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Case, Part 1 

• Marie is a 5-year-old girl being seen in your office for her annual check-up.
• She has just started school recently and her parents report that the transition has been difficult.
• She tries on multiple outfits before school each morning before finding one that is comfortable, and they have had to cut the tags off all her clothing.
• At school, she has been crying and throwing tantrums when the volume in the classroom gets loud or when other students jostle her.
• She complains about and refuses to eat most of the foods that her parents pack for her lunch.
• Her parents are concerned and don’t know what to do.
• Mother asks, “We’ve tried a reward system for her behaviours, but nothing seems to work. Is this just bad behavior, or is it something else?”

• Sensory processing disorder (SPD) is a condition in which the nervous system is unable to properly process sensory input, and as a result, the patient can become easily overwhelmed (or underwhelmed) in the presence of ‘normal’ levels of sensory input. SPD can lead to problems with attention, learning, behavior and moods (such as anxiety, anger, aggression and frustration).
• Sensory processing problems can occur alone, or be part of conditions such as ADHD, learning disabilities, or autism spectrum conditions.
• Terminology
  • Sensory integration” is the original term for this condition, which has been replaced by “sensory processing disorder”.

• 5-16% of elementary school-aged children (Ahn, Miller et al., 2004; Ben Sasoon et al., 2009)
• 40-60% of children with attention deficit hyperactivity disorder (ADHD) also have SPD
• 70-90% of children with autism spectrum disorders (ASD) also demonstrate SPD and the DSM-5 includes over and under sensitivity to sensation as possible diagnostic criteria for ASD.
• Between 58% to 75% of those with SPD do not have other disorders (Carter al., 2011; Van Hulle et al., 2012)

The three most common types of sensory processing problems are the following:

1.    Sensory modulation disorder (SMD), which is further divided into

• Sensory Overresponsivity: Individuals are extremely sensitive to sensory input
• Sensory underresponsivity: Individuals seem oblivious to sensory input
• Sensory seeking/craving: Individuals seek out continual sensory input

Other subtypes of SPD are:

• Sensory discrimination disorder
• Dyspraxia
• Postural Disorder. 

• Start with everyone in the room, i.e. parents and child
• With young children, direct questions to the parents first, and see whether or not the child has anything else to add
• With adolescents, direct questions to the adolescent first, and see whether or not parents have anything else to add

Examples of possible questions to ask:

Introduction: “We’re going to ask some questions about your child’s sensory systems, like hearing, touch, taste.”

• Sensory processing problems are not currently recognized as a unique disorder in the DSM-5
• Nonetheless, they are included in the diagnostic criteria for autism spectrum disorder (ASD), and are recognized in ICDL's Diagnostic Manual and the Diagnostic Classication: Zero to Three (DC: 0-3R)

Consider screening for sensory processing problems in children/youth with diagnoses such as:

• Rule out any particular sensory problems such as
  • Vision problems
  • Hearing problems

There are no diagnostic tests for sensory processing problems in the primary care setting, other than investigations that might be useful to rule out contributory conditions.

Note: Western Psychological Services is standardizing a new performance measure called the Sensory Processing Three Dimensions (SP-3D ) scale by Miller, Schoen and Mulligan expected to come out early 2017, meant to be completed by occupational therapists (OT).

If you suspect sensory issues, consider referral to occupational therapy (OT), which may be:

• Through the school: If the student is attending school, consider writing a letter to the school requesting a referral to the school OT; or if you are pressed for time, consider simply recommending “OT referral for sensory processing problems” on a prescription pad, which the parents can take to the school.
• Privately: There may be a shortage of school OT’s, and if the family has sufficient means, consider seeing an OT in private practice.
• Note
  • Prior OT: Even if occupational therapy (OT) has already been involved with a child’s care, this does not always mean sensory issues have been addressed, due to the fact that school OTs are often only able to focus on motor issues especially handwriting.
  • Even if the patient has previously been seen by mental health professionals, because awareness of sensory process is not universal, this also does not mean that sensory issues have already be addressed

• The following resources can be provided to patients and families:
  • eMentalHealth.ca handout on SPD 
    http://www.ementalhealth.ca/8890
  • Sensory Processing Disorder Foundation
    http://spdfoundation.net/

• There are no medications to treat SPD per se
• Nonetheless, if there are comorbid conditions that are treatable, ensure that those conditions are adequately treated

Each patient with SPD will have a unique profile of sensory needs depending on their symptoms, but the following are some general management principles:

• Develop a “sensory lifestyle”
• Help parents problem solve and learn to think through the sensory input that can help children in advance of a child’s responsivity (see “No Longer A SECRET” for more about strategies and solutions by Bialer and Miller).
• Create a personalized activity plan that provides the sensory input needed by the child which includes regular calming and/or alerting activities to maintain optimal alertness
• If the child is overloaded, adapt sensory expectations and encourage self-modulation technique
• E.g. massage, stretching
• Give advance warning about transitions

Some examples of specific school accommodations include:

• Marie is a 5-year-old girl being seen in your office, who is having extreme difficulties with various daily routines
• You note that she is easily overwhelmed by sensory input such as touch, sound and lights
• You mention the possibility of a sensory processing disorder and recommend some reading materials as well as suggest that they see a private practice occupational therapist (OT)
• When they return to see you a few weeks later, you notice that the patient is now wearing a baseball cap, which mother explains helps with fluorescent lights
• They report seeing a private practice OT who confirmed sensory processing issues, and is working with them to develop a sensory lifestyle
• As you leave the office that day, your receptionist tells you about the mother that asked to turn off the radio in the waiting room, and that other patients commented on how they preferred a quieter waiting room too!

Ahn, R. R., Miller, L. J., Milberger, S., & McIntosh, D. N. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287–293.

Carter, A.S., Ben-Sasson, A., & Briggs-Gowan, M.J. (2011). Sensory over-responsivity, psychopathology, and  family impairment in school-aged children. Journal of the American Academy of Child & Adolescent Psychiatry, 50(12), 1210-1219.

Van Hulle, C.A., Schmidt, N.L., & Goldsmith, H.H. (2012). Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis. Journal of Child Psychology and Psychiatry, 53(1), 64-72.

Sensational Kids, 2nd edition (Miller, 2014)

No Longer a SECRET: Unique Common Sense Strategies for Children with Sensory or Motor Challenges (BIaler and Miller, 2008)

Raising a Sensory Smart Child: The Definitive Handbook for Helping Your Child with Sensory Processing Issues (Biel and Peske, 2009).

The Out-of-Sync Child (Kranowitz, 2006)

The Everything Parent’s Guide to Sensory Processing Disorder (Mauro and Clark, 2014).

The Sensory Child Gets Organized: Proven Systems for Rigid, Anxious, or Distracted Kids (Dalgliesh, 2013).

The Sensory Therapies and Reseach (STAR) Center has an excellent overview of SPD and subtypes of SPD

http://spdstar.org/what-is-spd/  

Written by Kaitlin Baenziger (Medical Student, Class of 2017), and members of the eMentalHealth.ca Primary Care Team, which includes Drs. Mireille St-Jean (Family Physician, Ottawa Hospital), Eric Wooltorton (Family Physician, Ottawa Hospital), Farhad Motamedi (Family Physician, Ottawa Hospital) and Dr. Michael Cheng (Psychiatrist, Children’s Hospital of Eastern Ontario).

Special thanks to Dr. Lucy Jane Miller (SPDNetwork.org) for invaluable assistance with writing, editing and reviewing this article. 

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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