Amy’s Answers

A therapist asks for suggestions for a child who knocks over everything on table tops whenever classmates are singing happy birthday to another student. The therapist reports that they have talked it through with the child many times but the behavior continues.

That is a fun question to clinically reason through. I don't know all the details, but there are some connections to underlying deficits that I can make based on the information you gave.

What you are observing on the level of behavior is a response inhibition and that can be thought of on an executive functioning level. Interestingly, the networks in our brain that are responsible for that response inhibition are built on our motor capacity to inhibit. I was just listening to Tracy Stackhouse talk about how that inhibition (and also attention shifting) start at about 5 months old! And the brain networks needed later for attention and executive functioning are built through motor circuitry. I think that is why talking to him about it isn't working...he doesn't have the networks available to him to access that more adaptive behavior in those moments.

It sounds like it is more of an issue at certain times because it is only happening when other children are having Happy Birthday sung to them. I have a lot of questions about his profile and why that would be true. It is true for everyone that increased arousal (out of middle ranges) leads to a decrease in adaptability. I wonder if the sensory stimuli of the activity is activating for him, or if the emotional activation of excitement, or the emotional activation of jealousy/dissapointment that it isn't his birthday is activating for him...or maybe all of the above!

I wonder about his social emotional development and what helps him when things get tricky. Can he stay in a reciprocal interaction with an attuned adult when things are feeling challenging? Can he work through solving problems with another person (which is different than being able to solve problems on our own)? Can he use co regulation of another as a source of regulation or does he have to move away from people to regain regulation when dysregulated?

It is really tempting to want to talk to kids about perspective taking and following the rules, but it is typically not effective and doesn't address the underlying capacities needed for him to meet that expectation. I would consider a lot of different strategies based on how you answer the wonders that I had.

- If he is showing a defensive response to sensory input (like the noise of singing) I might be addressing his sensory modulation capacity through interventions that target the nervous system and decrease the protective response.

- If he has difficulty staying connected to an adult when things are challenging I would be using a sensory affective relationship based approach like DIRFloortime to build connection and help him access greater regulation through relationship.

- I would offer opportunities to build capacity for response inhibition through gross motor play. Using FUN as an activating activity helps to expand the window of arousal in which he can be adaptable. My job would be to find the just right challenge that pushes him to the edge of his current ability to use motor inhibition, but still respond appropriately, allowing his nervous system practice doing that in a way that he is engaged.

- Using a Floortime approach I might also engage in a lot of shared problem solving, which is built on that capacity for connection. Shared problem solving in connection with another is a skill that SO many adults lack. Even when I look at myself I notice my tendency to shut down when I am emotionally activated and lose some of my capacity for shared problem solving. I have built a strong network in my brain for solving problems independently, but that isn't always helpful in situations where I need to work with other people.

- If I am not able to fortify his skills using strategies that address the underlying challenges in his sensory, motor, affective, and regulatory systems, then I am going to provide accommodations and environmental supports. Does he need to be seated in a different place? Could he sit on a ball away from the table a bit? Could he sit with the teacher or another attuned adult? Could he hold something in his hands that he is interested in or that joins the celebration without disrupting? Does he need to leave the space (not as a punishment) while the song is sung?

I think that this answer illustrates why we can't just say we need to learn how to set boundaries as OTPs. It is so much more complex than that and if we see it as an issue of boundaries we are not doing everything we can to support the child being more adaptable and we are likely creating shame for the child who is honestly doing the best they can with the skills they have.

A child demonstrates the ability to use Zones of Regulation with the therapist, but parents struggle to implement strategies at home when the child is dysregulated. The therapist asks for suggestions of other strategies:

You have some great observations of what this child's current functioning allows and what it doesn't. I don't think that the strategies are the problem, rather it is an issue of state dependent functioning.

I'm not sure if you are familiar with Dan Seigel's "flip your lid model", but I find that to be a really relatable way to understand this concept. If you aren't familiar, there are lots of you tube videos that explain, basically, that when we are dysregulated, we don't have good access to our cortex, which is the part of our brain that allows for use of language and logic and taking care of others, etc. When we are in that dysreguated state we are functioning from the lower circuits in our brain that are responsible for emotions and protective behaviors like fight/flight/freeze. In that state we literally don't have access to parts of our brain that hold the tools you have mentioned, because our lower brain circuits have taken over and they don't respond to language or reasoning or logical thinking. They respond to co regulation, affective touch, rhythmic movement, deep pressure touch, etc.

What that means is that he still needs his parents to provide those things, when he is dysregulated, without him have to request or recognize the need for them (since those actions require language and reasoning). It can seem like he should be able to do them because they are available to him when he is in a regulated state, but that is the way state dependent functioning works! It is an adaptive way that our nervous system has evolved to help us survive. It prioritizes protective functions (fight/flight/freeze) to keep us safe.

It is great that he has picked up on the tools so well at times that he is regulated. But the way he will learn to access them when he is dysregulated is by having his parents coregulate and provide calming strategies with no language and no requirements of requesting/reasoning. Every time that they do that, they are creating a pathway for regulation in his brain, and with enough exposures he will begin to access those strategies more independently. But we aren't truly self regulated until our 20s!

If you haven't worked on his awareness of body sensations that would be a good way to help him start noticing how tools work for him and eventually help him to notice what it felt like in his body when he was just starting to get dysregulated. As we practice that "interoceptive pause" we start to build our capacity for regulation and are thus able to respond to our own needs, rather than just reacting to the situation.

A therapist asks for ideas for ways to desensitize a child's response to auditory input

I think of few things when I see questions like this about auditory defensiveness.

The first thing I think of is that some kids don't have the function of the middle ear muscles, like the stapedius, working well. The stapedius is responsible for tightening and relaxing our ear drum so that loud noises are dampened and don't come into our inner ear with as much intensity. If that isn't working well, everything might sound really loud and/or the child might not be able to do auditory figure ground and tune out the sounds that are less important to be able to tune into sounds that are more important. The only way that I know of to change the capacity of that middle ear mechanism to work is through auditory interventions that use a high pass/low pass/ gating process (done with sound equipment) to modulate the music. This gating provides an “exercising” of the middle ear muscles (I could feel those muscles working when I did a listening program on myself). If the child has that issue (and likely they do), all the behavior modification or listening to other sounds/practicing is going to be done to a child who is feeling discomfort for physiological reasons. I’m not ok with pushing a child to do something that they interpret as painful when there are other ways of getting to the bottom of the issue and training to muscles to support that capacity. I would always use an auditory intervention, likely in coordination with other sensory inputs that are regulating for the child’s nervous system.

The other thing I think of is related to desensitization and tolerance. Those terms are complicated. I’ve heard my mentors say “the goal isn’t tolerance” and “the goal isn’t to desensitize”. But then at other times those same advanced practitioners might report that a child is showing increased tolerance for something as an indication of how their nervous system is demonstrating less protective responses. That used to confuse me. Now I understand that it has to do with the fact that sensory input that comes into our system is always dual coded with affective information. In the simplest terms, it is coded as negative or positive, safe or unsafe. Dr Steven Porges calls this neuroception. Every sensation also has a neuroception of safety or protection. Sometimes people are working on “tolerance” by subjecting the person to a sound with the goal of them tolerating more intensity or longer times. They might use rewards or punishment to motivate the person to try to increase their tolerance. But when that happens, the sensory input is still being coded as unsafe, and most often the skills don’t generalize and the person can internalize the experience as there being something wrong with them or feel like a failure. That is IF they have decided to comply. Many children will refuse to try, and get into a battle of wills, or shut down, which just introduces more stress into their already stressed nervous system.

The only time that I feel it is appropriate to use systematic desensitization is when the person themselves has set a goal to increase their tolerance, and has the support of a connected relationship as the context for that work. That sense of connection, along with the internal motivation, can allow for a change in the way they affectively code the sensation from something that has a history of being coded as a protection signal to something that feels safe and allows for exploration.

The short version: I’d use an auditory intervention and (if necessary) follow up with activities that are completed in the context of a connected relationship with the therapist that allows for fun exploration of new things to widen the window of tolerance. If the child shows signs of protection (moving away, covering ears, holding breath, moving with less mature motor patterns, yawning etc) I would not continue until we were able to get regulated. If they can’t attain and maintain their regulation, I cannot challenge their window of adaptability for the purposes of growth.

A therapist asks if working on emotional regulation is out of our OT scope of practice:

OTs are definitely qualified and well within our scope of practice to work on emotional regulation!

Emotional regulation is a part of the bigger picture of state regulation and we have so many tools and so much expertise in that area, as OTs.

I tend to do a "typical two day interview" which is a technique I learned from the Wilbargers to get information about how the child is functioning in their life and start to get clues about what it is that is not supporting function for that child. If I need objective measurements for insurance purposes I might use an SPM or SP-2, but I don't find that those inform my clinical reasoning about what I will actually do with a child to improve function.

As an OT I am going to start with the big picture of who is this child and how are they functioning in their life and what do they want/need to be able to do.

After I understand the needs of the child and their family I will look at the task, the environment, and the person factors.

When I am considering the "person" factor (skills the child has) I am not just looking at sensory integration. I am also looking at affective capacities and motor capacities that support regulation. Dr Greenspan first identified those as SAM (Sensory, Affective, and Motor). Those are bottom up capacities that may need intervention to support higher level function. And I would look at executive functioning to see how those higher level processes might need support.

In Sensory I am going to be looking at the child's ability to modulate sensation (do they over or under respond and does that tip them into a nervous system activation or deactivation), as well as their ability to discriminate (get detailed information from) sensory information.

When I look at Affect I am looking at whether or not they have a sense of felt safety and do they feel connected to the people they are with. If not, how can we create that connection and what do we need to do to provide a sense of felt safety for the child. Always remembering that felt safety is all about how we perceive safety. Not just whether we are physically safe in the moment.

In Motor I am going to be looking at how basic motor capacities support regulation. Does the child have a well coordinated suck/swallow/breathe? Are they a mouth breather? Do they have the postural control to have graded, well coordinated movement? Are they breathing in 3 dimensions? Are they able to maintain good alignment and move without using compensations?

We can also look at executive functioning skills, if these bottom up processes are supporting regulation and the child just needs strategies and practice to build capacity.

ALL of these things are within our scope as OTs!

A therapist asks for a handout describing how to do tactile desensitization using texture play progressions

For the sake of discussion...systematic desensitization is not a sensory integration intervention. I know you didn't say you were following a SI perspective, but I think that it is important that we distinguish this in our field.

When we think about it from a sensory integrative processing perspective we think about the two ways sensation is processed: through evaluative circuitry that is judging the valence (pleasure to discomfort) of the sensation and modulating the response/recovery of our nervous system for the purposes of regulation; and through discriminative circuitry that is taking in the details of the information for the purposes of skill (see Tracy Stackhouse's work for more details).

Systematic desensitization can work if the client has a motivational bias that allows their nervous system to be open and to push themselves for the purpose of meeting their own goal; or if the relationship with the person driving the intervention is so strong and the association so positive that something that was previously perceived as negative gets recoded as positive. That does not happen when we have a goal of a child "tolerating" the activity while their body and brain are still coding it as a negative experience. It also is less likely to generalize to other tactile mediums because you are not necessarily shifting the nervous system in a way that decreases stress and creates openness to sensation.

A therapist on the thread shared a handout and I offered a further response

The authors of this handout name finger splaying as a sign of negative response. I would also recommend looking for things like breath holding, whole body extension patterns, increased heart rate, flushing, yawning, elevated shoulder/tension etc. All of these are signs that the nervous system is coding this experience as negative. While this approach may work for some kids it feels very cumbersome and in my experience would not work for a child whose sensory defensiveness causes their nervous system to be tipped into a protective response. I would address nervous system dysregulation directly and often the outcome is increased tolerance of sensory inputs without me specifically teaching tolerance.

A therapist asked for the strategies for interoception activities in early years, especially where there is under sensitivity that impacts toileting.

Most importantly , a sense of felt safety comes first. Our interoceptive awareness is inhibited when we are experiencing any perception of threat. Facilitating a sense of felt safety may require sensory supports or facilitation of motor patterns, and it will always require emotional /affective relationship based supports. Learning to notice signs of regulation/dysregulation in breath and motor patterns is one of the most effective things we can do as therapists. When we can observe those outward signs we have a better understanding of when to support and when to challenge. If the client doesn't have a feeling of felt safety, their brain literally shuts down interoceptive awareness.

Beyond that, with littles I think that doing any activity and helping them to notice their own body sensations while they are doing that activity is the best way to go.

It is often easier to start with exteroception (Tactile, auditory, etc) and then move to internal sensations, starting with muscluskeletal because that is easier to notice by creating tension etc.

It is important to remember that state regulation changes from moment to moment. And when we are even slightly dysregulated, our interoceptive abilities shift. So, a child might notice their need to go to the bathroom when they are sitting at home reading on the couch, but not when they are on the playground experiencing some sympathetic activation of the nervous system.

I am reminded in writing this that it is truly all about integration. We are a dynamic system and intervention can never be on one system in isolation.

The question was:
A CEU about sensory processing I am watching says that OVER-responsivity to sensory input (specifically vestibular, prop) could be seen in children who are quiet, passive, and hesitant to move. They are easily overwhelmed by the input that they receive which is why they withdraw from input and manifest those behaviors. On the other hand, children who are UNDER-responsive are those that are always 'on the go' and constantly seek movement and input, because they are not receiving enough from their environment.

However, the STAR institute and other similar websites says the opposite. "Individuals who are under-responsive to sensory stimuli are often quiet and passive, disregarding or not responding to stimuli of the usual intensity available in their sensory environment. They may appear withdrawn, difficult to engage and or self-absorbed because they do not detect the sensory input in their environment."

Both explanations make sense to me, and the second explanation is what I know from grad school. I know sensory processing is very complicated, but some more clarifications on the 'general rule' would be very helpful to a new grad.

This is a great question! And it is a place that as a profession we have not gotten the answer quite right. We have, in an attempt to make a complicated issue easier to understand, tried to reduce this to a linear continuum, but it can't really be seen as a linear continuum. It is more complicated than that.

Saying that a child is over or under responsive isn't enough. The reason that it isn't enough is that it doesn't lead us to a clear idea of how we would treat the child. 

The first issue is that sensory modulation is happening on a physiological level, but we are also observing it on a behavioral level. So when we talk about how a chlid is responding, we have to know whether we are talking about whether they are physiologically responding to thresholds that are higher or lower than typical, or are we talking about their behavioral response to those threshold. 

A person could be over responsive (threshold for stimuli is much lower than is typical) and defensively responding (having an adverse reaction) OR they could respond to this lower threshold by shutting down becuase they are overwhelmed. So a child with overresponsivity to sensation could look like they are avoiding, fighting back, or they could look very passive. 

And to complicate it further, they could be over responding in a particular sensory channel and not in another.

A person can be under responding on a physiological level (meaning their threshold for input is high..they need more for their body to respond) and that could mean that they seek more information to try to hit that threshold. OR, it could mean that they don't get enough input and look very passive, because they aren't getting enough information to the brain to fuel their body to interact with the environment.

Tracy Stackhouse has helped me to understand all of this better. And she has also put another question into my thinking when I see a child...She has taught me to take note of not only how is the child responding initially, but also, what is their recovery. Some kids respond with a fairly typical response to a sensory stimuli, but never recover to their baseline, so multiple stimuli add up to being pushed out of their window of tolerance (which again can result in an active sympathetic response, an avoidance response, or a shutdown response).

To further complicate it, we can't separate out sensory modulation from regulatory functions. For instance, when we are in a heightened state of autonomic arousal, our sensory modulation turns up our sensitivity in lots of sensory channels (typically auditory, tactile, vision) and turns DOWN our sensitivity in others (interoception). So we need to know about the state of the nervous system to know how that is interacting with the sensory modulation function to determine an appropriate intervention.

Tracy Stackhouse is doing a beautiful job of teaching this information in a way that, while complicated, is more understandable for me because it aligns with the brain. She relates our sensory modulation and sensory discrimination capacities to the way that our brain takes in and processes sensory information for the purposes of use. You can hear her in Spirited Conversations podcast.

Good for you for seeing this inconsistency. It is a problem in our field that this information isn't clear. But I think that we are headed towards more clarity. 

A therapist recalled ideas she had heard about spinning and asked for people to chime in on spinning as an intervention. She recalled rules and guidelines on spinning being up regulating and needing to be done in both directions.

We have to know why we are using spinning. The brain processes vestibular information for the purposes of awareness of body position relative to gravity, to understand start and stop, for regulation, motor control and praxis, and as the foundation for oculomotor control. We need to know whether we are working on modulation (response and recovery to input for the purposes of regulation) or discrimination (helping them to understand the details of the information they are taking in through the semicircular canals for the purposes of motor control, regulation etc), because it would lead us towards very different choices.

There is a misconception that spinning is always upregulating, but that isn't true. The semicircular canals are heavily tied to the parasympathetic system, which is why we get nauseous sometimes after spinning, and why kids fall to the ground and have decreased muscle tone when they are spun. So for some kids, it is down-regulating. For other kids, the effects are up-regulating, maybe because they are sensitive to movement and get overstimulated, or maybe because they can't make sense of the information from their vestibular system and that leads their nervous system to feel dysregulated resulting in behavioral responses and increased arousal. So we need to understand how a child is responding and how they are recovering from input to work on modulation.

When we are working on discrimination we have to pair the input with other activity (oculomotor tracking, balance tasks, etc) because that is how we use vestibular information for skill and pairing specific vestibular experiences with skilled action can build capacity.

There are 6 semicircular canals and if we were spinning to target all of them we have to put the head in different positions to do so. The blog provided by another commenter recommends spinning in prone extension, but doesn't specify head position. If the child is lifting their head to be upright (looking at the horizon) it is providing the same input to the semicircular canals as if they are spinning in sitting. Likely she meant with the nose pointing to the ground, which would change the position of the semicircular canals in relation to gravity, giving more intense stimulation than they would get in sitting.

Mary Kawar's course with Sheila Frick are a great place to learn more! Both Tracy Stackhouse has a short course on Medbridge on the vestibular system. Kim Barthel has Visual Vestibular matters that I’d also highly recommend.

A therapist asked about treating tactile defensiveness using desensitization

When I think about treating a child with tactile defensiveness I remind myself that defensiveness is a central nervous system issue. It is not an issue of faulty receptors in the tactile system.

Our sensory receptors (in every system) are constantly changing their receptivity. Depending on the overall state of our nervous system, our sensory receptors become more or less sensitive to input and more or less likely to perceive it as threatening.

You have offered solid strategies so far, and I think it is a matter of tweaking the way that these strategies are delivered.

For those that do not believe in the Wilbarger deep touch pressure protocol, I would suggest looking at the research on deep pressure and its' effectiveness in releasing neurochemistry of regulation. There are many studies in massage that support deep pressure as a strategy to increase serotonin, which decreases the stress response (cortisol/adrenaline). It is true that our research is limited on effectiveness as of yet, but it is not hard to understand why that would be true. Implementing effective sensory diets requires individualization that makes it difficult to study the strategy in a randomized controlled kind of study.

I think what has happened is that the interventions you have offered are not landing in her nervous system in a way that allows her to shift her regulation long term because of the way they are affectively coded.

Affect is the basic building block of emotion, but it is not full blown emotional experience. It is just a basic coding of negative or positive judgment that our body and brain make automatically, under the level of consciousness, in every millisecond. When we offer interventions to address defensiveness they must promote a feeling of "felt safety" to be effective at shifting the nervous system. We can create felt safety from many perspectives (changing the environment, supporting their postural/motor system and breath control if those are issues for them, using our attunement and coregulation etc).

There are red flags in your description of the child's relationship with mom that lead me to believe that the mom is not creating felt safety for the child in a way that would allow home programming to shift her nervous system. That is not to be critical of the mom, but just to say it sounds like she doesn't currently have the ability to provide what is needed to shift the child's nervous system.

The reason it is so important is that every sensation is dually coded with sensation and affect (negative or positive valence/judgement). So we can never address sensation without considering the perceived valence.

It seems like mom would benefit from some parent coaching to understand more about the nervous system and to learn how to interact with the child in a way that respects her nervous system and creates felt safety.

A therapist asks WWYD. OT reports she is evaluating a child that cannot attend to any task, will grab things, is aggressive/hits, and does not follow any directions. She did not feel comfortable taking him on due to her own health and wondered if he needs some ABA to regulate behaviors and then should come back for a OT eval.

I struggle so much in our OT spaces to answer questions like this because the answer I have can sound critical of the person asking the question. Let me preface my answer by saying our field is not supporting therapists to know everything they need to know. There are lots of reasons why...reimbursement, productivity, lack of depth of understanding in many of our continuing education courses, a huge lack of information provided in OT programs because there is only so much that you can cover when you have to teach such a wide variety of knowledge, etc. All that to say, everyone is doing the best they can with what they know. Always. I truly believe that.

That being said, if you don't know how to facilitate the emotional growth needed in this situation, you probably aren't going to help a child like this by providing OT, BUT that doesn't mean that he doesn't need OT. He needs OT from someone who has a great understanding of regulation and social emotional development.

There are bottom up and top down approaches to "behavior". ABA is going to try to "teach" him how to behave rather than facilitating the emotional growth needed to support regulation, interaction, and pro social behaviors. He doesn't have the underlying capacity to learn how to behave in a way that will generalize from a top-down teaching approach. He might improve certain behaviors because he has been punished and rewarded for those specific behaviors, but that isn't how regulation is internalized and it doesn't support the development of healthy social emotional capacity.

A relationship-based approach is going to facilitate him developing the capacity to use co-regulation for the purposes of regulation.

He desperately needs to have an internal sense of regulation and connection to others. That comes from interacting with others in a way that helps him to feel regulated and connected over and over until it becomes an internalized capacity.

There is so much that we as OTs can learn about the affective system, social emotional development, and the approaches we can use to support our kids who are struggling with regulation and behavior. It is not out of scope because our sensory, affective, and motor capacities contribute to every occupation and facilitate our participation in life. All sensory input is dually coded with affective valence and regulation depends on our perception of felt safety through the affective input and interactions we are receiving.

If this information doesn’t sound familiar I encourage you to check out the work of DIRFloortime and the work of OT Tracy Stackhouse. I would also encourage everyone to look at the information coming from autistic adults about the harm done by ABA before you make the choice to recommend it for a child.

It is ok to say that you don’t know how to work effectively with a child who has extreme behaviors. It isn’t ok to say that they don’t need OT.

OT asks what to do for a child who is having difficulty attending to learning tasks in the presence of sights, sounds and activity.

Our ability to filter or modulate sensory inputs is state dependent. Meaning: our body naturally shifts the way that we filter information from the environment depending on the state of our nervous system. When we are in a heightened state of arousal and autonomic arousal we are more likely to tune into sounds in the periphery of our environment, low frequency sounds, and unpredictable sounds. In that state we are also more likely to use peripheral vision and be alerted to things in our environment, rather than the task in front of us. Practicing attending to a task doesn't help if we don't address the often underlying challenge of regulation.

My intervention for a child that has difficulty filtering would be to support their regulation. And often they need support over the course of the whole day to start decreasing their overall stress, not just sensory strategies in the moment. That is a challenge in the school setting, but it is what needs to happen if the expectations are not going to change.

There are also auditory interventions that directly support auditory figure ground by modulating frequencies to exercise that skill, like Therapeutic Listening. TL works on both the state of the nervous system and the skill of filtering sounds.

OT reports: I have a first grade student who presents with handwriting difficulties and a significant resistance to participating in any fine motor tasks. He is able to cut with accuracy and he can write legibly when in the right frame of mind. This is a child who has suffered significant trauma and is manipulating and controlling to staff and students. This kiddo will not work for or with either in or out of the classroom setting. He is verbally aggressive, demanding and unkind. I am having a very hard time working with him. We are not close to meeting any of his goals at this time due to his refusals and behaviors. I am at a loss and need some guidance. His annual is coming up and I am considering discharge because he is unwilling to work on the skills he is struggling with. Help!!

When working as an OT I think that it is helpful to zoom out and think about our activity analysis whenever we are struggling. When we look at the task of handwriting there is a huge range of skills needed, as there is with any task. Included in those skills is the social emotional development needed to perform the task.

I think of the DIRFloortime model and how their developmental progression starts with regulation and connection which leads to the ability to do shared problem solving and have higher level social emotional capacities. The child you describe struggles with regulation and it sounds like it has been a challenge to create connection with him. When we are lacking regulation and connection it is almost always going to be challenging to solve problems together (like the problem of needing to work on a task that the child is not good at and doesn't prefer to do). We might see an area of need in their find motor skills or their visual perceptual skills, but if we don't have a foundation of relationship with the child, we are not going to be able to work on things that are hard for them.

It can be very challenging to attune to and connect with some kids, but I think that it is part of our job. I've found DIRFloortime, the work of Robyn Gobbel (psychotherapist who wrote Big Baffling Behaviors), and the work of Ross Greene helpful in changing my mindset on compliance and working with kids who struggle with affect driven skills.

Working in that way might mean that we spend entire sessions or even many sessions building rapport and strengthening the child's capacity for connection and shared problem solving. At one time earlier in my career I might have worried that I wasn't working on the goal of handwriting if I am not working on fine motor or at least trunk support to do fine motor. But if the biggest restriction in their ability to perform the task is their emotional regulation, then working on that is going to have the biggest impact on my goal.

It isn't easy, for sure. Phrases that help me to repeat over and over are "They aren't giving me a hard time, they are having a hard time" and "All of us are literally doing the best we can in every moment, given the state of our neurobiology and the level of support". I hope that you find the support you need to approach this child from a different angle, find a way to connect, and build his capacity for doing hard things.

An OT says: I’m really struggling with imposter syndrome lately. The majority of my caseload is sensory clients, which I love. But sometimes I feel like sensory is just not super tangible and usually the clients parents don’t have a clear goal, other than making life easier. Especially struggling with the under 3 crowd.

I feel very lost sometimes in the sensory world despite a lot of CEU in this area. And I feel like the more I learn, the harder time I have trying to balance everything. Like learning about neuro-affirming practice - I’m all for it, but at the same time it’s so tricky now to figure out my role in sensory within that framework.

Has anyone been in this spot and felt like they found a path forward?

This is such a common conundrum and I think it stems from the fact that our models for understanding "sensory" are not adequate. The models that many of us work off of that categorize kids and under responsive, over responsive, sensory seeking etc. are an oversimplification of a complicated process. They were created to do research or explain SI to families but they have become the way that OTs learn about sensory integrative processing and they are limiting.

The problem is that they don't accurately represent what is happening in the nervous system, so they don't lead us to knowing what to do! There are also a lot of people teaching "sensory" courses that don't truly understand sensory integrative processing and are only teaching what they understand based on those models. Their ideas will work for some kids. But often the generalizations that are made do not work reliably, and then we get the feeling that "sensory isn't the problem" or "sensory interventions don't work", when in actuality the problem is that we don't know how to apply the principles of sensory integrative processing with precision and specificity.

I had wonderful mentors who taught me solid treatment principles for my whole career. They were mostly clinicians who learned directly from Jean Ayres or were in that generation of therapists. In my opinion they understand SI from Ayres perspective, which was grounded in the neuroscience. The generation of therapists who learned SI from Dunn's model or from the Miller et al nosology (which characterizes under responding, over responding and seeking as the categories of dysfunction of modulation) are often not teaching from an understanding of the neuroscience.

I have recently seen ads and interactions on FB with popular "sensory" course instructors who obviously do not understand the underlying mechanisms of sensory integrative processing. It is so frustrating to know how many people are taking their courses because they want to be better therapists, but instead they are receiving limited or even false information. AOTA approval does not guarantee that the course is providing quality information, just that they can relate 5 recent research articles to their material, but that is how some people are validating their information when questioned...by saying that the course is AOTA approved so you can trust them. I hope that your course work has been better than that and that you are just still wrestling with the concepts. All of us who love SI interventions are continuously working toward a deep understanding. It isn't easy!!

Even with my wonderful mentors, it wasn't until I found the work of Tracy Stackhouse that it all truly clicked for me. The foundation of her work is the understanding of the structure and function of our brain and body. She teaches the functions of sensory modulation and sensory discrimination, based on the sensory pathways and circuitry and the unique ways that they process sensation. Sensory integrative processing cannot be understood without knowing how sensory modulation and sensory discrimination interact with our regulation capacity, because of the way that these functions are entertwined in our brain structure. Studying Tracy's work (which directly reflects Ayres work) has allowed me to see kids with more precision and solid clinical reasoning. The Dunn and Miller models lead to confusion when you don't understand how their representation of SI theory is limited. The foundation of Tracy's work is "theory neutral"; meaning it isn't her model of explaining SI, rather it is based on the widely accepted neuroscience as a basis for understanding.

When we understand sensory integrative processing from a foundation that allows precision and accuracy, it makes it easier to consider whether the work we are doing is neurodiversity affirming. Winnie Dunn will say that we should be understanding sensory processing for the purposes of making accommodations. And there are many that believe that a neurodiversity affirming way of practicing would not involve trying to "change" a person. However, Sensory Integration from a current Ayres perspective is not trying normalize processing. Variation is the norm and the world is better because of our differences. But if a child's sensory integrative processing is limiting their adaptability in a way that makes it hard for them to interact with their environment (and the people in it) in meaningful and joyful way, then it is so important that we provide support for their nervous system in a way that allows them to do the things that they want to do. If accommodations require that they must limit their interaction with the world to be comfortable in their body, then we need to be able to offer more than accommodations.

All that being said, it is HARD. It is complicated. I recommend finding mentors and groups of people that really understand and love their work. Two day courses that give you formulas or prescribed ways of applying sensory input are not enabling the deep clinical reasoning that allows for precision and efficacious treatment.

This is obviously a soapbox for me. I appreciated your question so much and I wish that I could bequeath you with the knowledge needed. I wish I had all the knowledge needed. My hope is to inspire you to keep going and find mentors that can help you understand sensory integrative processing on a deeper level because it is fulfilling and exciting work.

I took a course with Tracy this past weekend and she said that her ultimate goal is to inspire confidence and curiosity. Imposter syndrome means that you are willing to say you don't know everything, and that is what I tell OT students I want them to leave school being able to do. I hope that your curiosity leads you towards a deeper understanding. The way that you wrote your post makes me think that it will.

How do you handle kiddos dropping to the floor and refusing to participate? I have a non speaking autistic boy on my caseload, 6 years old: will drop to the floor and refuse all activities unless they’re preferred (occasionally) and will just say “no” and shake his head. I can’t get anything done. I’ve tried social stories and visuals but he knows he doesn’t want to do it so refuses. I’d love any tips!

It sounds like the things you want to get done are challenging for him and he doesn't have the capacity to maintain regulation when there is even a small challenge.

I think that often the challenge for us as therapists is knowing how to expand regulatory capacity. When we see the child as being able to regulate and choosing to have a behavioral reaction when doing a non-preferred activity, it can lead us to feeling frustrated or using behavioral modification to motivate. When we see a child as being unable to maintain regulation when challenged, we can reframe our intervention to build robust regulatory capacity.

One way of building regulatory capacity is to expand the child's ability to use co regulation for the purposes of regulation. We all know that co regulation is necessary for young children and we do not expect them to regulate independently. When we provide co-regulation through sensory experiences and a connected relationship, we are not only helping the young child in that moment, we are also building their capacity to access those brain connections of regulation in moments when we are not present. Providing co regulation over and over builds the capacity for self-regulation.

When we have an older child who is struggling with self-regulation it is easy to assume that it is a choice or that we can talk to them about it to help them understand how to be more regulated, but that isn't the way that self-regulation is built from a developmental standpoint, and so that way (social stories, self-regulation lessons etc.) is a much slower way to build regulation. Building self-regulation through co regulation is a much more efficient way to build regulatory capacity.

What I find most therapists struggle with is knowing how to measure progress in building connection. We can feel like we are a nice person who is doing our best to connect with the child and we can feel like they are connected.... until the moment that we challenge them. When we see that as an indicator that they cannot maintain regulation, we can focus our efforts on ways to maintain regulation. Rather than providing challenge after challenge, we can build capacity by increasing the amount of time they can stay in connection.

The functional emotional developmental capacities (FEDC's) in DIRFloortime have really helped me to see ways of quantifying connection and the ability to maintain regulation. They help you to think about things like: does this child feel connected to me? do they feel like we are in this together? how many back and forth interactions can we have and how can I increase that number to increase our connection? When I have that in mind, I can stay in an interaction with a child without increasing the task demands, and still have a way to measure progress.

Eventually, when we can stay in an interaction together (doing something that is preferred), we might come to a "problem" that the child wants to solve. The key there is that the child wants to solve it, and that allows us to be their partner and build our relationship by solving the problem together. Maybe they want a toy that they can't reach. And we can work with them to solve the problem, without just doing it for them. That practice solving a problem builds their capacity for connection, problem solving, and ultimately, self-regulation.

Eventually that capacity for problem solving, connection, and self-regulation can carry over into helping them participate in non-preferred activities. They need to not only have the ability to be regulated in moments that are easy for them; they also need to be able to maintain that regulation and be able to tolerate challenges.

The most important thing is being able to see the child's regulation from a developmental perspective because it allows us to meet them where they are, rather than expecting them to be able to regulate in the face of challenge, when that isn't within their skill set.

Having a way to quantify connection and regulation is helpful for me because it allows me to stick with building regulatory capacity and see how I am making progress, without increasing the demands of the task. Once the child has the ability to maintain regulation and solve some problems together, I can start to introduce activities that challenge other aspects of development.

Can someone explain the difference between sensory processing disorder and sensory integration disorder? New school-based OT here.

I’ve done some googling/research but I’m seeing mixed things so just curious if anyone has experience with this!

That is a great question that has a complicated answer. Some people don’t necessarily know why they use “sensory integration” vs. “sensory processing” but there is a back story of where the two terms came from and sometimes the terminology someone is using tells you about their background and where they have learned the information they know.

Sensory Integration is the term that was coined by Jean Ayres to describe a complex process of taking in sensory information for the purposes of use. She described how information is received, interacts with the whole brain, and results in output (usually motor action). Her terminology is Sensory Integration and refers to function (rather than dysfunction). It is a complicated process that involves interactions with the autonomic nervous system and state regulation. She did have categories of dysfunction of sensory integration that were born out of the testing and data including : somatodyspraxia, bilateral integration and sequencing dysfunction, dysfunction of praxis on verbal command, and visuodyspraxia. The SIPT was the test used to assess these categories. The EASi has now replaced the SIPT and has similar categories.

Other clinicians have come along since Ayres’ death and have explained Sensory Integration using simplified models and terminology. Some models describe function (how they conceptualize things might work) , some describe dysfunction (ways of describing when things aren’t working well).

One of those was Lucy Jane Miller. In her “nosology” LJM came up with a nomenclature of disorders of sensory processing (Sensory Processing Disorders). She was trying to get it into the DSM as a diagnosable disorder. This nosology was recently “retired” by the STAR Institute (the organization LJM started) and they are moving towards a more neurodiversity affirming way of viewing what they are referring to as “sensory health”. The SP3D is a test they are working on and it will be interesting to see what diagnostic categories are born out of their data.

The original theories of Jean Ayers are indeed complicated and nuanced and not all of what we do from a “sensory” perspective is going into that depth of understanding or clinical reasoning. Giving a weighted blanket or classroom recommendations is using information gleaned from the original work of Jean Ayres, but it should not be considered as providing a sensory integration intervention.

As far as the umbrella terminology, AOTA and others are moving towards broad and inclusive terminology that honors all of the contributions to our theory base. They are calling it Sensory Integration and Processing. Another similar term that I have heard and like is Sensory Integrative Processing.

Whatever we call it, to truly be providing sensory integration interventions from a sensory integrative processing frame of reference requires a lot of learning beyond OT school. To truly do SI therapy requires a knowledge of clinical reasoning etc that is extensive. Often people are just providing sensory strategies or sensory enhanced play opportunities.

This barely touches on some of the points of confusion in the SI world and terminology, but I appreciate the question!

A therapist asks: How do you handle the interoception curriculum with kids who are overresponsive? I can see its value in increasing awareness for kids who are underresponsive, but would it be harmful to do it with hyperresponsive kids? I have several kids on my caseload now who have goals to demonstrate calming sensory strategies when they're upset, so I'm thinking about going through the curriculum, teaching them to do a body scan, and then use calming strategies. I have one kid who seems to be overresponsive, however, and I worry this will harm him since he is already easily distressed by bodily sensations. On the other hand, being able to narrow down exactly what's wrong and address it seems like it would be valuable to any kid, including this one, and I would focus on more heavy work things for his calming strategies. Does this sound appropriate or should I avoid the interoception curriculum for hyperresponsive kids?

When you say hyper responsive the responsively you describe is on the level of observable behavior, and I'm not sure if you are describing regulation challenges, sensory defensiveness, or both. I think about how everyone's sensitivity to sensory input shifts based on their regulation in the moment. And knowing that I would want to understand what his reactivity and recovery is to sensory input at times that he is regulated vs times that he is not.

If he is responding defensively most of the time that would need to be supported with less cognitive supports (relational and somatosensory soothing) in order for him to be available for top down cognitive strategies like exploring interoceptive awareness. That would be addressing interoception from a sensory modulation standpoint.

Our brain processes information in two ways: through the modulation circuitry (which tells us generally whether the input is good/bad, safe/unsafe) and through the discrimination circuitry (which interprets the information it receives for the purposes of detail).

Sometimes people who have an increased responsivity to interoceptive information respond well to increasing their interceptive awareness (a function of the discrimination circuitry). It seems like the increased ability to distinguish body sensations with more detail allows them to be less responsive because the sensations make more sense and aren't just triggering a protective response.

I can't say for sure what will work for your child, but my guess is that if you have a good rapport with him, can reliably get him to a place where he feels regulated in the session with you and can enjoy playfully engaging in sensory exploration, that the increased ability to pay attention to the details of how he is feeling will be helpful for his regulatory capacity.

A therapist says: I’m a pediatric OT in a hospital based outpatient setting. I have a 5 year old F I’ve been working with for a while with tactile defensiveness to certain clothing, specifically anything that is tight around her waist, underwear, new shoes and leggings. There are some other non-preferred clothing types she doesn’t like but that’s what initially comes to mind. Getting dressed in the morning almost always leads to a meltdown. I’ve provided mom with what i feel is just about every kind of strategy including Wilbarger brushing, picking clothes out night before, not “forcing” her to wear anything (mom always wanted her in fancy dresses, so we had a lot of discussions focused on moms expectations), sensory diet, zones of regulation…. To name a few. I’ve stressed to mom the importance of home carryover. I’ve done sessions with her wear she brought in different types of clothing and we talked about how it feels on her body, what she likes, what she doesn’t like etc.. and she always tolerated even non preferred clothing items during sessions very well. We do episodic care so she just came back to me after a 12 week break and it seems like we are back at square one.

Another therapist commented: If it’s tolerated during sessions but not at home, it’s not sensory. It’s a behavior at this point. You’ll have to work on tolerating clothing when leaving sessions and giving “homework” assignments to wear clothes during the week. I do trials of clothes with sensorimotor activities as a distraction to build tolerance and then transition out with the clothes on.

To the commenter: This is not an accurate assumption. If you look at the neurological connections between the sensory modulation circuitry in the brain and regulation you will find that sensory modulation is a function that is completely state dependent. For example... when you are in a dark parking lot in the middle of the night your sensory systems will be more sensitive to sound, to movement in your peripheral visual field, and light touch on your skin, and your interoceptive awareness will decrease. Those are functions of the sensory modulation circuitry, and they are heavily influenced by state regulation.

All sensation is coded with not only sensory aspects, but also affective valence...negative or positive coding. That changes whether our body perceives the input as being safe or unsafe. That is true of every sensation perceived by our body. Sensory defensiveness is the perception of a sensation as dangerous. The environment we are in and the relationships we have with people in those moments are highly influential on the way we perceive sensation. And not from a cognitive perspective that we have control over....from a non cognitive automatic affective valence based coding perspective.

For more information on sensory integrative processing grounded in neuroscience I suggest the work of Tracy Stackhouse.

As for the original question: I would suggest that there are red flags in your description about the child's relationship and felt safety with her mom. My approach would be to first look at coaching the mom using a relationship based approach. This would provide the affective coding that allows sensory input (like the Wilbarger deep touch pressure protocol) to be regulating for the nervous system.