The Out-of-Sync Child

by Carol Kranowitz

  • Provide a vibrating toothbrush or facial/oral massager to desensitize the child’s lips and mouth

  • Take the child for sensory integration and provide a sensory diet at home. (See Chapter Nine.)

  DIGESTION AND ELIMINATION

  What goes in comes out. What doesn’t go in doesn’t come out. The picky eater who pushes away nourishing foods with naturally bright color, varied texture and lots of fiber—the stuff of stool, if you will—is likely to have chronic diarrhea or constipation.

  Aside from the sensory-based problem of picky eating, SPD may affect digestion and elimination in other ways. The child may not recognize signals of thirst, hunger, and satiety (fullness). This poor awareness of internal organs is a problem with interoception, which is sensitivity to stimuli coming from inside the body. Another cause of poor digestion is inactivity. The child who is sedentary because of difficulty moving his body may also have difficulty moving his bowels.

  Tactile problems may contribute to toileting issues. Underresponsivity to tactile sensations may mean that the child does not perceive wetness, and so he may not develop efficient bladder control. (Thick disposable diapers that carry wetness away to keep the child comfortably dry are part of the problem!) He may develop enuresis (en-yu-ree-sis) and become a chronic bed-wetter.

  Or, if he is a sensory craver, he may actually like how a fully loaded diaper or pair of underpants feels. Or smells.

  In addition, inefficient proprioception (the “body position sense,” or the “muscle sense,” discussed in Chapter Five) may affect the child’s muscle tone and make it hard for him to “hold it.” A problem with postural control may make it difficult to stay poised on the toilet seat. A problem with the vestibular sense may make him feel unbalanced and ungrounded, as if he is falling off the toilet—or worse, in.

  Suggestions include:

  • Plenty of water, fiber, and active movement throughout the day

  • Telephone book, box, or stool under the child’s feet to help him feel grounded

  • Working with an occupational therapist, nutritionist, or other professional with expertise in eating disorders and sensory processing

  AROUSAL, ACTIVITY LEVEL, AND ATTENTION

  Arousal, activity level, and attention are self-regulation problems that frequently coexist with SPD.

  • Unusually high arousal and activity level: The child may be always on the go, restless, and fidgety. He may move with short and nervous gestures, play or work aimlessly, be quick-tempered and excitable, and find it impossible to stay seated.

  • Unusually low arousal and activity level: The child may move slowly and in a daze, fatigue easily, lack initiative and “stick-to-it-tiveness,” and show little interest in the world. She may have been an easy baby—in fact, a too easy baby, who nestled into anybody’s arms, rarely complained, slept more than other children, and needed to be fed and dressed later than others.

  • Inattention: Perhaps because of sensory over- or underresponsiveness, the child may have a short attention span, even for activities he enjoys. He may be highly distractible, paying attention to everything except the task at hand. He may be disorganized and forgetful.

  • Impulsivity: To get or avoid sensory stimulation, the child may be heedlessly energetic and impetuous. She may lack self-control and be unable to stop after starting an activity. She may pour juice until it spills, run pell-mell into people, overturn toy bins, and talk out of turn.

  SOCIAL AND EMOTIONAL FUNCTIONING

  Another coexisting regulatory problem may be how the child feels about himself and relates to other people.

  • Poor adaptability: The child may resist meeting new people, trying new games or toys or tasting different foods. He may have difficulty making transitions from one situation to another. The child may seem stubborn and uncooperative when it is time to leave the house, come for dinner, get into or out of the bathtub, or change from a reading to a math activity. Minor changes in routine will readily upset this child who does not “go with the flow.”

  • Attachment problem: The child may have separation anxiety and be clingy and fearful when apart from one or two “significant olders.” Or, she may physically avoid her parents, teachers, and others in her circle.

  • Frustration: Struggling to accomplish tasks that peers do easily, the child may give up quickly. He may be a perfectionist and become upset when art projects, dramatic play, or homework assignments are not going as well as he expects.

  • Difficulty with friendships: The child may be hard to get along with and have problems making and keeping friends. Insisting on dictating all the rules and being the winner, the best, or the first, he may be a poor game-player. He may need to control his surrounding territory, be in the “driver’s seat,” and have trouble sharing toys.

  • Poor communication: The child may have difficulty verbally in the way she articulates her speech, “gets the words out,” and writes. She may have difficulty expressing her thoughts, feelings, and needs, not only through words but also nonverbally through gestures, body language, and facial expressions.

  • Other emotional problems: He may be inflexible, irrational, and overly sensitive to change, stress, and hurt feelings. Demanding and needy, he may seek attention in negative ways. He may be angry or panicky for no obvious reason. He may be unhappy, believing and saying that he is dumb, crazy, no good, a loser, and a failure. Low self-esteem is one of the most telling symptoms of Sensory Processing Disorder.

  • Academic problems: The child may have difficulty learning new skills and concepts. Although bright, the child may be perceived as an underachiever.

  Please note: Many children with SPD have behavior problems. However, most children with behavior problems do not have SPD! Every child is occasionally out-of-sync. Careful diagnosis is imperative to determine which symptoms are related to sensory processing problems, and which are not.

  Attention-Deficit/Hyperactivity Disorder (ADHD)

  While SPD is not the same as its “look-alike” ADHD, the two disorders may simultaneously affect the out-of-sync child. Attention-Deficit/Hyperactivity Disorder (ADHD) is an umbrella term for a problem interfering with one’s ability to attend to and stay focused on meaningful tasks, control his impulses, and regulate his activity level. Symptoms of this neurologically based disorder are hyperactivity, inattention (distractibility) and/or impulsivity.

  Determining if the child has one and not the other matters, because treatments for the two problems differ. Treatment for ADHD often involves behavior management and other psychological approaches, as well as psychostimulants such as Ritalin, to make the child’s brain available for learning.

  Dr. Lucy Jane Miller, PhD, is the principle investigator in the field of sensory processing research at The Children’s Hospital of Denver. She collaborates with other occupational therapists to define the underlying neurological and physiological foundations of SPD. The goals of this rigorous research include: 1) distinguishing SPD from ADHD and other disabilities, and 2) determining the best treatment for children with different types of SPD, because one treatment does not fit all.

  Among the researchers’ findings is evidence that many children with SPD differ from children with ADHD in their responses to unexpected sensations, such as light touches, loud noises, flickering lights, strong smells, and being tilted backward in a chair. Children with ADHD tend to alert to these novel sensations and then, like most people, habituate—i.e., become easily accustomed—to them. Life goes on.

  Some children with SPD, however, may not alert to these everyday sensations. Life does not affect them much. Other children with SPD may be continually on alert and may not become accustomed to the sensations at all. Life affects them too much.

  Outside the research laboratory, parents and teachers may notice other differences between SPD and ADHD. For instance, many children with SPD prefer the “same-old, same-old” in a familiar and predictable environment, while children with ADHD prefer novelty and diversion.
Many children with SPD have poor motor coordination, while children with ADHD often shine in sports. Many children with SPD have adequate impulse control, unless bothered by sensations, while children with ADHD often have poor impulse control.

  Another difference is that medicine may help the child with ADHD, but medicine will not solve the problem of SPD. Therapy focusing on sensory integration and a sensory diet of purposeful activities help the child with SPD.

  Learning Disability

  A learning disability (LD) can be defined in many ways:

  1) Simple definition: A learning disability is difficulty in the Four R’s—Reading, ’Riting, ’Rithmetic, and Relationships.

  2) Clinical definition: A learning disability is a neurological problem in processing information that causes difficulties mastering academic skills and strategies. A breakdown occurs in one of the four steps involved in learning: input (taking in information from the senses), integration (processing and interpreting the information), memory (using, storing, and retrieving the information), and output (sending out the information through language or motor activities).

  3) Formal definition: Our federal law, Individuals with Disabilities Education Improvement Act of 2004 (IDEA 04), defines a specific learning disability as “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations.”

  While SPD may affect the child’s auditory, visual, and motor skills and her ability to process and sequence information, it is not, at present, specifically identified as an eligible, qualifying disability. Thus, it does not necessarily make a child eligible for special education and related services, such as occupational, physical, or speech/language therapy. A child with SPD may be eligible for services if SPD coexists with an eligible disability and contributes to a child’s difficulties with participation in her educational program.

  Dyslexia

  Dyslexia is a common difficulty in reading, writing and spelling, despite a person’s intelligence and motivation. Dyslexia is many things: a neurological disorder; a hereditary, familial problem; a specific learning disability; and a syndrome, i.e., a group of related characteristics varying in severity from one individual to another.

  Sensations of sight, sound, and movement are involved in reading. The problem is in the way different brain parts simultaneously process the sensory components of reading. The timing involved in analyzing a word is out of sync, preventing instantaneous, automatic word recognition.

  Children with this multisensory syndrome can benefit from multisensory intervention, integrating visual, aural, tactile and kinesthetic (i.e., sight, sound, touch and movement) experiences.

  Autism

  Autism is a neurobiological disorder. The structures of the brains of people with autism are atypical. Research is pointing to differences in overall brain size and the numbers of certain cells; to abnormalities in the cerebellum that affect motor, sensory, language, cognitive and attention functions; and to altered genes that interfere with brain development. A new “underconnectivity theory” suggests that autism interferes with efficient integration, timing, and synchronization of brain activation patterns.

  Autism, or the umbrella term, Autistic Spectrum Disorders (ASD), is not one thing but many. Like SPD and LD, the term autism encompasses a wide array of symptoms. In broad terms, autism is a Pervasive Developmental Disorder (PDD) that affects verbal and nonverbal communication, social interaction, imagination, and problem-solving. Autism is usually evident before the child turns three and greatly affects educational performance. It causes the child to engage in repetitive motions and have a narrow repertoire of activities and interests.

  Another component of autism—and a very important one—is difficulty with sensory modulation, sensory discrimination, motor planning, and sequencing. Problems with sensations are sometimes overlooked or downplayed but are among the main areas of impairment.

  Every child with autism has a unique pattern of these challenges. For example, one autistic child may have excellent visual discrimination and be an incredibly talented artist but have poor auditory discrimination and relatively little language. Another child may have excellent auditory skills and remember song lyrics, compose rhymes, and enjoy stories, but have poor visual discrimination and meager motor-planning skills.

  Most children with autism have poor regulation, or modulation, of ordinary sensations. For some, the capacity to regulate touch, movement, sound, and visual stimuli will always be troublesome. However, for others, environmental sensitivity can be a bonus. For example, a keen sensitivity to sounds, including perfect pitch, may lead to a career in music.

  A spokesperson for autism, Temple Grandin, PhD, eloquently describes the torment of sensory stimulation. As a child, being touched and hugged by another person made her feel like a wild animal, until she designed a squeeze machine—her “hug box”—to satisfy her craving for the sensation of being held. Hearing ordinary sounds still makes her heart race and her ears hurt, unless she “shuts off” her ears by engaging in rhythmic, stereotypical autistic behavior.

  Whereas little Temple avoided touch and sound sensations, she craved visual sensations. “I loved striped shirts and Day-Glo paint,” she writes, “and I loved to watch supermarket sliding doors go back and forth.” Equipped with intense visualization skills, and simpatico with animals, Dr. Grandin grew up to earn her doctorate in animal science. Today, she specializes in the design of humane livestock-handling facilities.

  That most people with autism have some degree of SPD is a recognized fact. Understanding how sensory and motor problems complicate the child’s daily life is crucial for designing an appropriate intervention program. Parents must ensure that their child’s treatment program includes ample sensory-motor experiences and an individualized sensory diet. (See Chapter Nine.)

  Asperger Syndrome

  A subtype of autism and another form of PDD is Asperger Syndrome (AS). Most characteristics are similar to those of autism. Exceptions are that the child with AS may function better in social situations and at school and that he uses more typical speech and thinking patterns. Often the child is dubbed a “Little Professor,” because of his extraordinary depth of knowledge about a particular subject, such as the Civil War, railroads, the planetary system, and so forth.

  People with Asperger Syndrome tend to be anxious, poorly coordinated, and eccentric. They frequently have difficulties with hearing, vision, moving, touching, and other sensory areas. Sensory integration treatment often will lessen their anxiety and clumsiness and improve their social participation.

  Nonverbal Learning Disorder

  Nonverbal Learning Disorder (NLD) is a neurological syndrome that causes a person to have difficulty interpreting and understanding nonverbal cues in the environment. The name of the disorder may be confusing, because it seems to imply that the person is nonverbal. In fact, the person is quite verbal and expresses himself well; it is the nonverbal parts of communication like smiles and waves that he has trouble interpreting.

  One of the major deficits of the child is difficulty processing sensory information. SPD underlies the child’s problems with coordination and balance, visual discrimination, and the ability to comprehend gestures, facial expressions, and social cues. For children with NLD, sensory integration therapy can be very beneficial.

  Psychological Problems

  SPD is a physical problem, not a psychological problem, per se. It may certainly overlap with, and add to, psychological problems. As the child matures, serious psychological problems may develop, indeed, if the underlying SPD is neither recognized nor addressed early. The inability to cope with emotional, physical, and social challenges is often present by the age of three or four if sensory integration intervention has not yet begun.

  Distinguishing SPD from mental and emotional disorders is as important as distinguis
hing it from ADHD, because the treatments vary greatly. Unfortunately, symptoms of SPD are often misinterpreted as psychological problems.

  An example is Obsessive-Compulsive Disorder (OCD). Say a child washes her hands many times a day. Repetitive hand washing is a common symptom of OCD. But is it possible that the child goes frequently to the sink to wash away tactile sensations from her oversensitive palms?

  Another look-alike problem is Bipolar Disorder. A child with this psychological disability shows many symptoms that a child with SPD may have: depression or sadness, difficulty falling asleep, risk-taking behavior, extreme sensitivity to sensory stimuli, difficulty engaging in play, reluctance to engage in novel tasks, fidgetiness, and so forth. Could the problem be manic depression—could it be SPD—or could it be both?

  Selective Mutism

  Selective Mutism (SM) is a childhood anxiety disorder. It is characterized by a child’s inability to speak and communicate comfortably in select social settings, such as school or a friend’s house, where answering questions and having conversations are expected. A child with Selective Mutism is able to talk normally in settings where she feels secure and relaxed, such as home.

  In addition to this debilitating social anxiety, children with SM often have SPD. They may withdraw from some sensations and seek others, such as playground swinging.

  Experts speculate that sensory processing problems play a role in triggering the overwhelming anxiety that causes some children to withdraw and become mute. Addressing sensory needs is a successful means to help them “get the words out.”

  Genetic Syndromes

  A host of other disorders and genetic syndromes are characterized by sensory problems.

  Down Syndrome is a congenital disorder caused by an extra chromosome. The condition alters the typical development of the brain and body, causes mental retardation and affects the child’s sensory processing. Common problems include poor muscle tone and difficulties with fine-motor and gross-motor skills that affect movement and coordination, play and self-care, speech and eating.