Published On: 02/13/2023
Duration: 21 minutes, 4 seconds
Related Article: “Assessing Sensory Processing Challenges” The Carlat Child Psychiatry Report, October 2022
Dr. Feder: About 5%–16% of the general population have sensory differences that impact daily functioning. Difficulties in sensory processing can profoundly impact quality of life. As clinicians we need to recognize and address these issues so that we can improve relationships and adaptive abilities of individuals at an early age. In this podcast, Mara and I will discuss how providers can identify sensory challenges to address these barriers and provide effective care in teens and adolescents.
Drs. Virginia Spielmann and Dr. Sarah Schoen joins us today to help us unpack this topic. Dr. Spielmann is the Executive Director of the Star Institute for Sensory Processing. And Dr. Schoen is the Director of Research at the Star Institute for Sensory Processing.
Welcome to The Carlat Psychiatry Podcast.
This is a special episode from the child psychiatry team.
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice.
Before we begin, let's briefly discuss the concept of sensory processing disorder and its subtypes.
The concept of sensory processing disorder or SPD refers to the impact of problems related to how the brain processes sensory information or stimuli. Take a moment and think about how sensory processing relates to health and well-being, and how your experience of the sensory world can interfere with everyday life.
Sensory over-responsivity is the subtype of SPD that most mental health professionals recognize and has the most face validity. These patients are distressed by sensory experiences that other people do not typically experience as aversive. This happens fairly often in autistic children and teens, posttraumatic stress disorder, attention deficit hyperactivity disorder, generalized anxiety disorder, bipolar disorder, and schizophrenia. At its extremes, sensory over-responsivity can be extremely disabling, for instance, when rain sounds as loud as gunfire, or the texture of fabric feels like sandpaper or the smell of oatmeal is nauseating.
Dr. Feder: The opposite also happens. Sensory under-responsivity is a subtype where a person does not respond much if at all to stimuli, such as how some autistic kids do not register pain and might go along with their day despite having a fractured bone or infection. The third subtype is sensory craving where the individual actively seeks sensory stimulation, such as repeatedly crashing into furniture or people.
Some kids also have trouble with sensory discrimination, which is trouble detecting or interpreting the nuances of sensory modalities. For example, some kids might not be able to detect the difference in taste when a piece of fruit has gone bad, or how kids with ADHD routinely misinterpret a neutral look as a threat. This can happen across all sensory modalities including the usual five - sight, hearing, touch, smell, taste – but also the senses of position, movement, and internal sensations (also known as interoception).
Mara: Why isn’t sensory processing disorder included in the DSM-5? Its symptoms clearly seem severe enough to cause impairment or distress in patients.
Dr. Feder: Well, 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.
This inclusion of sensory problems in the diagnostic description of autism supports the recognition of assessment tools and the study of prevalence rates. And it’s worth noting that the early childhood diagnostic manuals such as the Diagnostic Classification manual put out by Zero to Three for infant and early childhood mental health have included sensory processing problems since 1994.
Mara: Are people born with these sensory processing challenges, or do they develop them due to outside events
Dr. Feder: Some seem largely genetic, like in autism, but traumatic events can heighten sensory symptoms like in PTSD. There can also be epigenetic transmission of high arousal states that render a person more likely to have sensory challenges. Nature and nurture can interact to intensify sensory processing problems. For example, misophonia, which is an over-sensitivity to sounds, can lead to elevated autonomic arousal, characteristic of a fight-or-flight state. 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.
Dr. Feder: Dr. Spielmann, how are motor functioning and posture connected to the process of sensory integration
Dr. Spielmann: What we really mean when we talk about motor and posture and how they’re connected to the process of sensory integration is that we’re talking about how – you know, there’s a sensory event in your body or in the world around you that is registered at that very, very body-based level. It is then the neurons fire and often they fire together with two or more pieces of sensory data, so that multi-sensory neural firing.
And what we want at that level is for the nervous system to be able to register and modulate the neural firings, so that we’re not over-responsive or under-responsive. We’re able to respond contingently or proportionally to the event. It is then that it goes into the more of the software of the brain where we are discriminating the qualities of the event. What’s the geographical location? Was it far away? Was it hard, soft? And, of course, before all of that we’re deciding if it’s life-threatening or not.
But you produce an adaptive response to the events and that usually involves motor planning. But it also involves postural orientation and postural control. And so, all that sensory data that we’re getting about how much we’re moving, or things are moving around us, where our body is in space, proprioception and vestibular inputs. That’s helping us have the appropriate posture, hopefully, for the task at hand, be able to orient and anticipate with regards to new things in the environment.
And that sensory input from infancy is what helps bring posture online. It’s not the only thing that contributes to posture and healthy posture, but it’s a massive piece that very much gets overlooked and so, you know, often when you look at the research papers, we look at posture or we look at sensory. And what we really want is to see more and more research that’s sensory informed and really seize those connections in a way like system thinking
Mara: Dr. Schoen, how common are these sensory processing problems?
Dr. Schoen: The early research from what – 17 years ago I guess now – was about 5% of the population seems to have sensory features that can impact daily life functioning. There was more of an epidemiological study by Dr. Alice Carter, who was at Yale at the time, who found as high as 16%.
Now, that’s looking at really just one subtype and so, the numbers could be somewhere between 5 and 16%, but we do see children who do not quality for other diagnosis and in fact, her research found that Dr. Harold Goldsmith did some twin studies where he found a subgroup of children who had sensory features that did not quality for any other mental health diagnosis.
Mara: Dr. Spielmann, are there cultural or social determinants that interact with the presentation and treatment of SPD?
Dr. Spielmann: You know, we’ve got everyone has experienced collective trauma from the pandemic and now what we have is children who, if we really look from that systems perspective, have experienced that trauma, have had less exposure to social relationships.
But also we’re wondering how many infants, for example, have not had torticollis identified that would otherwise have had it noticed by a healthcare worker, if the world was open and we were all visiting each other. And so, you know, you have this lack of experience now – social, environmental, and developmental conditions not being picked up, as well as the sort of collective trauma. So, huge there.
And then there’s a lovely article and it’s really related specifically to autism by Deandra Stratton and Achshis Ridha. It’s on our podcast and I’ll try and find the link. But they really talked about the diagnostic pathway for autistic children who are black or indigenous people of color, and the differences and the inequities in the system and the need for antiracist work to address that and change that.
Dr. Feder: Dr. Spielmann, can you provide an example of how the environment can impact sensory development
Dr. Spielmann: The whole issue with when we were putting all our kids into car seats and they were never being taken out was huge in the development of sensory-motor competence in an individual.
You know, one of the things we say at Star is like, the struggle is gold. The struggle is where the therapy is and that baby like struggling against gravity and then struggling to roll over and left in prone, left in tummy time, that struggle is where the growth happens. But the baby left in the container sitting supine, not really working against gravity and only moving in this sort of linear plane with that vestibular input, so I’m just moving in one direction. I’m not being flung upside down and all these other things, really impacted the development of children who were already perhaps, vulnerable to differences in sensory integration and processing.
And I believe we see that in posture, oral motor tone, our children’s eating skills, they way they can organize the muscles of their mouths, all sorts of things.
Dr. Feder: Dr. Shoen, where should we refer patients with sensory processing disorder? And what types of interventions are available.
Dr. Schoen: We do believe that occupational therapists have historically had the expertise in this area and the tools available to assess.
I don’t think we’re at the level of being able to do neurophysiological studies – you know, cost and just feasibility alone. But behaviorally, we can do a lot in terms of a one-to-one evaluation with a clinician collecting information, report data from parents and teachers, really understanding the context within which the sensory features might be interfering with that child’s daily life.
So, I do think what you want to look for is a clinician who has had advanced training. It is as you’ve said repeatedly, a very complex area as we’ve been describing. So, oftentimes, it’s not well taught in the schools, and we do rely on professionals to take advanced trainings to qualify themselves to work with this population across the lifespan.
The most popular treatment is Ayres sensory integration, which is the foundation of the what we do at Star and many other clinics around the country and has been recognized even in the National Clearinghouse of Autism Evidence and Practice by the University of North Carolina, Chapel Hill that their latest publication said that it was designated as an evidence-based practice for children – I think it’s 5 to 12 on the autism spectrum.
Mara: Screen for sensory challenges in your evaluations. Ask about sensory oversensitivity, 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 under sensitivity for each of these, and remember that people may have mixed pictures, for instance when a child cannot tolerate loud noise unless they are making the noise. Part of that may have to do with their volitional control over the noise. Ask about motor coordination and motor planning as it relates to challenges in daily life. Can the child or teen figure out how to do what they want to do or are they frustrated? An example might be a child who wants to eat and might even know the food is in the fridge but cannot figure out how to open the door.
Dr. Feder: Once you recognize that a client has sensory processing problems, what do you do next? 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, electric 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. Kids who cannot tell where they are when on a regular chair and become agitated might do better in a bean bag chair. These are very individualized approaches and while some difficulties can be managed with environmental accommodations, children who are not doing well should be referred for an occupational therapy assessment.
Mara: Parents often bring kids to us because of tantrums that may be related to challenges in sensory processing. How do you explain to parents the connection between sensory challenges and behavioral outbursts?
Dr. Spielmann: The simplest and shortest way might be when we’re discussing these externalizing behaviors really talking about the fact that these are distress behaviors and what we want to identify is what’s causing the distress and why it manifests this way. We’ve got post-school restraint collapse where children are holding it together all day long and diverting a lot of resources that should be available for the classroom to just moving around in space.
They come home and absolutely have a huge meltdown because home is their safe space and Mom is a great punching bag or trashcan for all of those icky feelings that have been building up all day long and this is how the child is closing their stress cycle. So, let’s look at the stressors. What is going on that is causing this? I would humbly suggest that this is the sort of thing that’s thought about with regards to explosive behaviors, oppositional behaviors, demand avoidance behaviors before simply naming the behavior as the difficulty itself. I hope that made sense.
Mara: When you explain sensory processing problems to kids, connect their emotional experiences with their body experiences. With depressed teens, you might say: “Your body and brain are connected. When you are sad, you might 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 might be hard to figure out how to do that—almost like you’ve forgotten.”
Dr. Feder: Before we wrap up, Dr. Spielmann, what resources do you recommend for parents and clinicians to understand sensory processing and integration?
Dr. Spielman: I would point people towards our website, sensoryhealth.org, and there is an “About SPD” page there that really talks about how, for the majority, differences in sensory integration and processing are subtle and can easily be accommodated. For others, differences in sensory integration and processing are more apparent and they might need environmental changes, or they might need environmental accommodations and some therapeutic supports.
And then, for some people, the sensations that come with being and moving in the world are so overwhelming and confusion at the brain/body level that they rarely feel safe. And those people really deserve and need very, very well-informed sensory supports all the way through their life for the most part.
And, so that’s there on our website and there is also, if you go to “Resources,” a red-flags download that people have really – it’s one of our most popular downloads – and you can go there and look at how serious is this? Is this sensory or is it something else? And it should help sort of guide that process.
Mara: Sensory issues are common in many mental health conditions. Once you recognize them you will see them really often and when you address these problems and partner with your local OTs it can really help your patients feel better and function better.
Dr. Feder: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
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Mara: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.
As always, thanks for listening and have a great day!