As Occupational Therapist’s we enable a better fit between the person, their everyday activities and their environment. For children, everyday activities can include dressing, writing, playing, PE, going out into the community e.g. going shopping.
Sensory processing is the way we process information we receive from the environment and our bodies and then use this information to respond appropriately.
We all have sensory differences and preferences. Some of us like very strong tastes and smells like spicy foods, garlic, blue cheese, whilst others avoid them. Some people enjoy a day of going on as many roller coaster rides as they can, whilst others would avoid even a slow roundabout or swing. As long as we can manage to take part in the things we want and need to do these sensory processing differences don’t matter or need support. It only becomes a problem if they impact on our ability to carry out the activities we need to do.
For some children their sensory development is delayed or disordered, and this impacts on their ability to take part in everyday childhood occupations. A child might be so distressed by noise, they miss out on a friend’s party or avoid the busy parts of the playground, missing out on opportunities to practise and develop their motor skills. A child may hit out when someone brushes up against them when lining up or sitting near them at carpet time as they experience it as painful.
Sensory Processing Disorder is not recognised as formal diagnosis within Diagnostic Statistical Manuel Version 5 (DSM5) or International Classification of Diseases version 10 (ICD10); although hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment is included in the diagnostic criteria for ASD.
There are 8 sensory systems: 5 of them you learn about in school: vision, hearing, taste, smell and touch. There are 3 more that you won’t be as familiar with: vestibular, proprioception and interoception. We will explain these in the following slides.
The vestibular sense provides us with information about balance and movement. Different movement can have different effects on us, for example:
- Linear (straight) predictable movement can help calm and sooth e.g. rocking a baby, or going in buggy or car ride
- Rotatory (circular) unpredictable movement can be alerting e.g. going on a roundabout or fairground ride.
Some children need a higher level of vestibular input to function and can present with behaviours including being fidgety, rocking, always on the go, bumping into people or things, struggling to sit still. These children are trying to increase input into their system to provide them with the information they need to be able to engage in their activities.
Some children are over sensitive to vestibular input and can present with behaviours including slumping in their chair, avoiding movement, avoiding climbing and playground apparatus, difficulty walking up and downstairs, or feeling travel sick. These children are trying to avoid being overwhelmed by the vestibular information.
For us to try and get an understanding of what this might be like, it can be similar to if we have had an inner ear infection or labyrinthitis. Has anyone played that game where you spin around and then try to walk between obstacles? Tricky isn’t it?
The proprioceptive sense gives us information about where our body parts are in space and grading how much force we are using in movements and activities.
For example if close your eyes, put your arms out to side and touch your finger to your nose you can you do it accurately enough to find your nose and gently enough not to hurt yourself. You can reach down to a bowl of popcorn on your lap, open your hand, grab a handful and bring it up to your mouth while watching a film at the cinema..
Deep pressure provides lots of information to the proprioceptive system and can be calming and organising for all of the sensory systems.
Feeling secure about our position helps us feel safe. Lots of the children we see have bendy joints, floppy muscles or weak core. Messages around body position and movements don’t register so effectively in these children and they may seek more intense proprioceptive input to give them the information they need to in order to use their bodies more effectively.
Some children struggle to grade the force required for activities, for example pushing hard through their pencil, throwing the ball too hard or soft and lacking the feedback to be able to adjust this, seeking rough and tumble play or breaking toys.
The impact on body awareness and posture results in slumping, leaning against things, bumping into things, falling over nothing and co-ordination difficulties.
Your sense of touch, also known as the tactile sense, provides us with information about light touch, deep pressure, pain, texture and temperature. It can keep us safe, e.g. you pull your hand away from a candle flame.
Some children are sensitive to touch and may present with behaviours such as: not liking labels or seams in clothes and not being able get used to the feeling, over-reacting to being touched or find haircutting, nail cutting and teeth cleaning painful.
Some children are under sensitive to touch and may seek more intense touch input for example touch everything, fiddling with things, have a very high pain threshold.
Your visual sense allows you to focus, attend and understand what you are seeing. Some children are over-responsive to visual input and may present with behaviours such as being distracted by wall displays in class, finding it difficult to locate a green pencil in their pencil case, finding it difficult to keep track of the place they are copying from, or finding bright lights difficult to cope with.
Some children are under responsive to visual input and may seek out more input and present with behaviours such as wanting to use lots of different coloured pens when writing, look at bright lights or needing a lot of visual stimulus to keep them engaged.
Your sense of hearing allows you to attend to and make sense of what you are hearing. Children may demonstrate preference or sensitivity to different volumes or pitches. Children with a hypersensitivity to noise struggle in supermarkets, shopping centres or public toilets with hand dryers. Children that are under-responsive to noise find it difficult to attend to verbal information, may not respond to their name, may miss important parts of verbal instructions or may appear to be daydreaming. When our sensory system is working well, we regulate our ability to focus and concentrate in relation to sound without thinking about it e.g. when parallel parking you may turn the radio down or ask people in the car to stop talking.
Taste is an example of a sense where we all have distinct preferences. It is normal for people to have differences in the tastes that they like or will avoid. We can use tastes and textures of food to help ourselves to self-regulate e.g. cold, sour, crunchy foods are alerting and warm, sweet, chewy foods are calming. Some children will seek out strong flavours or mouth non-food items or present with a very limited diet. If you are concerned about your child’s diet or mouthing of non-food items your GP, health visitor or a dietician may be able to help.
The sense of smell can keep us safe, for example if we smell smoke or fire we go to investigate. Familiar smells can help us feel comfortable and safe and smells that we find offensive can produce a physical reaction such as gagging or may make us want to leave that environment. Some children find it difficult to tolerate the smells in the school dinner hall or they may not like their teachers perfume or the products used to clean the classroom floor.
The importance of interception and its effect on how we feel and behave is becoming more recognised. It is the messages that we get from inside our bodies that gives us information such as pain, hunger or needing the toilet.
A child may not be able to tell the difference between feeling hungry, needing to go to the toilet or being about to vomit. This confusion can result in anxiety as they don’t know what their body needs which leads to them becoming overwhelmed by emotion and reacting in negative ways e.g. having a meltdown, getting aggressive or laughing inappropriately.
If a child is more responsive, they will be distracted by the messages they are getting from inside their bodies and need to attend to them more frequently, for example going to the toilet frequently during a lesson or always feeling hungry. If a child is less responsive then they are not aware of when they need to eat or drink and they only react to extreme messages from their body, for example they don’t eat until they feel they are starving.
This video from the National Autistic Society is helpful in demonstrating how sensory processing difficulties may feel.
Processing of sensory information happens in stages for example,
- You notice a sound e.g. a loud bang from outside
- You respond based on the volume of the sound, whether you are familiar with the sound, whether you are expecting the sound.
- You decide whether you need to respond to the noise, is the noise directed to us, does it call for a response from us or is it something we can ignore.
- You then respond appropriately, e.g. if it is the doorbell you answer it, if it is the bins being emptied you ignore it.
Your ability to process information appropriately allow you to screen out and ignore irrelevant information e.g. people talking in the office when you are writing a report but at times you can’t screen out the noise as there are large numbers of people talking very loudly. This can make you feel frustrated as it constantly interrupts your train of thought and work tasks can take longer. So for a child in a busy classroom, they can fall behind in their work resulting in frustration, anger and giving up.
We all move through different stages of regulation. Some people are naturally more Tigger and some people are naturally more Eeyore. Our ability to change and control our levels of regulation allow us to be ready to engage in activity with the right level of energy. For example, if you are going to a party or a theme park the Tigger is very appropriate, if you are going to a cinema or getting ready for bed, Tigger is less appropriate. For children with regulation difficulties, transitions can be difficult e.g. one minute you are running around, laughing, screaming, chasing with your friends, the next a loud bell goes off and you are expected to line up, stand still, come in quietly, sit down and start your work.
Many of the concerns that have been raised in trainings relate to trying to change the child or fully resolving an issue; however this is often not possible or realistic. Instead, what we are focussing in our training and resource pack is:
- Managing our expectations about how a child reacts in different situations, or how they complete an activity, or how much of an activity they should be able to complete or how much of an environment they should be able to tolerate.
- Our resources will look at how focussing on how we can adjusts tasks or environments to meet the needs of our children can be effective in increasing participation and functioning and reducing distress and withdrawing from activities.
For example:
- Changing the expectation- There is an expectation that children should sit at the table to complete their homework however some children are in a better state of regulation to complete the task if they are allowed to stand up or lay on the floor.
- Changing the task - Grading activity based on what a child is able to do, rather than just what they would be expected to be able to do, for example completing homework in shorter blocks rather than one longer block.
- Changing the environment – when doing homework, turn the tv /radio off or on, depending on the child’s sensory preferences.
Many of the children we see are quite complex and their sensory needs may be one part of the whole jigsaw puzzle, for example if a child is expected to focus for longer than their developmental level allows them to they will display behaviour that can be interpreted as sensory in origin but is in fact a result of frustration. Or a child that has communication difficulties and is given little opportunity for making choices may demonstrate behaviours such as removing clothes as a way of expressing themselves.
It is therefore important to keep an open mind about children’s behaviours and the reason for them as other services may be more appropriate in dealing with them. These are some of the other services that can provide support with behaviours either alongside or instead of sensory strategies. Some examples of the approaches/strategies that these services may be able to help with are TEACCH, behavioural support programmes, sleep clinics.
This presentation aims to provide you with strategies and tools that you can use to address the functional difficulties that your child is experiencing.
We all use different strategies to change our arousal level. Our ability to self-regulate develops. Babies are unable to self-regulate and are dependent on their carers to soothe them – holding them close, rocking gently in a predictable back and forth movement, allowing them to suck and patting them rhythmically. Toddlers start to experiment with regulating themselves sucking their blanky or thumb, curling up tightly, snuggling into you and refine their strategies as they get older.
What do you do to alert yourself? - drink a cup of coffee, splash water on yourself, get up and move round. In meetings I often find myself sitting heavily on my hands, crossing my legs really tightly, twiddling my pen lid or eating more biscuits than anyone really needs!
What do you do to calm yourselves after work? – get changed into comfortable clothes e.g. pyjamas, listen music. Have a glass of your favourite tipple. What we do may depend on the kind of day we’ve had – some days we may need to do more to bring us back to that ‘just right state’ – we may take a longer detour on the way home, play some soothing or alerting music, stop off at the petrol station for chocolate, have rant to a friend.
What some find calming, others find alerting. E.g. some people like to listen to music when writing others need silence. Some will seek intense movement – going to the gym, for a run, whilst others will prefer more gentle movements like Pilates/yoga to calm.
Children with difficulties processing sensory information may need support to remain in a regulated state - adapting to changes in sensory stimulation and returning to a regulated state if they become dysregulated (in a state of arousal where they cannot engage/participate effectively, have withdrawn or become distressed).
In order to maintain a regulated state we need to have activities spread throughout the day, similarly to needing food spread throughout the day – you wouldn’t have a big breakfast and then not eat anything for the rest of the day.
When planning a sensory activity diet for your child, it is important to include longer periods of sensory input that they need as well as bite size pieces. For example, they could walk to school carrying a backpack and then participate in a whole school activity such as ‘The Daily Mile’ before then going into class. Then during lessons they could be encouraged to be the classroom helper, use movement within tasks, have access to fiddle toys or a Move n Sit cushion
Sensory circuits can sometimes be put in by schools at set times e.g. 9.30 and then no other changes are made to the day. The need for a sensory strategy/movement break can be considered like food – 3 meals a day and occasional snacks that are planned in around the day. Therefore the impact of an early morning sensory circuit is unlikely to last throughout the day.
Sensory activities should be meaningful for the child, e.g. include their interests. It should be used before the behaviour occurs rather than after. To understand what your child needs, monitor how your child is throughout the day and if there are particular times they find difficult. Sensory interventions can be used prior to these times to help them remain in that just right regulated state ready for the next activity. Please don’t stop children having break / physical exercise as a punishment. You wouldn’t stop them having food for negative behaviour.
Here are some examples of alerting and calming activities. Some children will be able to self-regulate, developing their own movement strategies to keep them in the just right state. Other children will need you to suggest activities for them to do and structure these activities throughout the day.
This is a tool that you can use to help identify strategies that you can try with your child; it is not intended as a prescription. The focus continues to be on functional activities. The tool supports implementing strategies and making adjustments to the task, environment and expectations that supports you child to engage and participate in functional activities impacted by sensory differences.
In the middle (in blue) you put the functional task your child finds difficult. In the middle ring (in green) you put strategies that may help support your child with this task. These are grouped into the headings in the outer ring (pink). The sections do have some degree of linking together—however it is not essential to fill every box.
This is an example of a completed planning wheel so you can see how it is used. Although the detail is very small and difficult to read on here, they are available in the resource pack that accompanies this training.
The following slides contain tables for some functional tasks with strategies that would be put into the planning wheel. The areas identified in these wheels and in the resource pack are tasks that have been collated from parent and teachers feedback on common areas of functional difficulty. These strategies are a support tool, they may not completely remove the difficulty, but they may help in supporting your child in managing their difficulties. This would ideally link in with support from other services, for example a child with difficulties with behaviour may use strategies suggested by CAMHS, nurse led clinics, or behaviour management workshops. Don’t get too tied up in which circle to put the strategies in, this is simply a tool to help you think about the different areas that can be changed to help your child.
This is a table of example strategies that you can use to fill in the planning wheel if the functional task your child finds difficult is Dressing. Following this there are similar slides for hair care, toileting and writing.
To support this presentation, there is a resource pack available on the website which has been developed based on issues that have been highlighted by parents and school at previous trainings. This provides more detailed information of activities to help support the specific needs of the child with different situations.9