Opening the Black Box of Ayres Sensory Integration®: Clarifying Mechanisms of Change from Treatment Theory to Participation

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Ayres Sensory Integration® (ASI) remains one of the most widely used and debated intervention approaches in occupational therapy and related disciplines. Recent advances in rehabilitation treatment specification and reporting frameworks, including the Rehabilitation Treatment Specification System (RTSS) and the Reporting Guideline for Intervention Description in Rehabilitation (GUIDE-Rehab), emphasize the need for precise articulation of treatment ingredients, mechanisms of action, and targets. However, interventions grounded in neurodevelopmental theories, such as Ayres’ theory of sensory integration, are complex, and may present challenges when interpreted within linear causal models. This paper argues that ASI theory is best understood as a treatment theory targeting proximal sensory–motor capacities, while participation-level outcomes may be more comprehensively explained through an enablement framework. Integrating this perspective with data-driven decision making (DDDM) clarifies longstanding ambiguities in the ASI literature and strengthens intervention specification, evaluation, and interpretation.