 Males 1 Male 42 Males
The findings from the CVI ratings showed good to
Mean Age 59 61 54 excellent validity acceptance (22). The mean of the
LE picture on FBP 5 (23.8%) 3 (50%) 5 (9.4%) sub-scales I-CVI was excellent, ranging between 0.97
Phenotype 12 ET 3 ET 8 ET and 1.00. The total S-CVI/Ave of the instrument was
4 MF 2 MF 1 MF
5 PV 1 atypical CML 7 PV
also reported as excellent, at 0.98, with a subscales
1 MDS/MPN S-CVI range between 0.75 and 1.00. Therefore, no
36 MPN-U
items/questions needed to be removed from the initial
Ethnicity 15 Malays 1 Malay (20%) 31 Malays questionnaire.
(71%) 5 Chinese (58.5%)
6 Chinese (80%) 18 Chinese
(29%) (34%) Final development of the questionnaire
2 Burmese
(3.5%) The development of the self-administered questionnaire
1 Bangladeshi was then finalised to include three sections: a) The
(2%)
1 Indian (2%) respondents’ demographic information (gender, age,
LE: leucoerythroblastic, FBP: Full blood picture, ET: essential thrombocytosis, PV: Polycythe- race, professional qualifications, and work experience),
mia Vera, MF: myelofibrosis MDS: myelodysplastic syndrome, MPN-U: MPN-Unclassifiable.
b) the Ayres Sensory Integration® Intervention Process
Element, and c) the Ayres Sensory Integration®
study. After the occupational therapists had signed their Intervention Structural Element.
consent form, they were handed the questionnaire and
given two weeks to complete the survey. A reminder via Ten factors were evaluated under the process elements:
a telephone call to the administration office was made (1) ensuring physical safety, (2) presentation of sensory
one week after the questionnaire distribution to ensure opportunities, (3) supporting sensory modulation, (4)
acceptable response rates could be obtained (21). The facilitating postural, ocular, and bilateral integration
collected questionnaires were kept in a secure locker levels, (5) facilitating the praxis and organisation of
and could only be accessed by the researchers involved behaviour, (6) therapist-child collaboration (7) providing
in the study. just-right challenges, (8) maximising the child’s success,
(9) creating play contexts, and (10) establishing a
Ethical clearance therapeutic alliance. These ten elements were evaluated
This study was approved by the Medical Research and with regard to the therapists’ perceptions of their ‘level of
Innovation Secretariat, Universiti Kebangsaan Malaysia importance’, ‘use of the elements’, and ‘level of comfort/
(No. NN-2018-169) and the National Medical Research confidence’ in their practices.
Registration (NMRR) Ethics Committee, Ministry of
Health, Malaysia (No. NMRR-19-2441-50131 (IIR)). Meanwhile, six core structural elements were evaluated:
(1) competency and interest, (2) a safe environment, (3) a
Data analysis record review, (4) the physical space, (5) communication
The responses collected were keyed into the Statistical with parents and teachers, and (6) equipment availability.
Package for Social Sciences (SPSS) version 22 by the The questionnaire was utilised to collect data in the next
researcher involved. The data were then analysed phase of this study. The completed questionnaire can
quantitatively using the software. No missing data were be accessed from the first author upon request. The
found during this process. developed questionnaire is known as Sensory Integration
Intervention Practice Questionnaire Survey.
RESULTS
Findings from the reliability process
Phase 1 All 30 occupational therapy practitioners also
participated in the re-test process. The internal
Review and recommendations from experts consistency determined from the first test showed that
The initial questionnaire, which consisted of 17 sub- Cronbach’s alpha was 0.80, while the ICC for test-retest
scales and a total of 101 items, was further improved reliability ranged from 0.80 to 0.95, so the questionnaire
based on the experts’ opinions and suggestions. Changes demonstrated excellent test-retest reliability (23).

79 Mal J Med Health Sci 19(2): 76-85, March 2023

Phase 2 Table I: Respondents’ characteristics
Characteristics N Frequency
Response rates (percentage)

In all, 161 occupational therapists returned their Gender

Female 136 84.5%
questionnaires during the four-month data collection Male 25 15.5%
period, thus giving a valid response rate of 29.3% for Age
21-30 years old 98 60.8%
the total of 161 respondents, which can be considered 31-40 years old 54 33.5%
acceptable for a mailed survey (24). 41-50 years old 6 3.6%
More than 50 years old 3 1.8%
Race
Characteristics of the respondents Malay 127 78.9%
Chinese 10 6.2%
The results show that the gender breakdown of the Indian 8 5%
occupational therapists who took part in the study was Others 16 9.9%
Professional Qualification in occupational
84.5% female and 15.5% male. The majority of the therapy field
respondents were aged between 21 and 30 (60.8%), Diploma 99 61.5%
Bachelor 54 33.5%
and the majority were Malays (78.9%). In terms of the Master 8 5%
occupational therapists’ professional qualifications Working experience as an occupational
therapist
in occupational therapy, most were diploma holders 1-3 years 37 22.9%
(61.5%). Moreover, 29.8% of the occupational 4-6 years 51 31.7%
7-9 years 25 15.5%
therapists had more than ten years of work experience as More than 10 years 48 29.8%
occupational therapy practitioners, and 49.7% reported Experience in treating paediatric cases or
working with children
having between one and three years of experience 1-3 years 80 49.7%
in treating paediatric cases. The majority of the 4-6 years 48 29.8%
7-9 years 14 8.7%
occupational therapists worked in government hospitals More than 10 years 19 11.8%
(67.7%). Table I shows the detailed characteristics of the Years of sensory integration approach/ tech-
niques in occupational therapy service
respondents involved in the survey. 1-3 years 95 59.0%
4-6 years 31 19.3%
7-9 years 21 13.0%
With regard to the sensory integration approach/ More than 10 years 14 8.7%
techniques, 59.0% of the occupational therapists Current practice setting
Government hospital 109 67.7%
reported that they had been practising it in their OT Private clinic/centre 30 18.6%
intervention for between one and three years, 66.5% Government clinic 15 9.3%
Higher institution 4 2.5%
had gained sensory integration knowledge from School based 2 1.2%
attending courses organised by universities/colleges NGO 1 0.6%
Source of knowledge in sensory integration
(attending after graduating from occupational therapy University/college
colleges/universities), and the majority (52.2%) reported Attending courses 107 66.5%
Internet resources 75 46.6%
having received supervision from qualified professionals Books 57 35.4%
in sensory integration. However, 89.4% of them had Journals 55 34.2%
Guidance/supervision/mentor in sensory 28 17.4%
yet to acquire professional certification to become integration from qualified professional
certified sensory integration practitioners. Children and Yes 84 52.2%
No 77 47.8%
adolescents with ASD, ADHD, and global developmental Professional certification in sensory integra-
delay were reported as those most in need of sensory tion (Certified SI Practitioner)
integration intervention, whereas the Sensory Profile/ Yes 17 10.6%
No 144 89.4%
Short Sensory Profile were the assessment tool most Frequency usage of sensory integration to
commonly used by the majority of the occupational condition
Autism spectrum disorder 158 98.1%
therapists (96.3%) involved in the survey. ADHD 155 96.3%
Global developmental delay 144 89.4%
Learning disability 141 87.6%
Adherence to the process elements in ASI intervention Down’s syndrome 134 83.2%
Regarding the level of importance of the process Cerebral palsy 123 76.3%
Others 46 28.6%
elements, the majority of the occupational therapists Usage of assessments used to evaluate senso-
reported that it was very important to adhere to these ry processing/integration in clinical setting
Sensory profile/short sensory profile 155 96.3%
process elements, while the presentation of sensory Sensorimotor clinical observations 56 34.8%
opportunities, establishing a therapeutic alliance, and Sensory integration praxis test 11 6.8%
Sensory processing measure 7 4.3%
facilitating postural, ocular, and bilateral integration Others 8 4.8%
levels were the leading three elements indicated as
very important by the respondents. Meanwhile, most
respondents reported ‘always’ adhering to the use comfortable’ when practising the process elements in
of three process elements in their practice: ensuring ASI, except for the aspect of maximising the child’s
physical safety, establishing a therapeutic alliance, and successes. Details of the process elements results are
the presentation of sensory opportunities. In addition, presented in Table II.
most respondents indicated feeling ‘very confident/

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Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

Table II: Adherence to 10 core Process Elements in ASI intervention

Level of importance
Process elements Not Important Slightly Important Important Very Important
n (%) n (%) n (%) n (%)
Ensuring physical safety 2 (1.2%) 8 (5.0%) 46 (28.6%) 105 (65.2%)
Presentation of sensory opportunities 0 0 41 (25.5%) 120 (74.5%)
Supporting sensory modulation 1 (0.6%) 3 (1.9%) 56 (34.8%) 101 (62.7%)
Facilitating postural, ocular, bilateral integration level 0 1 (0.6%) 47 (29.2%) 113 (70.2%)
Facilitating praxis and organization of behaviour 0 7 (4.3%) 66 (41.0%) 88 (54.7%)
Therapist-child collaboration 0 6 (3.7%) 61 (37.9%) 94 (58.4%)
Providing just-right challenges 0 10 (6.2%) 57 (35.4%) 94 (58.4%)
Maximizing child’s success 0 3 (1.9%) 64 (39.8%) 94 (58.4%)
Creating play context 0 3 (1.9%) 61 (37.9%) 97 (60.2%)
Establishing therapeutic alliance 0 3 (1.9%) 41 (25.5%) 117 (72.7%)
Use of the elements
Process elements Never Seldom Often Always
n (%) n (%) n (%) n (%)
Ensuring physical safety 2 (1.2%) 8 (5.0%) 46 (28.6%) 105 (65.2%)
Presentation of sensory opportunities 3 (1.9%) 13 (8.1%) 62 (38.5%) 83 (51.6%)
Supporting sensory modulation 2 (1.2%) 30 (18.6%) 70 (43.5%) 59 (36.6%)
Facilitating postural, ocular, bilateral integration level 0 4 (2.5%) 80 (49.7%) 77 (47.8%)
Facilitating praxis and organization of behaviour 0 33 (20.5%) 70 (43.5%) 58 (36.0%)
Therapist-child collaboration 2 (1.2%) 26 (16.1%) 79 (49.1%) 54 (33.5%)
Providing just-right challenges 2 (1.2%) 24 (14.9%) 72 (44.7%) 63 (39.1%)
Maximizing child’s success 1 (0.6%) 25 (15.5%) 67 (41.6%) 68 (42.2%)
Creating play context 0 31 (19.3%) 69 (42.9%) 61 (37.9%)
Establishing therapeutic alliance 0 12 (7.5%) 63 (39.1%) 86 (53.4%)

Level of comfort/confidence
Process elements Not at all Slightly Very Extremely
n (%) n (%) n (%) n (%)
Ensuring physical safety 2 (1.2%) 16 (9.9%) 89 (55.3%) 54 (33.5%)
Presentation of sensory opportunities 2 (1.2%) 19 (11.8%) 89 (55.3%) 51 (31.7%)
Supporting sensory modulation 3 (1.9%) 28 (17.4%) 84 (52.2%) 46 (28.6%)
Facilitating postural, ocular, bilateral integration level 1 (0.6%) 15 (9.3%) 90 (55.9%) 55 (34.2%)
Facilitating praxis and organization of behaviour 0 36 (22.4%) 81 (50.3%) 44 (27.3%)
Therapist-child collaboration 2 (1.2%) 27 (16.8%) 91 (56.5%) 41 (25.5%)
Providing just-right challenges 2 (1.2%) 23 (14.3%) 90 (55.9%) 46 (28.6%)
Maximizing child’s success 1 (0.6%) 25 (15.5%) 78 (48.4%) 57 (35.4%)
Creating play context 0 28 (17.4%) 81 (50.3%) 52 (32.3%)
Establishing therapeutic alliance 0 18 (11.2%) 82 (50.9%) 61 (37.9%)

Adherence to the core structural elements in ASI findings from the aspect of the core structural elements
intervention practised by the respondents.
The results show that most respondents indicated that
they were ‘moderately competent’ when applying ASI DISCUSSION
intervention in their practices (59.6%) and ‘highly
interested’ in practising the intervention (75.8%). Most The fidelity measure in ASI focuses on two essential
respondents were able to provide appropriate structural elements (1) process elements and (2) structural
elements when applying ASI intervention, except for elements, which are important aspects underlying the
the provisions that no less than three hooks are used for theoretical principles and procedural guidelines in ASI
hanging suspended equipment; one or more rotational intervention. To assess this measure, a self-administered
devices are attached to a ceiling support to allow 360° questionnaire with three sections was developed in
of rotation; and one or more sets of bungee cords are on Phase 1 of the study. During the testing process, the
hanging suspended equipment under the physical space questionnaire exhibited high validity and reliability. The
aspect. Most respondents reported having 50% or more questionnaire was used in Phase 2 of the study to collect
of the equipment required to practise ASI intervention information from occupational therapists in Malaysia
in their clinical settings (64.0%). Table III details the about their practices when applying ASI intervention.

81 Mal J Med Health Sci 19(2): 76-85, March 2023

Table III: Adherence to 6 core Structural Elements in ASI intervention
1) Competency and interest Not competent/interested Moderate competent/interest Highly competent/interested
(0, 1, 2, 3) (%) (4,5,6,7) (%) (8,9,10) (%)
Competency level in applying ASI 10 (6.2%) 96 (59.6%) 55 (34.2%)
Interest level in practicing ASI 5 (3.1%) 34 (21.1%) 122 (75.8%)
2) Safe environment Able to provide Unable to provide
n (%) n (%)
Mats, cushions and pillows to pad the floor underneath all suspended equipment during 149 (92.5%) 12 (7.5%)
intervention.
Equipment is adjustable to child’s size. 99 (61.5%) 62 (38.5%)
Equipment can be easily monitored for safe used by the therapist. 139 (86.3%) 22 (13.7%)
Equipment not being used is stored, anchored, or placed at the side of the room so that 143 (88.8%) 18 (11.2%)
children would not fall or trip on it.
Routine and frequent monitoring and documentation of equipment and safety occurs 126 (78.3%) 35 (21.7%)
3) Record review
Historical information 161 (100%) 0
Current information of child’s occupational/social performance 161 (100%) 0
Assessment results 160 (99.4%) 1 (0.6%)
Goal setting when Ayres Sensory Integration is recommended 134 (83.2%) 27 (16.8%)
4) Physical space
Adequate space is available to allow vigorous physical activity. 105 (65.2%) 56 (34.8%)
Equipment and materials are flexibly arranged to allow for rapid change of the physical 119 (73.9%) 42 (26.1%)
and spatial configuration of the intervention environment.
No less than 3 hooks are used for hanging suspended equipment 73 (45.3%) 88 (54.7%)
One or more rotational devices are attached to a ceiling support to allow 360° of rota- 63 (39.1%) 98 (60.9%)
tion.
A quiet space is available 109 (67.7%) 52 (32.3%)
One or more sets of bungee cords are on hanging suspended equipment. 72 (44.7%) 89 (55.3%)
5) Communication with parents and teachers
The therapist routinely has ongoing communication/interchanges of information with the 160 (99.4%) 1 (0.6%)
child’s parents or teachers regarding the course of intervention.
The therapist routinely discusses with the parents or teachers on the influence of sensory 156 (96.9%) 5 (3.1%)
integration and praxis on the child’s performance of valued and needed activities.
The therapist routinely discusses with the parents or teachers on the influence of child’s 156 (96.9%) 5 (3.1%)
sensory integration and praxis abilities on the child’s participation at home, in school and
community
Available 50% and more (%) Available less than 50% (%)
6) Equipment availability
103 (64.0) 59 (36.0)

The majority of the occupational therapists involved in manage ASD cases. Hence, Malaysian occupational
the study practised in a hospital-based setting. The data therapists implemented SI when seeing ASD cases,
collected for this study came mostly from occupational while taking into consideration the sensory processing
therapists who had worked as occupational therapists issues. This is fairly consistent with the reports from
with children and adolescents for one to three years. the occupational therapists involved in this study that
Experience in paediatrics plays an essential part in the children and adolescents with ASD formed the group for
skill level of an occupational therapist when handling which the SI approach was the most utilised intervention
clients who need ASI intervention. Despite the need to deal with sensory processing difficulties. It has been
for certified practitioners in sensory integration, it has estimated that between 42% and 88% of individuals
been reported that limited numbers of practitioners diagnosed with ASD have difficulties related to sensory
have acquired this certification. Hence, evidence-based processing, including under- and over-responsivity (26).
practice would not be a success, and this may impact
the effectiveness of the interventions. Meanwhile, the The Sensory Profile (SP)/Short Sensory Profile (SSP) was
occupational therapists in this study reported ASD as the reported as the most frequently used assessment tool in SI,
most prevalently treated type of case in their practices. which might be due to the availability of that assessment
According to the Clinical Practice Guidelines (CPG) on over a long period (27). Interestingly, the occupational
the Management of Autism Spectrum Disorder (ASD) therapists chose this assessment tool as their leading
in Children and Adolescents developed by the Ministry choice rather than similar assessments listed in the
of Health, Malaysia in 2014 (25), sensory integration questionnaire. This might be due to the administration
intervention is listed as one of the treatments used to duration, availability, and/or practicality of possible

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Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

assessments, which may influence the occupational use of stretchy fabric is beneficial for tactile sensory
therapists’ choice of the assessment/s to use in their stimulation. However, some occupational therapists
practices. Moreover, occupational therapists may have may have limited space in which to provide suspension
more exposure to the tool, as several talks and courses equipment, especially those who work in smaller
on the SP have recently been conducted in Malaysia. departments with fewer occupational therapists. The
The only downside is that if this is the only tool used by majority of the occupational therapists who participated
occupational therapists when providing ASI intervention, in this survey were aware of the importance of having a
the assessment may not be sufficient or appropriate. complete set of SI equipment; however, reports showed
Thus, a client analysis before ASI intervention might be they were implementing ASI with limited equipment.
inaccurate because the SP/SSP had not been included This may be due to budgetary constraints and restrictions
in the test’s postural, ocular, bilateral integration and on purchasing add-on equipment for their setting, as the
praxis. However, a combination of clinical observation majority of the occupational therapists were working in
and other standardised assessments might capture more public hospitals and had to adhere strictly to purchasing
accurately the important components involved in ASI. A procedures. In comparison, occupational therapists
recent publication by Petersen et al. in 2021 indicated practising in private clinics may have greater control
that the Evaluation in Ayres Sensory Integration (EASI), a of equipment purchase and space usage than those
new and comprehensive assessment of sensory, motor, working in other settings (13). However, further study is
and praxis functions, exhibits good concurrent and needed to explore and conclude this issue.
construct validity of the vestibular and proprioceptive
tests for clinical utility in paediatric practices (28). Hence, The respondents also reported limitations in providing a
this assessment tool could be taken into consideration safe environment, like their counterparts in South Africa,
by occupational therapists when performing ASI who also reported having fewer safety measures at their
assessments during their practices. facilities (13). In contrast, occupational therapists in the
United States were reported to have higher levels of
The majority of the occupational therapists emphasised safety monitoring (13). These differences may reflect a
the necessity of practising in accordance with all the lack of understanding of the significance of systematic
process elements in SI, as they described ASI fidelity safety monitoring and inadequate choices regarding
by indicating that it was either ‘slightly important’, the types of affordable equipment. These deficiencies
‘important’, or ‘very important. Parham et al. (12) could be resolved at individual facilities by determining
reported that the structural and process sections of ASI safety monitoring procedures and increasing the types
fidelity precisely signify the important features of the of equipment available. It may be necessary to design
ASI intervention. The instrument is responsive to the and construct inexpensive equipment that can be used
dynamic therapy process that distinguishes ASI from functionally in some settings. Cultural differences would
other interventions. Its unique and essential elements be reflected in education levels and potentially the
differentiate SI from other sensory-based interventions availability of mentoring.
and other interventions in general. It is important to
correctly define SI using specific fidelity as the first The effectiveness of the intervention provided might
step to evaluating evidence of intervention (1). Recent be affected due to the limited number of practitioners
systematic reviews have also highlighted the importance who have acquired ASI certification. It is suggested
of correct SI definition (1, 4). Poorly defined intervention that training for ASI certification should be taken
may change the research/study results, thus providing by practitioners to improve the current practice in
irrelevant research evidence. Malaysia. Meanwhile, considering sharing the resources
and training offered by certified practitioners during
However, according to the occupational therapists training may develop deeper levels of understanding
involved in this study, there is evidence of discrepancies of ASI intervention among practitioners yet to obtain
in the adherence to structural elements when their certification. This may help them to improve their
implementing ASI. This applied to one of the ASI understanding of the fidelity measures needed. The
fidelity structural elements outlined by May-Benson et higher and relevant authorities, on the other hand, could
al.: the physical elements of the environment in which invite certified personnel to be consultants and actively
intervention is provided distinguish this intervention involved in room setting planning to ensure the fidelity
from others (13). The physical space component and the measures are properly addressed.
equipment currently available at the setting were less
strongly adhered to, as reported by the occupational One limitation of this study is the representation in the
therapists involved in this study. It is crucial to have sample, with a majority of the occupational therapists
suspension equipment to implement SI, specifically involved working in hospital settings. There may have
when targeting vestibular sensory processing in children. been social desirability when reporting their facilities.
Specific sensory techniques are frequently incorporated For future research, representation could be improved
into ASI intervention to support a child’s performance by widening the settings, as well as performing direct
during the intervention sessions (12). For example, the observation of the practices and settings rather than

83 Mal J Med Health Sci 19(2): 76-85, March 2023

collecting therapists’ reports. Additionally, future studies May-Benson, T. A. Efficacy of occupational therapy
could include a comparative analysis of the provision using Ayres Sensory Integration®: A systematic
of ASI intervention in different countries, which would review. Am J of Occup Ther. 2018;72(1):1-10. doi:
provide a better picture and understanding of the 10.5014/ajot.2018.028431.
practices of occupational therapists. The current study 5. Case-Smith, J., Weaver, L. L., & Fristad, M.
focused mainly on the adherence to the fidelity measures A. A systematic review of sensory processing
when providing ASI intervention among occupational interventions for children with autism spectrum
therapists in Malaysia. Thus, it is recommended that disorders. Autism. 2015;19(2):133–148. doi:
future studies attempt to understand their challenges 10.1177/1362361313517762
as well. Considering that most participants in this 6. Kantor, J., Hlaváčková, L., Du, J., Dvořáková,
study indicated that it was important to adhere to the P., Svobodová, Z., Karasová, K., & Kantorová,
process and structural elements when providing ASI L. The effects of Ayres Sensory Integration and
intervention, some elements still could not be fulfilled. related sensory based interventions in children
Therefore, understanding their challenges might give a with cerebral palsy: a scoping review. Children.
better perspective on the problems they faced, enabling 2022;9(4):483. doi: 10.3390/children9040483.
the appropriate formulation of solutions. 7. Watling, R., & Hauer, S. Effectiveness of
Ayres Sensory Integration® and sensory-based
CONCLUSION interventions for people with autism spectrum
disorder: A systematic review. Am J of Occup Ther.
The results of this study show that, regardless of the 2015;69(5). doi: 10.5014/ajot.2015.018051.
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educational levels, and healthcare systems, they review of the research evidence examining the
illustrated their consistent knowledge and understanding, effectiveness of interventions using a sensory
allied with the evidence base regarding ASI structural integrative approach for children. Am J of
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ACKNOWLEDGEMENT Koomar, J., Brett-Green, B., Burke, J. P., Cohn
E. S., Mailloux, Z., Miller, L. J., & Schaaf, R. C.
This study was funded by a research grant from The Development of a fidelity measure for research on
Universiti Kebangsaan Malaysia (GGP-2017-085). the effectiveness of the Ayres Sensory Integration
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