The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model, W Dunn

Tags: thresholds, Sensory Processing, Sensory Profile, habituation, performance, sensory input, children, Western Psychological Services, Movement, Emotion, Touch, Sensory Integration, Ayres AJ., sensory sensitivity, sensory stimuli, regulatory disorder, poor registration, American Occupational Therapy Association, daily lives, Occup Ther, difficulty, Dunn W. Performance, typical children, behavioral science, Sensation seeking, Young Children, neuroscience, NCCIP Task Force2, functional performance, MAc performance, infants and young children, Dunn W. Motivation, Dunn W. Sensory, Dunn W, Dunn W., Human Performance
Content: The Impact of Sensory Processing Abilities on the Daily Lives of Young Children and Their Families: A Conceptual Model The article describes a proposed model for considering sensory processing an important factor in young children's performance. The author reviews constructs from neuroscience and behavioral science to propose how the transaction among these constructs may provide a framework for understanding various patterns of behavior and for developing methods for handling young children's sensory processing needs in a functional and supportive manner. The author reviews data from a series of studies on the Sensory Profile, a family-report measure of a child's responses to sensory experiences during daily life, to illustrate the utility and possible quantitative support for the proposed model components in young children with and without disabilities. Key words: habituation, modulation, neuroscience, performance, regulatory disorders, sensation, thresholds sensitivity
Winnie Dunn, PhD, OTR, FAOTA Professor and Chair Department a/Occupational Therapy Education School of Allied Health University of Kansas Medical Center Kansas City, Kansas
ALTHOUGH THERE are many frameworks for observing and interpreting young children's behaviors, the role of sensory processing in performance has received increasing attention in recent years.''5 Professionals and parents are recognizing that when young children have poor sensory processing abilities, it can affect social, cognitive, and sensorimotor development.' -b With this awareness, it becomes important to understand the mechanisms that support or create barriers to sensory processing abilities because these mechanisms can also affect functional performance in daily life.7 This article examines some of the key constructs that may be operating to enable young children to create responses to sensory events in their daily lives. We propose that both neuroscience and behavioral science knowledge can offer information that is useful to professionals and care providers who support young children. We also propose that the neuroscience factors provide a mechanism for interpreting behavioral factors, providing insight for practice, because this interaction offers a more complex view of young children's evolving / wish to acknowledge Catana Brown, MA, OTR, for the collaborative efforts in Data Analysis and interpretation, particularly in the scholarly discourse about the meaning of our findings for persons' lives. Inf Young Children 1997; 9(4); 23-35 © 1997 Aspen Publishers, Inc. 23
24 INFANTS AND YOUNG CHILDREN/APRIL 1997 performance repertoires. Data from studies of children's current biobehavioral state. For example, young children
responses to sensory events in daily life (using a sensory can have a slightly or very low threshold for responding to
history called the Sensory Profile) support this initial stimuli. Similarly, young children could have a tendency
thinking about possible model components.
to challenge the thresholds (ie, counteract) or could
aggressively challenge their thresholds. It is also likely
A PROPOSED WORKING MODEL
that young children have variability within their central
We propose that there is an interaction between neuroscience and behavioral concepts, such that the neuroscience concepts can help us interpret young children's behavior and performance. Figure 1 depicts our working proposal about this interaction. Neurological
nervous systems (CNS) on particular days (eg, when more rested or tired) and within particular sensory systems (eg, the system that responds to touch [ie, somatosensory] being more sensitive than the system that responds to movement [ie, vestibular\).
thresholds indicate the amount of stimuli needed for the nervous system to notice or react to stimuli (ie, the vertical
Concepts from neuroscience Neuroscience provides a background for understanding
axis), while the behavioral responses indicate the manner how the sensory receptors receive and transmit stimuli,
in which the young child responds in relation to the thresholds (ie, the horizontal axis). Each axis represents a
how the CNS codes and interprets the information, and how the information gets used to design motor output.8'9
continuum of actions; young children's performance can be The more recent neuroscience literature also emphasizes
characterized at any place along these axes related to the intensity of response and the children's
the importance of modulation of all input as part of optimal CNS functions.10 Modulation is the ability to
monitor and
Neurological Threshold Continuum
Behavioral Response Continuum
HIGH (habituation)
responds in ACCORDANCE responds to
with threshold
COUNTERACT the
threshold
Poor Registration L.
Sensation Seeking
LOW (sensitization)
Sensitivity to Stimuli
Sensation Avoiding
Figure 1. Relationships between behavioral responses and neurological thresholds.
regulate information in the interest of generating an appropriate response to particular stimuli. Key neurophysiological processes related to modulation of input are habituation and sensitiza-tion."'12 Habituation is considered the simplest form of learning in the CNS and occurs when the nerve cells and CNS systems recognize the stimulus as familiar and decrease transmission among the cells because there is not a perceived need to continue to respond to the stimulus.'2 Young children need habituation responses; for example, if a child's CNS continued to send information about how clothing felt, it would be difficult for the child to focus on anything else throughout the day. Habituation enables the young child to screen out the familiar sensations of the clothing to attend to friends, toys, and play schemas. Sensitization in the CNS involves enhancement of cells. During sensi-tization, the CNS recognizes the stimulus as important or potentially harmful and generates a heightened response. Sensitization can sometimes be associated with anatomical changes, such as an increase in the number of neuron connections available for a task.12 Young children use sensitiza-tion to remain aware of what is going on in their surroundings. For example, Sensitization enables young children to notice a bug landing on the skin while playing outside and to brush it away. Neurological thresholds continuum The CNS is complex; none of its systems contains only habituation or only Sensitization patterns. In order to produce functional behaviors, the CNS must modulate information by creating a continuous interchange among habituation and sensitiza-tion. The patterns for the interchange are called thresholds and are established by young children's experiences and genetic endowment.121-' When young children have poor modulation between habituation and Sensitization, they exhibit mal-adaptive behaviors, such as being overly excitable or hyperactive (ie, too much Sensitization--low thresholds) or overly lethargic and inattentive (ie, too much habituation--high thresholds).
Sensory Processing Abilities 25 Young children who have high neurological thresholds react less readily to stimuli or take a longer time to react; the mechanisms of habituation support high thresholds.12 When young children have low thresholds (ie, there is Sensitization), neurons trigger more readily and, therefore, cause more frequent reactions to stimuli in the environment. It is likely that young children have a typical threshold level that reflects their particular overall CNS makeup. However, it is also likely that there is a range for this typical threshold and that shifts in the range are based on additional factors, such as which sensory systems are involved in a task or the child's capacity for that day (eg, rested or tired). Concepts from behavioral science Young children are not simply a collection of neurons and other cells. They are human beings with interests, motivations, skills, and behavioral patterns to support their performance needs.14 Researchers from the behavioral sciences have long sought ways to interpret the meaning of Individual Differences in behavior as well as the meaning of behavioral repertoires in certain groups of children.13'15 Stellar and Stellar'6 described several conditions they believed were necessary to produce goal-directed behavior: · an internal environment that supports the behavior · an external environment that provides reasonable opportunities · a stimulus to trigger the behavior · opportunities to learn If we were to characterize these conditions in relation to sensory processing, the internal environment would be the CNS's capacity for processing and modulating sensory input. The external environment would represent the sensory experiences available to young children throughout their daily lives. As children notice and respond to particular sensory stimuli (ie, the triggers for behaviors), they discover (ie, leam) their own capacities to act. Young children can have difficulties with performance in daily life as a result of dysfunction with
26 INFANTS AND YOUNG CHILDREN/APRIL 1997 any of these conditions.14 If the CNS is not processing placing blocks into a bottle, spilling them, and placing
sensory information, a young child may not be able to learn them in again) can be viewed as a set of sensorimotor
about the environment and may appear unresponsive or experiences that are satisfying because of their
clumsy. In an impoverished environment, a young child predictability and the support they provide for cognitive
will not have opportunities to develop knowledge for acting, even with an adequate internal environment.17
development. The young child obtains touch and body position input from holding and releasing the blocks and
Those of us who serve young children and their families from shifting the body to reach the blocks, there is visual
must recognize the potential impact of these factors on input as the child locates each block and watches it drop
young children's behavioral repertoires, so we can interpret into the bottle, and the sound of each block dropping into
the meaning of behaviors effectively.
the bottle and all of them spilling onto the floor provides
In addition to considering the conditions necessary to auditory input to the schema.
support behavior, we must also consider the factors that
When observing young children, their preferences for
generate motivation to act. Brody'" offered three factors sensory experiences become apparent. For some children,
that contribute to a person's tendency to perform a task. the noise of the blocks is exciting; these children will find
First, the person must need and value the goal, that is, have many ways to obtain additional auditory input (ie, banging
an incentive to perform. Second, the person must pots, making vocal noises, choosing musical toys). For
understand and believe that performance of a particular other children, the noise of the blocks will be disruptive;
task will lead to the goal, that is, have an expectancy about they might hold their ears as blocks drop. These children
performance. Third, the person will select tasks based on are more likely to select activities that have fewer auditory
his or her needs to complete the task correctly, that is, to be features and may display less functional performance
successful.
when the environment or activity contains a lot of auditory
Although adults try to guide their interests and choices, stimuli (eg, a noisy day-care center). Experience and
young children have many ways to display their motivational tendencies. Some children are very assertive
genetic endowment also play a role in the evolution of behavioral repertoires.13 From a sensory processing
about performing tasks of interest;
perspective, the tendency to act in certain ways is a
they persist in finding a way to get a desired toy or engage manifestation of the young child's needs for certain
in a self-care or play ritual over and over again, fascinated sensory information (ie, internal motivation) to support
by the experience of the ritual itself. Other young children performance and learning. Neuroscience knowledge
are responsive but seem to need more external support for provides a means of interpreting behavioral observations.
performance and do not generate experiences for themselves as easily. At the extremes of the range of motivated behavior, there are some children who appear to be so driven to act that their behaviors interfere with daily life activities and others who seem so disengaged that daily life passes by them. To put motivational tendencies in the sensory processing framework, we must consider that young children have preferences for certain sensory experiences and that sensory experiences can support or be disruptive to their
Behavioral responses When considering young children's daily life needs, we must observe behavior rather than gather data from electrodes in the brain that could indicate the neurological thresholds. The model in Figure 1 proposes a continuum of behavioral responses, with the farthest points being characterized to facilitate initial discussion. On the one end of the continuum, young children can respond in accordance with their thresh-
learning and performance. Persistence in a play schema
(eg,
olds; this suggests that their behavioral repertoire mirrors their thresholds. In this case, young children with high thresholds would respond to very few stimuli, while young children with low thresholds would respond to many stimuli. On the other end of the continuum, young children can respond to counteract their thresholds, these children might either try to exert excessive energy seeking stimuli to try to meet high thresholds or exert energy to avoid triggering low thresholds. FINDINGS THAT PROMOTE THINKING ABOUT THE PROPOSED MODEL Occupational therapists are interested in young children's daily experiences. Within this general Area of expertise, there has been a particular interest in the way that young children respond to sensory experiences in daily life--an interest that stems from the study of sensory integration. There are standardized tests that document sensory processing abilities, but they do not provide data about how particular sensory processing problems affect performance in daily life.6 To address performance in daily life, occupational therapists solicit information from parents, teachers, and children themselves.19"22 In 1992, Dunn and colleagues17 began collecting formal data about children's performance as reflected in these informal measures. The Sensory Profile contains 125 items that describe various responses children have to sensory experiences during their day; caregivers report the frequency with which these behaviors occur (ie, always, frequently, occasionally, sometimes, never). Since the items were derived from interviews with parents of children who had disabilities, therapists presumed that all the items represented some sort of sensory processing difficulty, but this had never been tested. To address this issue, Dunn and colleagues17'24'28 conducted a series of studies to identify the nature of the items on the Sensory Profile, including which items were uncommon for children without disabilities, which items were characteristic of specific disabilities, and which items might be used to discriminate among various disabilities.29
Sensory Processing Abilities 27 Findings about children with and without disabilities A pilot study (.N = 64) and a national study (N = 1,115, matching the 1990 census on density of state populations) were conducted to investigate how parents of children without disabilities (3-10 years of age) responded to the items.2124 There were no age or gender differences among the items, and more than two thirds of the items were uncommon for children without disabilities (ie, at least 80% of the parents reported that their children displayed the behavior "seldom" or "never"), suggesting that the items held promise for helping to understand sensory processing abilities in children with disabilities. The Sensory Profile then needed to be tested on children with various disabilities. A series of studies is being conducted, including studying Children with Autism (.N - 34),26 children with attention deficit hyperactivity disorder (ADHD; N- 61),27 and children with tic disorders (in process). The children in all of these groups displayed significantly higher rates of behaviors on the Sensory Profile when compared to children without disabilities; however, each diagnostic group had higher rates on different items, suggesting that the behaviors on the Sensory Profile might be useful in differential diagnosis and more refined intervention planning. Findings that support model components and extend thinking Also conducted was a principal component Factor analysis on the data from the children without disabilities to examine patterns of performance. Found were factor groupings that were like behavioral patterns seen in children with disabilities.25 The nine factors are the following (see Table I): 1. sensory seeking (n = 17 items) 2. emotionally reactive (n = 16) 3. low endurance/tone (n = 9) 4. oral sensitivity (n = 9) 5. inattention/distractibility (w = 7) 6. poor registration (n = 8) 7. sensory sensitivity (w = 4)
28 INFANTS AND YOUNG CHILDREN/APRIL 1997
Table 1. Factor analysis item loadings
Factor
Sensory System
Sensory Profile Items
Factor Loading
1: Sensory
Movement Takes excessive risks during play
.72
seeking
Movement Takes movement or climbing risks during play that compromise
.68
personal safety
Movement Continually seeks out all kinds of movement activities
.67
Body
Seeks opportunities to fall without regard to personal safety
.65
Movement Seeks all kinds of movement and this interferes with daily routines
.62
Movement Twirls/spins self frequently throughout the day
.60
Body
Appears to enjoy falling
.59
Movement Becomes overly excitable after a movement activity
.58
Movement Turns whole body to look at you
.58
Touch
Is always touching people and objects
.56
Activity Is always "on the go"
.53
Touch
Avoids wearing shoes; loves to be barefoot
.47
Auditory Enjoys strange noises/seeks to make noise for noise's sake
.46
Emotion Is overly affectionate with others
.46
Activity Jumps from one activity to another so frequently it interferes with play .44
Body
Hangs on other people, furniture, objects even in familiar situation
.44
Touch
Doesn't seem to notice when face or hands are messy
.42
2: Emotionally Emotion Has difficulty tolerating changes in plans and expectations
.70
reactive
Emotion Displays emotional outbursts when unsuccessful at a task
.66
Emotion Has poor frustration tolerance
.66
Emotion Cries easily
.66
Emotion Has difficulty tolerating changes in routine
.64
Emotion Seems anxious
.62
Emotion Is sensitive to criticisms
.62
Emotion Seems to have difficulty liking self
.60
Emotion Expresses feeling like a failure
.57
Emotion Is stubborn or uncooperative
.56
Emotion Has definite fears
.54
Emotion Has trouble "growing up"
.53
Emotion Has temper tantrums
.52
Emotion Needs more protection from life than other children
.52
Emotion Has difficulty making friends
.52
Emotion Is overly serious
.48
3: Low
Body
Seems to have weak muscles
.74
endurance/
Body
Tires easily, especially when standing or holding particular body
.69
tone
position
Body
Has weak grasp
.66
Body
Locks joints for stability
.63
Body
Can't lift heavy objects
.58
Movement Has poor endurance/tires easily
.57
Body
Props to support self
.56
Body
Moves stiffly
.56
Movement Appears lethargic
.45
4: Oral
Taste
Shows preference for certain tastes
.74
sensory sensitivity continues
Taste
Will only eat certain tastes
.74
Taste
Shows strong preference for certain smells
.74
Taste
Avoids certain tastes/smells that are typically part of children's diets
.64
Touch
Picky eater, especially regarding textures
.62
Sensory Processing Abilities 29
Table 1. Continued
Factor
Sensory Sensory Profile Items System
Taste
Craves certain foods
Taste Touch Taste
Seeks out certain tastes/smells Limits self to particular food textures/temperatures Routinely smells nonfood objects
5: Inattention/
Auditory Is distracted or has trouble functioning if there is a lot of noise around
distractibility
Activity Auditory Auditory Auditory Auditory Visual
Has difficulty paying attention Appears not to hear what you say Can't work with background noise Has trouble completing tasks when the radio is on Doesn't respond when name is called Looks away from task to notice all actions in the room
6: Poor
Emotion Doesn't express emotions
registration
Emotion Emotion Touch Visual Taste Touch Touch
Doesn't perceive body language or facial expressions Doesn't have a sense of humor Doesn't seem to notice when someone touches arm or back Doesn't notice when people come into the room Doesn't seem to smell strong odors Has decreased awareness of pain and temperature Avoids going barefoot especially in sand or grass
7: Sensory
Movement Becomes anxious or distressed when feet leave ground
sensitivity
Movement Fears falling or heights Movement Dislikes activities where head is upside down, or rough-housing Movement Avoids climbing, jumping, bumpy or uneven ground
8; Sedentary
Movement Prefers sedentary activities
Movement Seeks sedentary play options Activity Spends most of (he day in sedentary play Activity Prefers quiet, sedentary play
9: Fine
Visual Has trouble staying between the lines when coloring or when writing
motor/ perceptual
Visual Visual Emotion
Has illegible writing Has difficulty putting puzzles together Has temper tantrums
Other items;
Auditory Responds negatively to unexpected or loud noises (ie, vacuum cleaner
items that did
dog harking, hairdryer)
not load on
Auditory Holds hands over ears
the typical
Auditory Talks self through task
children
Auditory Seems oblivious within an active environment
factor
Visual Expresses discomfort or avoids bright lights (ie, sunlight through
analysis
window in car)
Visual Is happy to he in the dark
Visual Looks carefully or intensely at objects/people
Visual Becomes frustrated when trying to find objects in competing
backgrounds (eg, an overfilled drawer)
Visual Prefers to be in the dark
Visual Hesitates going up or down curbs or steps
Visual Gets lost easily
Visual Is bothered by bright lights after others have adapted to the light
continues
Factor Loading .60 .57 .53 .42 .68 .60 .59 .55 .52 .52 .44 .61 .60 .57 .54 .48 .48 ,46 .42 .75 .71 .71 .70 .79 .75 .72 .71 .74 .66 .54 .40
30 INFANTS AND YOUNG CHILDREN/APRIL 1997
Table 1. Continued
Sensory Sensory Profile Items System
Factor Loading
Visual Has hard time finding objects in competing backgrounds (ie, shoes in
a messy room, favorite toy in the "junk drawer")
Visual Stares intensely at objects or people
Visual Covers eyes or squints in bright lights
Visual Watches everyone when they move around the room
Visual Avoids eye contact
Activity Avoids quiet play activities
Taste
Chews/licks on nonfood objects
Body
Walks on toes
Movement Avoids playground equipment or moving toys
Movement Rocks unconsciously during other activities (ie, while watching television)
Movement Dislikes riding in a car
Movement Holds head upright, even when bending over or leaning
Movement Holds onto walls or banisters
Movement Becomes disoriented after bending over sink or table
Movement Rocks in desk/chair/on floor
Touch
Avoids getting "messy" (ie, in paste, sand, finger painting, glue, tape)
Touch
Expresses distress during grooming (ie, haircutting, face washing,
fingernail cutting)
Touch Prefers long-sleeved clothing when it's warm or short-sleeved clothing
when it's cold
Touch
Expresses discomfort at dental work or toothbrushing
Touch
Is sensitive to certain fabrics (ie, is particular about certain clothes or
bedsheets)
Touch
Touches props and objects to the point of irritating others
Touch
Reacts emotionally or aggressively to touch
Touch
Has rigid rituals in persona] hygiene
Touch
Withdraws from splashing water
Touch
Has difficulty standing in line or close to other people
Touch
Rubs or scratches out a spot that has been touched
Touch
Gags easily with food textures, food utensils in mouth
Touch
Displays unusual need for touching certain toys, surfaces, or textures
Touch
Mouths objects frequently (ie, pencil, hands)
Touch
Leaves clothing twisted on body
Emotion Uses inefficient ways of doing things
Emotion Seems accident prone
Emotion Has nightmares
Emotion Has fears that interfere with daily routines
Note: The complete factor analysis is reported in Reference 25. 8. sedentary (w = 4) 9. fine motor/perceptual (n = 4) This analysis provides preliminary evidence about the nature of sensory processing for all children; perhaps some of the patterns of behavior seen in children with disabilities are different in relation to rate, intensity, or the manner that they do or do not interfere with daily life.29 For example, both children without disabilities and children with ADHD display sensory-seeking behaviors (Factor
1); however, children with ADHD also show high rates of inattention/distractibility (Factor 5). Perhaps sensoryseeking behaviors enable children without disabilities to learn but generate distract-ibility in children with ADHD. Also conducted was a discriminant analysis with data from children without disabilities, children with ADHD, and children with autism.28 Using the nine factors, the three groups of children were compared, and children were placed correctly in groups 89% of
the time. Four factors (1, 4, 5, 9) contributed to the differences; children with autism had the opposite pattern of performance from children without disabilities, which is consistent with the pervasive nature of this disability. Children with ADHD were more like children without disabilities. However, distractibility was apparent only in children with ADHD; this may be a key factor in the performance difficulties of children with ADHD. PERFORMANCE PATTERNS THAT EMERGE FROM THE PROPOSED MODEL When the impact of the neurological thresholds on the behavioral response continua is considered, a wider range of possible interpretations of behaviors emerges. Professionals can consider potential effects of high or low thresholds on performance and possible effective interventions for children with various sensory processing responses. Based on the data from the studies of the Sensory Profile thus far, we are proposing names for the four comers of the model (see Figure I): Poor Registration, Sensitivity to Stimuli, Sensation Seeking, and Sensation Avoiding. The model components are also supported by the work completed to specify types of regulatory disorders in infants and young children.2 Poor registration When young children have difficulty registering stimuli due to high neurological thresholds and act in accordance with those thresholds, they tend to have a dull or uninterested appearance. The data from the Sensory Profile studies suggest that there may be three factors that fall into this pattern: Factor 3 (low endurance/tone), Factor 6 (poor registration), and Factor 8 (sedentary). Factor 8 may be related to sensation-avoiding behaviors (see below) rather than poor registration, if the sedentary behaviors serve to reduce the amount of input the person must process. Young children who have a behavioral response pattern congruent with these factors may not have adequate neural activation to sustain focus or endurance for tasks or contextual cues. The National Center for Clinical Infant Programs (NCCIP) task force2 characterized a Type II regu
Sensory Processing Abilities 31 latory disorder as underreactiue. Children in this category can be withdrawn and difficult to engage or selfabsorbed. Those who are withdrawn are easily exhausted, appear apathetic, and need highly salient stimuli to engage them. The children sometimes engage in repetitive play, presumably to increase the stimuli so they can "fully experience" the activities. This description is consistent with "poor registration" proposed in this model. When serving young children who have poor registration, this model suggests that providers would want to find ways to enhance the task and contextual experiences so that there is a greater likelihood that thresholds will be met. One can increase the contrast and reduce the predictability of cues in the task; for example, make objects weigh more, change the color of items, or add the angular movement of bending (ie, a more arousing input) to the task routine. For young children who have poor registration, the provider works to make the experience more dense with sensory stimuli; the more they have the opportunity to trigger their thresholds, the more they are likely to improve functional performance. The NCCIP Task Force2 also suggests using "robust" responses to the child's cues as a means to enhance responsivity for children who are withdrawn and underreactive. Sensitivity to stimuli Young children who are sensitive to stimuli due to low thresholds and who act in accordance with those thresholds tend to be hyperactive or distract-ibie. Data indicate three factors might support this pattern of neurological threshold and behavioral response: Factor 4 (oral sensory sensitivity), Factor 5 (inattention/distractibility), and Factor 7 (sensory sensitivity). Young children who demonstrate behaviors congruent with these factors would have difficulty remaining on task to complete them or to learn from their experiences.Their behavioral repertoire of responding in accordance with their low neurological thresholds would keep directing their attention from one stimulus to the next, whether it was part of the ongoing task or not. The NCCIP Task Force2 characterizes a Type I regulatory disorder as hypersensitive. Children who
32 INFANTS AND YOUNG CHILDREN/APRIL 1997
are hypersensitive can be either fearful and cautious or
The NCCIP Task Force2 characterizes a Type III
negative and defiant. Those who are fearful and cautious regulatory disorder as motorically disorganized and
are easily upset, are fragmented, have excessive fears, and impulsive. Children with this type of regulatory disorder
may be easily distracted. This description is consistent with display high Activity Levels, lack caution in play, display
our proposed category of sensitivity to stimuli.
excitability, and crave sensory input. This description is
When serving young children who have sensitivity to consistent with our proposed category of Sensation
sensory stimuli, it may be important to emphasize the Seeking. The high need to seek sensation can be associated
discriminating features of sensory systems,30'31 because with impulsive behavior and poor motor modulation.
these aspects of sensory input do not increase arousal. For
When serving young children who seek sensation, it
example, touch-pressure stimuli (ie, firm contact with the may be important first to observe them carefully to obtain
skin) do not excite the reticular formation, a generalized information about what sensations they add to their
arousal center in the brain stem, but light touch stimuli (ie, behavioral repertoire in an attempt to meet their high
tickling, soft contact with skin) do activate the reticular neurological thresholds. The most effective interventions
formation.32 Therefore, it would be better to make contact for these young children may be to incorporate the
with a young child who has tactile sensitivity using touch- sensations they need into their daily life repertoires. For
pressure input; this would reduce the possibility of example, if a young child seeks movement input, but this
generating more generalized arousal. Young children with is interfering with life performance, we can reconstruct the
sensory sensitivity may need organized input that does not functional tasks to include more movement, so the child
generate additional arousal to draw them away from the gets the input desired as part of the daily life routine. In
task at hand. The more nonarousing (ie, organizing) input this example, we can move clothing items to different parts
these young children can obtain, the better their chances of the room, so it will require more walking, bending, and
for completing tasks and learning from them. The NCCIP reaching to get ready for the day. Honoring the input these
Task Force2 suggests that caregivers employ flexibility and children seek might also reduce the anxiety associated with
assertiveness in caring for these children. It also agrees that trying to meet high thresholds and assist with attentional
it is important to use empathy when observing and focus. The NCCIP Task Force2 suggests that caregivers
responding to the children's affective responses.
support exploration that is creative and purposeful, so the
children can obtain the sensory input they desire and need.
Sensation seeking When young children have high thresholds but develop responses to counteract their thresholds, they may engage in behaviors to increase their sensory experiences. Factor 1 (sensation seeking) contains items that represent more intense sensory experiences. According to the items in this factor, young children who are sensation seeking add movement, touch, sound, and visual stimuli to every experience. They might make noises continuously, fidget in their seats, touch everything, handle objects or people, or chew on things in an attempt to meet their high thresholds.
Sensation avoiding When young children have low thresholds and develop responses to counteract their thresholds, they try to avoid activating their thresholds; they might appear to be resistant and unwilling to participate. Data indicate that Factor 2 (emotionally reactive) supports this pattern of behavioral response and neurological threshold; the behaviors represented in the items in Factor 2 indicate a need to reduce unpredictable stimuli that occur during activities (ie, routines and rituals become predictable patterns of input and responses). Possibly meeting their neurological thresholds is uncomfort-
able, and, therefore, young children may try to circumvent this event by reducing their activity, many times through withdrawal. For example, with a low threshold for ambient noise, the child might become ill or have an emotional outburst when it is time to go to the church performance; these behaviors reduce the possibilities that the child would have to cope with the inevitable noise level in the community room. Young children who avoid sensation may also develop rituals for conducting daily life tasks; perhaps these rituals provide a pattern of neural activity that is familiar and acceptable. Factor 8 may also be related to sensation avoiding, if the child's motive for selecting sedentary tasks is to keep away from other sensory experiences. There are two possible NCCIP regulatory disorder types that would coincide with the sensation-avoiding category proposed here. If the children displayed more stubborn, controlling behaviors, preferring repetition to manage input, this would be consistent with the negative and defiant Type I hypersensitive regulatory disorder. However, if the children display more inattention to stimuli, preoccupation with certain stimuli, and more solitary focus and pursuits, this would be consistent with Type II underreactive regulatory disorder--the self-absorbed subtype. Further documentation of the differences between these types will be needed to characterize more clearly their meanings for assessment and intervention planning. When serving young children who avoid sensation, providers may need to honor the discomfort they experience. Observing their rituals and analyzing the features of the rituals provide a wealth of information. It is often successful to begin intervention with one of the rituals, expanding it in some small way, so that there is a blending of familiar and new stimuli.31 This enables the child to incorporate the new stimuli into a comfortable pattern. Disrupting the rituals too aggressively can only lead to more avoidance behaviors and further decline of functional performance. For children who tend to be negative and defiant, the NCCIP suggests a flexible, supportive caregiving strategy that avoids
Sensory Processing Abilities 33 power struggles. This strategy supports the proposal here that overloading the children who avoid sensation can cause more withdrawal and avoidance. For those who tend to be self-absorbed, the NCCIP suggests caregiving that acknowledges the children's cues and signals about what they need and combines these needs with play rituals. Relationships among behavioral repertoire categories To test this model, discrimination among its behavioral categories is required so that providers can identify problems correctly and design effective interventions. For example, it may be important to discriminate young children who avoid sensation from those who have poor registration. Young children with poor registration may not appear to notice what is going on, while young children who are avoiding sensation would display behaviors that indicate the child notices and withdraws from the situation. The interventions for young children who have poor registration need to address meeting a high threshold, while the interventions for young children who avoid sensation need to honor their discomfort due to typical levels of sensory input. If providers mistake withdrawal behaviors for poor registration, they would design intense sensory experiences for the person, which would lead to further withdrawal rather than adaptation. The NCCIP regulatory disorders descriptions and suggestions can provide guidance for investigations of the various types of regulatory disorders. OTHER FACTORS The factor with the weakest loading is not accounted for in this working model (ie, Factor 9, fine motor/perceptual). The items that loaded on this factor clearly relate to fine manipulation and tended to be more age-sensitive in earlier studies.2324 It is interesting that these items loaded together and without items that have a more clear sensory processing component. Separate factor loading is consistent with findings in other studies of fine manipulation and sensory processing (ie,
34 INFANTS AND YOUNG CHILDREN/APRIL 1997 the motor accuracy [MAc] subtest of the Sensory
Integration and Praxis Tests [SIPT]). In factor analytic studies, MAc was associated with tests of dyspraxia, visual motor skills, and ocular pursuits,33"36 suggesting that the MAc performance measured eye-hand coordination and is affected by praxis and visual motor coordination.6 Future studies of the Sensory Profile on children with disabilities may or may not indicate whether there are relationships between Factor 9 and the other eight factors in this analysis.
tions of providers and families are needed to advance this thinking. Additional factors, such as the intensity of a child's behaviors, the rate of dysfunctional performance, the rate of recovery from disruptions in activity, and the child's general capacity from one day to the next, all must be considered in a comprehensive model for interpreting the meaning of children's performance patterns for daily life. The four types of regulatory disorders identified for infants and young children2 seem congruent with the
This working model is a crude version of what is likely categories proposed here. It would be interesting to
to be true about the interactions among neurological compare the NCCIP regulatory disorders diagnoses with
thresholds and behavioral response continua; additional parent reports on the Sensory Profile as a method to
studies and skilled observa
validate the diagnoses and the strength of parent-report
data as a critical piece of the diagnostic process.
REFERENCES 1. Sears C. Recognizing and coping with tactile defen- siveness in young children. Inf Young Children. 1994;6(4):46-53. 2. National Center for Clinical Infant Programs. Diagnostic Classification of mental health and Developmental Disorders of Infancy and Early Childhood. Arlington, VA: Zero to Three; 1994. 3. Baranek G, Berkson G. Tactile det'ensiveness in children with developmental disabilities: responsiveness and hahituation. / Autism Dev Disord. 1994;24(4):457-471. 4. Dunn W. Performance of typical children on the sensory profile: an item analysis. Am] Occup Ther. 1994;48(11):967-974. 5. Wilbarger P. The sensory diet: activity programs based on sensory processing theory. Sensory Integration Special Interest Section Newsletter. 199'5;18(2):1-3. 6. Ayres AJ. Sensory Integration and Praxis Tests Manual. Los Angeles: Western Psychological Services; 1989. 7. Coster W, Haley S. Conceptualization and measurement of disablement in infants and young children. Inf Young Children. 1992;4(4): 11-22. 8. Held R, Hein A. Movement-produced stimulation in the development of visually guided behavior. JComp Physiol Psychol. 1963;56:872-876. 9. SanesJN, Mauritz KH, Dalakas MC, Evarts HV. Motor control in humans with large-fiber sensory neuropathy. Hum Neurobiol. 1985;4:101-ll4.
10. Kandel E, Schwartz J, Jessell T. Principles of Neural Science. 3rd ed. New York: Elsevier; 1993. 11. Kupfermann I. Learning and memory. In: Kandel E, Schwartz J, Jessell T, eds. Principles of Neural Science. 3rd ed. New York: Elsevier; 1993:997-1,008. 12. Kandel E. Cellular mechanisms of learning and the biological basis of individuality. In: Kandel E, Schwartz J, Jessell T, eds. Principles of Neural Science. 3rd ed. New York: Elsevier; 1993:1,009-1,031. 13. Clarke AM, Clarke ADB. Early Experience: Myth and Evidence. New York: The Free Press; 1976. 14. Dunn W. Motivation. In: Royeen C, ed. Neuroscience Foundations of Human Performance. Rockville, MD: American Occupational Therapy Association; 1991. 15. Nuttall EV, Romero I, Kalesnik J. Assessing and Screening Preschoolers: Psychological and Educational Dimensions. Boston: Allyn & Bacon; 1992. 16. StellarJ, Stellar E. The Neurobiology of Motivation and Reward. New York: Springer-Verlag; 1985. 17. Dunn W, Brown C, McGuigan A. The ecology of human performance: a framework for considering the effect of context. Am] Occup Ther. 1994;48:595-607. 18. Brody N. Human Motivation. New York: Academic Press; 1983. 19. Ayres AJ. Sensory Integration and the Child. Los Angeles; Western Psychological Services; 1980. 20. Royeen C, FortuneJ. Touch inventory for Elementary School aged children. Am] Occup Ther. 1990;44:155159.
21. Larson J. The sensory history of developmentally delayed children with and without tactile defensiveness. AmJOccup Ther. 1982,36:590-596. 22. DeGangi G, Berk R. DeGangi-Berk Test of Sensory Integration (TSI). Los Angeles: Western Psychological Services; 1983. 23. Dunn W. Performance of typical children on the sensory profile: an item analysis. AmJ Occup Ther. 1994,48:967-974. 24. Dunn W, Westman K. The sensory profile: the performance of a national sample of children without disabilities. AmJOccup Ther. 1997;51(1):25-34. 25. Dunn W, Brown C. Factor analysis on the sensory profile from a national sample of children without disabilities. AmJ Occup Ther. In press. 26. Kientz M, Dunn W. A comparison of children with autism and typical children using the sensory profile. AmJ Occup Ther. In press. 27. Bennett D, Dunn W. Performance of children with attention deficit hyperactivity disorder on the sensory profile. AmJOccup Ther. Submitted for publication. 28. Ermer J, Dunn W. Discriminant analysis on the sensory profile: discriminating children without disabilities, children with autism and children with attention deficit hyperactivity disorder. AmJOccup Ther. Submitted for publication. 29. Dunn W. The sensory profile: a discriminating measure of sensory processing in daily life. Sensory
Sensory Processing Abilities 35 Integration Special Interest Section Newsletter. In press. 30. Dunn W. The sensorimotor systems: a framework for assessment and intervention. In: Orelove F, Sobsey D, eds. Educating Children with Multiple Disabilities: A Transdisciplinary Approach. 2nd ed. Baltimore: Paul H. Brookes Publishing; 1991. 31. Dunn W, DeGangi G. Sensory integration and neurodevelopmental treatment for educational programming. In: Royeen C, ed. Classroom Applications for School-based Practice. Rockville, MD: American Occupational Therapy Association; 1993. 32. Dunn W. Sensory performance components. In: Christiansen C, Baum C, eds. Human Performance Deficits: Assessment and Intervention in Occupational Therapy. Thorofare, NJ: Slack; 1991. 33. Ayres AJ. Patterns of perceptual motor dysfunction in children: a factor analytic study. Percept Mot Skills. 1965;20:335-368. 34. Ayres A), Mailloux Z, Wendler C. Developmental dyspraxia: is it a unitary function? Occup Ther J Res. 1987;7:93-110. 35. Ayres AJ. southern California Kinesthesia and Tactile Perception Tests Manual. Los Angeles: Western Psychological Services; 1966. 36. Ayres AJ. Interrelation among perceptual motor abilities in a group of normal children. AmJOccup Ther. 1966;22:289-292.

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