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SENSORY INTEGRATION AND SPEECH & LANGUAGE THERAPY
A position paper for Speech and Language Therapists using
Ayres Sensory Integration Theory in their practice
December 2020
This position paper has been developed to support Speech and Language Therapists (SLT) who use, or wish to use, Ayres Sensory Integration (SI) Theory in their practice. The document includes the rationale for the use of SI theory by SLTs and also aims to clarify the difference between the practice of an SLT using SI and that of a similarly qualified Occupational Therapist or Physiotherapist. In addition to supporting SLTs, the document may provide information for those commissioning their services.
The document has been developed through consultation and discussion with the members of the SI-SALT Clinical Excellence Network which is registered with the Royal College of Speech and Language Therapists (RCSLT). The project has been led by three Speech and Language Therapists and Advanced Practitioners in SI: Amy Stephens, RCSLT SI Advisor, Judy Goodfellow, PG. Dip. SI. and Alison Dear, MSc. SI. For the purposes of this document, an SLT who has achieved post graduate qualifications in relation to SI is referred to as an SI-SLT.
The document consists of ten sections each addressing questions raised and discussed by the membership of the SI CEN who met in September 2020. These sections and their contents are detailed below:
Section 1. The role of the Speech and Language Therapist
What is the core remit of an SLT? Why have some SLTs undertaken postgraduate training in SI?
Section 2. Theories underpinning the practice of an SI-SLT
Who devised SI theory? What is SI? Is SI theory used outside the field of Occupational Therapy?
Section 3. The relevance of SI Theory for Speech and Language Therapists
What are the impacts of sensory difficulties? Why are clients’ sensory difficulties relevant to the remit of an SLT?
Section 4. Clinical populations relevant to an SI-SLT
Which client groups do SI-SLTs currently work with? Is SI relevant across the lifespan?
What is ASI therapy? How is ASI therapy delivered? How is the therapy tailored to individual clients? What elements should the therapy contain to be described as ASI therapy? What other approaches have similar theoretical underpinnings? What sensory based therapies cannot be described as ASI? When would an SI-SLT use ASI Therapy?
Section 6. Use of the term ‘ASI Practitioner’
Who can describe themselves as an ASI practitioner? Which organisations currently provide training in the UK and Ireland? Is training provided outside of the UK and Ireland? Is there a central register for SI trained therapists?
Section 7. Boundaries of practice
When is referral to an SI-SLT appropriate? Why should SLTs not accept all referrals relating to sensory difficulties?
Section 8. The benefit SI-SLT assessment
What is the benefit of SI-SLT assessment rather than that delivered by a similarly qualified Physio or Occupational Therapist?
Section 9. ASI Therapy and evidence based practice
What are the three elements of evidence based practice? What is the research evidence relating to ASI therapy as an effective treatment for communication difficulties? Can an SI-SLT be described as delivering evidence based practice? What research is currently being undertaken by the NHS to investigate the effectiveness of ASI therapy for children with autism? Why is this research study particularly relevant to the SLT profession?
Section 10. The role of the SI-SALT CEN
What is the role of the CEN in relation to research evidence? Will clinical guidelines be produced?
Section 1 - The role of the Speech & Language Therapist
The role of a Speech and Language Therapist is to provide life-improving treatment, support and care for children and adults who have difficulties with communication, eating, drinking or swallowing (RCSLT 2020a).
Facilitating engagement and participation is fundamental to the practice of an SLT. Because of this, over the last decade, an increasing number have undertaken post-graduate training in the field of SI in order to increase their understanding of their clients’ difficulties and to offer a wider range of effective interventions.
Section 2. Theories underpinning the practice of an SI-SLT
Depending on the clinical populations they support, SLTs have for many years found it useful to adopt theories and intervention approaches which originate in other disciplines but are widely accepted within the field. Examples include the Picture Exchange Communication System stemming from behavioural theory (Bondy and Frost 2001); the widespread use of Social Stories from the field of special education (Gray and Garand 1993); and Zones of Regulation from the field of occupational therapy (Kuypers and Winner 2001).
The practice of an SI-SLT is underpinned by theories of Dr. Jean Ayres, an Occupational Therapist, Researcher and Educator; and the theory she developed is referred to as Ayres Sensory Integration (ASI) Theory, or, more simply, ‘SI’. Writing in 1979, Ayres (2005, p.5) described sensory integration as "the organization of sensation for use" which refers to the way sensory input from the five senses and other sensory systems is conveyed to the brain via an individual's central nervous system, and the development of perception, discrimination, and motor skills which it underpins. She proposed that sensory integration developed during childhood through self-directed physical play. In these activities children challenge their proprioceptive sense (sense of limb position) and vestibular sense (sense of balance and motion) in addition to their other senses of vision, hearing, touch, taste and smell. The sensations they experience during these activities are necessary to increase connections/synapses between neurons in the brain and to facilitate adaptive responses (Ayres 2005). It has long been recognised that the use of SI theory is not exclusive to the field of occupational therapy (Kelly 1991) and, following Dr Ayres’ death in 1988, her theory has continued to evolve. Around the world this framework is now used in research and clinical contexts beyond occupational therapy, notably that of that of neuroscientific research.
Section 3. The relevance of SI Theory to Speech and Language Therapists
In broad terms, sensory processing and integration dysfunction can manifest in two areas: difficulties with modulation and/or difficulties with discrimination and praxis (Mailloux et al. 2011; Bundy and Lane 2020). Modulation difficulties mean that a person may typically under- or over-responds to sensations in comparison to the general population. Bundy and Lane (2020, p.11) described how
“individuals who have difficulty modulating sensation behave as though the amplitude of their response is consistently greater or less than of most individuals, decreasing the effectiveness of their performance.”
It is important to recognise that these reactions are automatic and stem from dysfunction within the nervous system resulting in an individual being unable to manage the sensory stimuli from within their body or their immediate environment. The automatic nature of the response may result in difficulties in being able to communicate their needs effectively and may impact on the building and maintaining of relationships throughout their lives.
If a person has praxis difficulties, they have difficulty planning and executing new movements rather than ones they are familiar with. Cermak and May-Benson (2020 p.115) reported that, in 1985, Ayres defined praxis as:
“The neurological process by which cognition directs motor action; motor or action planning is that intermediary process that bridges ideation and motor execution to enable adaptive interactions with the physical world. Thus praxis pertains to more than just physical acts of interacting with the environment, it encompasses the process of conceptualising and planning those motor acts.”
Modulation and praxis difficulties have the potential to impact upon the professional remit of an SLT in a variety of areas including communication, social interaction, eating, drinking and swallowing, as these all require the processing of sensation and motor control. For example, gaze stabilisation and tracking are essential to tracking conversation in a group or to notice and respond to non verbal communicative acts such as gesture. Where sensory processing challenges are creating a barrier to a client’s ability to access and/or engage effectively in some forms of therapy, addressing these sensory needs will be a starting point in an episode of care. For example, if the goal of intervention with a person with social communication needs is to support their ability to co-regulate and sustain attention, the SLT will need to be able to understand the client’s regulatory and sensory-motor needs.
Since effective and appropriate assessment and, if necessitated, treatment in the areas of communication, eating, drinking and swallowing is within the remit of speech and language therapy, in circumstances where sensory processing difficulties contribute directly to concerns of these areas of function, this assessment and treatment should be carried out by SLTs who have undertaken post-graduate training in sensory integration.
Section 4. Clinical populations relevant to the work of an SI-SLT
Currently, the practicing SLTs who are trained in SI work with autistic children and adults, children and adults with learning disability, children and adults with complex physical needs including cerebral palsy, children who have experienced trauma and adverse childhood experiences, deaf children and adults, children and adults with dyspraxia, and children with sensory-feeding difficulties. Other clinical populations are supported by SI-trained professionals and it is likely that, as more SLTs train in SI, the clinical populations with whom this approach is considered will increase.
Sensory integration theory is rooted in neuroscience research, and continues to evolve as new research emerges. We understand now, for example, that neural plasticity and synaptogenesis is present across the lifespan. Ayres Sensory Integration as a clinical approach is similarly applied across the age range including neonatal and older adulthood.
Section 5. ASI Therapy
ASI therapy is a specific intervention approach based on Ayres SI theory and delivered directly 1:1 by a qualified sensory integration practitioner (an SI qualified Occupational, Physio or Speech and Language Therapist). It has been described as “individually tailored sensory motor activities contextualised in play” (Schaaf and Mailloux 2015, p.105). The client is provided with opportunities to experience the sensations they find difficult to process or integrate, and which are having a negative impact upon participation, through their self-directed actions. It should be emphasised that the description of contextualising in play does not limit the use of therapy to young children. The practitioner supports in a way that ensures that the sensory challenges the client experiences are met successfully and enjoyably, an experience which is relevant to all age groups.
To be described as ASI therapy, as well as being delivered by someone who is appropriately qualified, the therapy must demonstrate high fidelity to the structure and process treatment principles laid out in the Ayres Sensory Integration Fidelity Measure (Parham et al. 2011). This means that the therapy contains specific elements that are listed in the fidelity measure, although the way those elements are provided means ASI therapy sessions can vary with clinical context (Parham et al. 2011). For example, while in all sessions, opportunities for integrating vestibular, proprioceptive, tactile and visual input are facilitated, for some clients the therapist may increase the focus on providing a wide range of intense vestibular experiences through the provision of a variety of suspended equipment; in others the focus may be the provision of deep pressure tactile and proprioceptive sensation.
There are other intervention approaches which are closely linked in their theoretical underpinnings to ASI. These might include, for example, DIR Floortime Therapy and Sensory Attachment Intervention. There is variation in how congruent with ASI principles each approach is, but crucially each includes active and individually-tailored activities delivered in a playful context. By contrast, approaches which offer generic and/or passive prescribed sensory experiences (previously known as sensory diets) would not be consistent with an ASI approach and have a lower level of evidential support. Examples of these would include Brain Gym, The Listening Programme and Brushing Protocol therapies.
It should be emphasised that ASI therapy is an intervention which would be utilised by an SI-SLT when assessment indicates that sensory modulation or praxis difficulties may be having a significant detrimental impact upon their client’s communication, eating, drinking or swallowing experience. The therapy may be used alongside other Speech and Language intervention approaches which would also be driven by the therapist’s clinical reasoning.
Section 6. Use of the term ‘ASI Practitioner’
The term Ayres Sensory Integration Practitioner refers to clinicians who have passed approved postgraduate courses. Currently, in the UK and Ireland, the two providers of approved courses are Sensory Integration Education and ASI-WISE (under the Collaborative for Leadership in Ayres Sensory Integration [CLASI]). Their courses are also available to Physiotherapists and Occupational Therapists. Therapists from overseas practicing in the UK and Ireland may have undertaken approved courses through other providers e.g. the South African Institute of Sensory Integration (SAISI). It should be noted that ‘ASI’ is a registered trademark and only therapists who have undertaken approved courses to a practitioner level are entitled to describe themselves as providing ASI therapy.
At the current time there is no central register of clinicians who have completed ASI training, although some training providers give information on their websites as to who has completed and passed each level of certification. Clinicians should encourage potential clients to ask for details of their formal post-graduate training in ASI.
Section 7. Boundaries of practice for an SI-SLT
The core professional remit of the SLT is the assessment and treatment of communication, eating, drinking or swallowing difficulties. Ayres SI therapy is only an appropriate intervention tool for SI-SLTs where the client’s presenting difficulties in these areas have an identified sensory component. The decision by an SLT to employ an SI approach when assessing or treating a client’s communication, eating, drinking or swallowing difficulties is driven by clinical reasoning stemming from their expertise in these areas. Speech and Language Therapists, unlike Physiotherapists and Occupational Therapists, are not specialists in assessing and treating the gross and fine motor difficulties which may result from a range of neurological and musculoskeletal conditions. When accepting referrals, Speech and Language Therapists should always be mindful that it is their responsibility to ensure they do not undertake work outside their scope of practice as required by the standards of the Health and Care Professions Council.
Section 9. ASI Therapy and evidence based practice
As Speech and Language Therapists, evidence based practice i.e. the integration of best available evidence, clinical expertise and service-user preferences and values, guides our clinical decision making (RCSLT 2020b).
In terms of research evidence, the highest level of evidence for any treatment is a systematic review of randomised control trials (RCT). Very few speech and language interventions have been researched by means of an RCT but are used by SLTs in both NHS and independent practice. Currently there are no RCTs of ASI therapy that have focused solely on the effect on communication. However, an RCT involving thirty-two children with autism was published in the American Journal of Occupational Therapy in 2014. This study (Schaaf et al. 2014) reported a positive effect on children with autism in relation to socialisation. A later systematic review carried out by Schaaf et al. (2018, p.1), described the strength of evidence relating to ASI therapy and the positive impact on play and language skills as “emerging” but insufficient. At the time of writing this position paper, a larger scale RCT is being carried out by the University of Cardiff funded by the National Institute of Health Research, the research arm of the NHS. Known as the “SenITA study” this research is investigating the effect of ASI therapy vs ‘usual care’ in over 200 children with autism (Randell et al. 2011). The outcome measures relate to a number of areas including challenging behaviour and socialisation, both of which are highly relevant to SLTs.
In relation to ASI therapy as an effective treatment for speech/articulation difficulties or language development, this is an area of research need; however, there is research that begins to address the impact of SI difficulties on language and social interactions, from which a clinician could begin to build a working hypothesis (Magrun et al. 1981; Ayres and Mailloux 2012; Preis and McKenna 2014; Emad and Salehi 2016).
Depending upon their clients’ assessed needs, SI-SLTs might opt to use sensory interventions other than ASI therapy, for example, suggesting specific strategies to modify the environment. Some SI-SLTs may also prescribe bespoke sensory diets. However they should make clients and or carers aware of the more limited evidence for the effectiveness of these therapies in comparison with ASI therapy.
Section 10. The continuing role of the SI-SALT CEN
The SI-SALT CEN aims to support SLTs at all stages of their professional development. One of its main roles will be to evaluate emerging evidence in ASI as it relates to the perspective of the SLT profession with the long term goal of producing clinical guidelines.
Section 8. The benefit of SI-SLT assessment
There are increasing numbers of SLTs undertaking postgraduate training in SI. An SI-SLT is uniquely placed to differentially diagnose communication, eating, drinking and swallowing difficulties that have a sensory basis from those that do not. For example, an SI-SLT rather than an Occupational or Physiotherapist could ascertain if:
Auditory processing or discrimination difficulties are impacting upon the client’s difficulties e.g. differential diagnosis between developmental language disorder; auditory processing disorder; and a sensory modulation dysfunction.
Challenging behaviour is being driven by a communication difficulty or a sensory difficulty e.g. a child may hit themselves or others because they are seeking proprioceptive and/or tactile sensation or because they are unable to express their frustration in other ways.
A client’s dysphagia stems from difficulties at the oral rather than pharyngeal stage, e.g. hyper-reactivity to tactile stimulation, and clients may well have a combination of motor and sensory difficulties affecting the oral stage.
References
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