Why is “Is it sensory or is it behavior?” the wrong question to ask?
The question “How do you know if it is sensory or behavior?” comes up over and over again in the world of occupational therapy practitioners (OTPs) and I have addressed it on a surface level in this blog that has been widely shared and viewed several hundred thousand times. Many times, when I see the question since writing that blog, I just share a link. But today I took the time to write out a longer answer for those who want to understand the basics of why it is the wrong question to ask.
1. There is a levels of analysis issue. “Behavior” is an outcome. It is what we can see happening on the outside as the person interacts with the world. “Sensory”, in our OT profession, is slang for sensory integrative processing, a process that is happening on a neurophysiological level in our brain and sensory receptors. We can’t make assumptions about what is happening on the level of neurophysiology (one level of analysis) just by observing behavior (another level of analysis). Questionnaires can be helpful to gather information about behavior, but interpreting what is happening on the level of neurophysiology takes more advanced clinical reasoning, since we don’t currently have tests that can tell us what is happening in the brain and sensory receptors.
2. Many of the same observable behaviors can be caused by a wide range of underlying issues. For example: sensation seeking is a behavior that is often mentioned. Sensation seeking can be happening for many reasons. For example it could be happening: because we are using that sensory input to calm our nervous system (think of rocking a baby or hugging ourselves when we are scared); or because our brain hasn’t figured out how to process the details of the information and keeps trying to get more to make sense of it (think of a toddler walking up and down a ramp until they master that task); or because the amount of information we need for our brain to be aware of that information is more than is typically expected, or we might be sensation seeking because of something as simple as we are tired. It takes more than observing a behavior to know why it is happening.
3. The word “sensory” isn’t specific. Sensory integrative processing encompasses two different ways that sensory information is processed in the brain: 1) through evaluative brain circuitry that is responsible for modulating our response and recovery to the million bits of sensation that are coming in every second, and 2) the brain circuitry that is responsible for discriminating the details of that sensory information. The way we work on sensory modulation challenges and the way we work on sensory discrimination challenges is very different. We need to understand whether the issue is a sensory modulation or a sensory discrimination issue to know what we can do to support their system.
4. The question “Is it sensory or is it behavior?” is a false dichotomy. On the surface, it is a compassionate question. Asking if the behavior we are seeing is coming from a “sensory” origin encourages adults to assume a less judgmental stance on the behaviors they are seeing, if the child has sensory integrative processing challenges. But underneath the question “Is it sensory or is it behavior?” is the assumption that if it is not “sensory” it is “just behavior”. To most people that implies it is a willful choice, if it isn’t “sensory”. But there are lots of reasons for behavior that we need to consider other than a child’s sensory integrative processing before we decide that they are just choosing to misbehave.
5. Behavior is affected by our sensory integrative processing but behavior is also affected by: our attention, the expectations, the environment, our level of comfort and relationship with the people we are with, our personal history and experiences, our ability to use our body efficiently, our emotional maturity, our executive functioning, our health, our cognition, the list goes on and on. Even our ability to breathe efficiently affects our behavior and may not have anything to do with the way we are processing sensation. Many things on that list are things that can be addressed by an OT, so ruling out “sensory” doesn’t mean that it is “just behavior”, and it doesn’t mean that it can’t be addressed by an OT.
6. Even if there is an underlying sensory integrative processing challenge, a sensory strategy might not work. The question “Is it sensory or is it behavior” is a question that is often asked by people who are wondering whether a sensory activity can be suggested and used to “fix” the behavior. But sensory strategies are not the same thing as supporting the child’s sensory modulation or sensory discrimination functions. You absolutely cannot say that you gave a child an opportunity to use sensory strategies and it did not change their behavior and conclude that “the issue isn’t sensory”. Sensory integration interventions are sophisticated, specific to the child, responsive, and require a high level of clinical reasoning to implement effectively. Our profession has watered down that information and now all pediatric OTs are expected to know “sensory” despite a lack of training in sensory integrative processing.
7. On the other hand, even if it is volitional behavior, it can be supported by sensory strategies. Think of a toddler who is throwing a temper tantrum because they didn’t get something they wanted. Giving them a hug, or something to drink, or getting their body moving are all sensory strategies that can support them shifting their behavior, regardless of whether they have an underlying sensory integrative processing challenge. Our children NEED more sensory opportunities and we should be advocating for that in all of our systems.
8. When we say “sensory” we often do not understand that sensory information is dually coded with affect. Every sensation has information about the sensory qualities of the sensation (like the texture, or the volume, or the position of a joint), but that’s not all. That sensory quality is dually coded with positive or negative valence. That valence tells us if the sensation is safe or threatening, good or bad for us, something that we want to approach or avoid. Think of reaching into a bag and feeling something slimy. It isn’t just the slightly wet and soft texture that we notice. For many of us there is also an “icky” feeling. Or maybe, instead, we are someone who loves playing with slime and we have a pleasant feeling as a result of that texture and want more of that sensation. That affective valence is dually coded with every sensation we take in.
So it isn’t just about the quality of the sensation but the WAY that sensation is delivered when we provide sensory inputs for the purpose of changing behavior. It matters whether the sensation is comfortable for our nervous system or not and whether the sensation is received within a connected relationship or not. It all affects how we process the sensation and how our brain responds.
Think of how a rub on the back from a trusted loved one feels very different than a rub on the back in a dark alley from someone you don’t trust. The way that sensation is delivered matters and if you don’t understand dual coding, you may not teach people to use sensory strategies in a way that would be effective.
I could go on and on. If the things I am saying are new to you, you are probably wondering what you can do. First of all, be compassionate with yourself. Sensory Integrative Processing is complicated and often we don’t learn about it in school. There is also a lot of coursework and information out there that doesn’t encompass a deep level of understanding, and that has hurt our body of knowledge.
A good starting place would be reading the rest of the blogs here.
If you would like to learn more about this topic from extremely knowledgeable sources I will be compiling a list of recommendations soon. Sign up to receive that information with the form below.
If you would like to learn more about self-regulation, an underlying function that affects behavior, I’ve got a course called Empowering Self-Regulation: Learning to be Powerfully You. Learn more on this website or register here.