PUBLICATIONS & NEWS OT PRACTICE MAGAZINE 2017 SENSORY INTEGRATION EDUCATION ISSUE

Building Competency in SI: Evidence-Based Guidelines for Occupational Therapy

Baltazar Mori, A., Carrasco Koester, A., Holland, D., Fernandes, P., Gray Rogers, R., Smith Roley, S., Soechting, E., &
VanJaarsveld, A. (2017). Building competency in SI: Evidence-based guidelines for occupational therapy using Ayres
Sensory Integration®. OT Practice, 22(12), 8–13.

By Annie Baltazar Mori, AnjaLi Carrasco Koester, D’Andre Holland, Paulo Fernandes, Rosalind Gray Rogers, Susanne
Smith Roley, Elisabeth Soechting, and Annemarie VanJaarsveld

Occupational therapy practitioners are seeking information to build their knowledge and skills through postgraduate
continuing education in sensory integration.

Over the years, sensory integration (SI) has gained popularity in practice, with increasing acknowledgement for expertise in
this area of occupational therapy practice (American Occupational Therapy Association [AOTA], 2011, 2015a, 2017;
Royeen, & Lueben, 2009; Schaaf et al., 2014; Schaaf et al., 2015; Watling, Koenig, Davie, & Schaaf, 2011). Pediatric
occupational therapy practice has also grown. A 2015 AOTA survey showed early intervention and schools as the top work
settings for occupational therapists and occupational therapy assistants in terms of number of practitioners—more than one
third of the total workforce (AOTA, 2015b).

From as early as 1999, Case-Smith and Bryan (1999) found that occupational therapists in the United States working with
children with autism in schools most frequently used a sensory integrative approach. According to Schaaf (2011), 99% of
occupational therapists apply principles of SI in their work with children with autism. SI was identified as one of the three
most requested approaches by parents (Green, Pituch, Itchon, & Sigafoos, 2006; Mandell, Novak, & Levy, 2005), with a
steady increase in the incidence of autism, now at 1 out of 47 children, ages 3 to 17 years (Autism Speaks, 2017).

SI originated in occupational therapy and is strongly linked to occupational therapy practice. Currently, most health and
education professionals recognize that occupational therapy is the go-to profession for SI and sensory processing
(Reynolds, Watling, Zapletal, & May-Benson, 2012). Because of the complex nature of SI, occupational therapy
practitioners are seeking information to build their knowledge and skills in this area through postgraduate continuing
education.

Historical View of SI Education in OT

With the increasing demand for occupational therapy services; an increase in the number of individuals with SI and
processing issues, such as those with autism; and a rise in employment in early intervention and school-based practice,
training in evidence-based practice using SI and sensory processing is essential for occupational therapy practitioners.

To determine the level of training of entry-level occupational therapists using SI, AOTA’s Sensory Integration Special
Interest Section (SISIS) conducted two surveys. In 1999, the SISIS conducted a survey of all occupational therapy
programs in the United States, inquiring about how much SI was taught within the curricula. Results indicated that SI
theory and intervention were introduced in all programs. This content was typically embedded within the curricula, varying
from a brief introduction of 1 or 2 hours to approximately 10 hours on the topic. The authors concluded that this did not
constitute adequate training to ensure competencies in SI at entry level (Jacobs, Koomar, Mailloux, & Roley, 1999). The
SISIS revisited a similar question that prompted an additional survey with similar results in 2012 (Reynolds et al., 2012).
They concluded that instruction in this knowledge base was variable in what was taught and the number of hours spent on
the content. Respondents indicated a desire for additional resources for SI at entry level (Reynolds et al., 2012).

Since Ayres (1968, 1972) introduced her theory and methods to the field of occupational therapy, it has been considered
an advanced level of occupational therapy practice. While diligently working within her practice on developing assessments,
interventions, and research, Ayres created training programs with content that she determined to be at the master’s level.
The program was formalized in 1974 through the OT610 4-month clinical training course through the University of Southern
California (USC), an elective within the master’s program for occupational therapy. The OT610 USC course has attracted
therapists from all over the world.

In 1976, colleagues and supporters of Ayres began the Center for the Study of Sensory Integrative Dysfunction (CSSID).
At the suggestion of Dottie Ecker, MA, OTR/L, FAOTA, Ayres consented to offering a “certification” in SI offered through
postgraduate continuing education formats. Sensory Integration and Praxis Tests (SIPT) certification entailed theory,
assessment, and interpretation using the Southern California Sensory Integration Tests. When the SIPT were published, the
certification program was updated. Later, in the 1990s, an SI intervention course was added. The format and content of
these courses were designed by Ayres and colleagues and continue to be the foundation for trainings that are offered
throughout the world.
At the same time that CSSID was forming, AOTA started an initiative on Special Interest Sections to better support its
members in their unique areas of practice. Ginny Scardina, MA, OTR/L, advocated for the inclusion of SI as an emergent
and critical specialty area of occupational therapy practice. Discussions with then AOTA President Mae Hightower
Vandamm included whether AOTA might take over the SI certification courses. However, it was not felt to be the sole
purview of occupational therapy, and therefore not appropriate for AOTA at the time. Nonetheless, AOTA adopted the
Sensory Integration Special Interest Section (SISIS) as one of the first five SISs. The SISIS has always had an active
membership and continues to play an important role for AOTA members interested in this specialty area.

Although AOTA has not historically provided certification or in-depth training programs in SI, the SISIS has supported
members by providing solid information and guidance for practitioners through changes in practice over these decades. In
this tradition, this article provides updated information on postgraduate training in Ayres Sensory Integration® in order to
assist practitioners in identifying expected standards and to help them determine the best advanced training program to
meet their professional goals.

CSSID, later known as Sensory Integration International, offered SIPT certification courses until it closed in 2007. USC
continued its commitment to postgraduate SI training and offered the Certificate Program in Sensory Integration from 1998
to 2016, in partnership with Western Psychological Services (WPS), owner and publisher of the SIPT. Unfortunately, the
closure of the USC/WPS program has resulted in concerns that there is no longer a need or availability for certificate-level
postgraduate training in SI. That is not the case.

Current View of SI Education in OT

Modeled after Ayres’ original training programs, there are well-established programs offering SI certification through
organizations such as the Austrian Society of Sensory Integration, the Sensory Integration Network UK/Ireland, the South
African Institute for Sensory Integration, 7Senses Portugal, and the Finnish SI Association. Most of these SI-training
organizations have either nonprofit or university-affiliated status. Starting in 2016, two U.S.-based nonprofit organizations,
the Spiral Foundation and the Collaborative for Leadership in Ayres Sensory Integration, began offering in-depth training
programs, including a certificate in Ayres Sensory Integration. In 2017, USC offered a new postgraduate education program
in SI. In each of these examples, instructors have been trained by Ayres or by first-generation experts who were trained by
Ayres. Another organization, the STAR Institute, provides training for sensory processing disorder, a derivative of Ayres’
work in SI.

With the increasing popularity of SI throughout the world, additional organizations for training and research are proliferating
in other countries. A critical concern among leaders of the organizations is maintaining the integrity of the body of work of
SI and supporting best practice in occupational therapy. Some organizations offering SI training restrict the SI certificate to
occupational therapy. Some organizations, such as those in the United States, additionally offer training to speech-language
pathologists, physical therapists, and physicians. Professionals outside of these professions are not eligible for an SI
certificate through the organizations previously mentioned.

In 2008, at the USC/WPS annual instructor meeting, U.S. representatives and leaders from several international SI
organizations, including those previously noted, joined efforts to ensure equivalency in quality of educational materials and
an exchange of ideas, including innovative educational methods. This informal group became the International Coalition for
Education in Sensory Integration (ICESI) and is in the process of formalization as the International Council for Education in
Ayres Sensory Integration (ICEASI).

In 2016, the leaders of the organizations partnering in ICESI and others, including representatives from the United States,
met to establish international guidelines for education in ASI.

Considerations for drawing up guidelines included the varying levels of professional education for occupational therapy in
different countries, including the foundations in neuroscience and typical development. In some countries, there has been
encroachment of other disciplines into the use of sensory methods, often without adequate knowledge of the research and
fidelity to the methods.

Proposed guidelines for building expertise in ASI include the following:

Instructors are experienced occupational therapists with acknowledged training in sensory integration.

Curricula are rigorous and research-based developments of SI theory by Ayres and her successors, including the
neurophysiological bases, specific sensory integrative clinical reasoning based on knowledge of assessment and
interpretation of the results, the intervention approach as described by the Fidelity Measure to SI (Parham et al., 2011),
and relationship between sensation, engagement in needed and desired occupations, and participation in life.

All courses are based on empirical research and evidence, from Ayres’ research to current studies, and emphasize the
occupational therapy perspective (i.e., strongly linking sensory integrative processes to health and participation via
engagement in daily life occupations).

There are four levels of entry into the process of developing expertise in ASI. The length and style of courses may vary
depending on the program. Individual mentorship and hands-on experience are highly recommended.

Postgraduate Education in Ayres SI: Relevance to OT Practice

According to co-author D’Andre Holland, a relatively recent occupational therapy graduate, “The SI certification course was
instrumental in progressing my clinical reasoning and judgment through the following ways: (1) Building a solid foundation
in understanding the body of ASI evidence; (2) increasing my knowledge of assessment and treatment approaches that
govern an SI intervention; and (3) improving my ability to communicate the ‘why in the middle of the what’ in my
interventions from a sensory standpoint.”

We have often heard that advanced training in SI is transformative to one’s occupational therapy practice. SI educational
programs have been built on a model of evidence-based occupational therapy practice; guided by theory; discretely
identifying the concerns through rigorous assessments; and using research to guide the goal setting, intervention, and
outcomes measurement. With concern for supporting therapists to move from novice to expert, a variety of options exist
through postgraduate education and mentorship. Ultimately, consumers should request high-quality continuing education no
matter who the provider and should ensure adherence to evidence-based practice with the best available research and
practice possible.

References

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across the lifespan: The role of occupational therapy.
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American Occupational Therapy Association. (2015a). Occupational therapy for children and youth using sensory
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Annie Baltazar Mori, OTD, OTR/L, is the chief executive officer of playSense, in Redondo Beach, California.

AnjaLi Carrasco Koester, OTD, OTR/L, is director of the Center for Developing Kids.

D’Andre Holland, OTD, OTR/L, is the lead pediatric therapist in the outpatient clinic at Citrus Valley Health Partners–
Queen of the Valley Hospital.

Paulo Fernandes, MA, OT, is the president of 7Senses Portugal.