CCPR: Sensory processing disorder (SPD) wasn’t included in the DSM-5. Tell us what happened. 
Dr. Schoen: The DSM-5 committee looked at population-based studies, twin studies, neurophysiological studies, and animal research, but ultimately decided that the presentation of symptoms was not yet well enough defined to be included as a stand-alone diagnosis. They did, however, include sensory processing challenges in the section on autism and suggest that some sensory features can negatively impact autistic children.

CCPR: How do sensory processing challenges impact everyday life? 
Dr. Schoen: Think about sensory processing as it relates to health and well-being, how your experience of the sensory world can interfere with everyday life. Sensory over-responsivity (SOR) is a subtype that most mental health professionals recognize and has the most face validity. Think of patients who are distressed by sensory experiences that are not typically experienced by others as aversive—this happens in children and teens with autism spectrum disorder, posttraumatic stress disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, bipolar disorder, and schizophrenia.

Dr. Spielmann: At its extreme, SOR is like being bombarded. It’s disabling. 

Dr. Schoen: Sensory under-responsivity is a subtype where the person does not respond to stimuli, such as how some autistic kids do not register pain. We also see individuals who are sensory craving, where a person seeks out sensory stimulation. Here, think about a child who repeatedly crashes into furniture or people, apparently in an attempt to feel their body or soothe some need. 

Dr. Spielmann: Some kids have trouble with sensory discrimination, which is trouble detecting qualities within or between sensory modalities: sight, hearing, touch, smell/taste, position/movement, and internal sensation (also known as interoception). For example, kids with ADHD routinely misinterpret a neutral look as a threat, and kids with anxiety disorders might believe that a scratchy sweater is actually injuring them. 

CCPR: These sensory problems must affect a child or teen’s ability to respond to the world in an adaptive way.
Dr. Schoen: Yes. Motor function depends on sensory perception and processing, and so sensory processing problems can cause dyspraxia (problems with knowing what you want your body to do and with sequential motor actions). Dyspraxia is common in autism, ADHD, and developmental coordination disorder. For instance, a child on a playground might want to run for a ball but has trouble turning herself toward the ball. She can’t make it there before the other kids, or maybe she knows that it’s pointless to try. Either way, it’s hard for her. Postural challenges also occur. Think of kids who flop over in their seats at school or fatigue easily during movement activities. 

CCPR: How common are these sensory processing problems?
Dr. Schoen: About 5%–16% of the general population have sensory differences that impact function (Ahn RR et al, Am J Occup Ther 2004;58(3):287–293; Ben-Sasson A et al, J Abnorm Child Psychol 2009;37(5):705–716). Sensory differences have been reported in 80%–90% of autistic individuals and in about 40% of individuals with ADHD. But these problems can occur without a separate mental health diagnosis. Two research groups found subgroups of children with sensory differences who did not have another mental health diagnosis (Van Hulle CA et al, J Child Psychol Psychiatry 2012;53(1):64–72; Carter AS et al, J Am Acad Child Adolesc Psychiatry 2011;50(12):1210–1219).

CCPR: Are people born with these challenges, or do they develop them due to outside events?
Dr. Spielmann: Some are largely genetic, like in autism, but traumatic events can heighten sensory symptoms. There can also be epigenetic transmission of high arousal states that render a person more likely to have sensory challenges. For example, misophonia, which is an over-sensitivity to sounds, can lead to elevated autonomic arousal, characteristic of a fight-or-flight state. Either way, repeated exposure to an aversive sensory experience leads to a chronic stress state, and from that the person may develop a more sensitized stress response. 

CCPR: Do you have another example of how environment can impact sensory development?
Dr. Schoen: Sure. Those car seats that snap into strollers give babies fewer opportunities for natural touch, smells, visual shifts, postural changes, struggling against gravity, and struggling to roll over into a prone position—all of this is important for developing sensory-motor abilities. When the baby is left in the container, she experiences limited proprioceptive and vestibular sensations from motion, and she moves only in limited directions. Later, this same child may be upset by different kinds of motion that she’s never experienced. She may be unable to participate as well as her peers in activities that include more varied motion. She might avoid sensations that would help her develop greater competency, such as in playground games, swimming, or sports. 

CCPR: Are there cultural or social determinants to think about with sensory processing? 
Dr. Spielmann: Collective stress, such as the pandemic, increases the number of children who suffer from sensory over-reactivity. This is also true for Indigenous peoples, generations exposed to conflict, and people experiencing the stresses of climate change. Children and teens from distressed groups, including people of color, may have sensory difficulties that drive difficult behavior but are more likely to be misdiagnosed as oppositional.

CCPR: How can mental health clinicians screen for sensory challenges?
Dr. Spielmann: Ask about sensory sensitivity, under-responsivity, and motor aspects of the conditions you are looking at. Take time to go through all the sensory modes—sight, hearing, touch, taste, smell—and internal sensations such as movement, position in space, and internal discomfort. Ask about over- and undersensitivity, as well as motor coordination and motor planning as it relates to challenges in daily life. Remember that there can be mixed situations where a child might talk loudly or even scream without seeming sensitive to their own volume but can’t tolerate loud speech or noises around them. Part of that may have to do with their volitional control over the noise. 

CCPR: Once we recognize that a client has sensory processing problems, what do we do next?
Dr. Spielmann: First, try accommodations that allow the individual to function better in varied environments. For instance, for a child who is sensitive to heat and attends a school with no air conditioning, recommend that the school use cooler spaces, place fans, or get AC. For a child with poor auditory processing, you might recommend an assisted technology assessment for an in-class amplification system where the teacher wears a transmitting microphone and the student wears a receiver headset or has a receiver box on their desk. Our website has an “About SPD” page that describes the differences in sensory integration and processing (www.sensoryhealth.org). While some difficulties can be managed with environmental accommodations, children that are not doing well should be referred for an occupational therapy assessment.

Dr. Schoen: For these types of occupational therapist (OT) referrals, make sure the OT is a specialist in sensory integration and sensory processing—not all OTs do this work. The OT will perform an assessment that covers all sensory modalities and motor abilities and looks at the child’s social participation and emotional regulation. The OT will determine if sensory differences are contributing to challenges in daily life activities.

CCPR: What does OT treatment for sensory challenges look like?
Dr. Schoen: OT intervention is an individualized, child-directed, play-based approach that integrates sensory-motor experiences. We help caregivers (parents and others) assist the child in being calm and regulated, and we build the child’s abilities to recognize, tolerate, and interpret sensory experiences. Research shows that even in depression and anxiety, movement and stimulation of the sensory systems can be mood-elevating and regulating/calming. Parent or caregiver participation is essential for carryover into other contexts and environments.

CCPR: How effective is treatment for SPD? 
Dr. Spielmann: The most popular treatment is Ayres sensory integration (www.tinyurl.com/4bjyse4a). It is recognized in the National Clearinghouse of Autism Evidence and Practice by the University of North Carolina, Chapel Hill as an evidence-based practice for autistic children ages 5–12 for improving quality of life, including relationships, play, and adaptive abilities (www.tinyurl.com/3t9e9kar; Schoen SA et al, Autism Res 2019;12(1):6–19). Several studies demonstrate improvement in daily life activities at home, in the community, and in school (Schoen SA et al, Open Journal of Occupational Therapy 2018;6(1)). We see fewer problem behaviors, greater social participation, and better play abilities in children who participate in occupational therapy (Andelin L et al, Am J Occup Ther 2021;75(6):7506205030; Schaaf RC et al, Am J Occup Ther 2018;72(1):7201190010p1–p10). Some of these children have autism or ADHD, but many have no other comorbid clinical conditions.

CCPR: How do you explain sensory processing problems to kids? 
Dr. Schoen: Connect their emotional experiences with what is happening for them physically. With depressed teens, you might say: “Your body and brain are connected. When you are sad, you hear things differently and even see them differently. It’s like the world is harder to hear and see. And when you try to do things that are usually automatic, like get up and get dressed, it’s hard to figure out how to do that—almost like you’ve forgotten.” 

CCPR: Parents often bring kids to us because of tantrums that, based on what you are saying, may be related to challenges in sensory processing. How do you explain to parents the connection between sensory challenges and behavioral outbursts?
Dr. Spielmann: We tell parents that rather than simply giving a consequence, we need to look at the reasons for difficult behaviors. Tantrums, explosive behaviors, oppositional behaviors, and demand avoidance are often linked to sensory processing. For example, some children have visual processing difficulties and become lost in their own classroom. They lose track of where the teacher is, where their class materials are, and how to get back to their seat. It takes a lot of energy for them to function in class. They come home exhausted from the effort and may have a huge meltdown. 

CCPR: What resources do you recommend for parents and clinicians to understand sensory processing and integration? Also, how do we find the right OTs to refer clients to? 
Dr. Spielmann: The STAR Institute website has information and resources for both clinicians and parents (www.sensoryhealth.org). The introductory pages have information that covers definitions, red flags, and research. Additionally, there is a resource directory of therapists who have attended advanced training. More resources can also be found on the Spiral Foundation website (www.thespiralfoundation.org).

CCPR: What’s the bottom-line message for child psychiatrists and other mental health clinicians?

Dr. Schoen: Sensory issues are common in many mental health conditions. If you recognize and address them, the kids will do a lot better. 
Dr. Spielmann: Yes, so partner with your local OTs to collaborate in the care of your patients. 

CCPR: Thank you both for your time.