Why is getting an accurate and thorough sensory processing disorder (SPD) diagnosis so hard? There are a few major factors, but here’s a big one:
There are virtually no quality clinical tests to assess for it.
Right now, the only clinical tests for SPD are old and outdated and are only for children 8 years old and younger.
Clinicians who have specialized training can use their judgment and reasoning to document signs and symptoms of SPD that are apparent when using other, primarily motor-based assessments or by testing for “soft” signs of neurological impairments. This isn’t always a very accurate method and does not always convince physicians and insurance companies of the validity of an SPD diagnosis.
The only other way of assessing for SPD are questionnaires that have been standardized* (like the Sensory Profile and Sensory Processing Measure), but these are limited by how aware of symptoms the person filling out the questionnaire is (usually a parent, teacher, and/or the person being tested). These questionnaires are also limited in the scope of symptoms assessed and may not provide a complete or accurate picture of symptoms. (*Standardized means the assessment tool has been researched on a sample of people of varying abilities and statistically analyzed to determine what is “typical” and “atypical”.)
Now, here’s the good news: There is a new test in development for clinical assessment of SPD!
The test was developed by clinicians and researchers at the STAR Institute for SPD and the University of New Hampshire and is being published by Western Psychological Services.
Sensory Modulation Disorder, including sensory over-responsivity, sensory under-responsivity, and sensory seeking/craving.
Sensory Discrimination Disorder
Sensory-Based Motor Disorder
My post entitled What is Sensory Processing? defines Sensory Modulation Disorder and Sensory Discrimination Disorder. This is a follow-up post about the third subtype: Sensory-Based Motor Disorder.
Simply put, some motor coordination difficulties are due, at least in part, to faulty sensory processing. There are two sub-types of Sensory-Based Motor Disorder: Postural Disorder and Dyspraxia.
To understand Postural Disorder, it’s important to first understand postural control. The terms for postural function vary somewhat among professionals and in the literature. Most experts agree, though, that there are two main functions of the postural control system:
To keep you upright against gravity and help you maintain your balance, for which I prefer the term postural stability. This can be further broken down into static and dynamic functions. Static posture (meaning still, unchanging) is when you are holding a position against gravity without moving, and dynamic posture (meaning ever-changing) is how you keep your balance while moving.
To keep the rest of your body still so you can use a part of the body to push, pull, reach and/or use force to complete a task. For this function, I like the term postural regulation. To conserve energy and increase the accuracy and precision of your movements, you must stabilize parts of your body and use isolated movements to carry out actions.
Postural control is a lot more complex than just standing and sitting up straight, which is what many equate with “good” posture. In addition to keeping us in good alignment, research has shown postural control actually prepares the body to move, which is referred to as anticipatory or feedforward postural adjustments. Postural control also contributes to your body schema or internal map of where you and all your body parts are in relationship to gravity. This is crucial for maintaining joint and muscle alignment as well as determining your center of gravity. Additionally, reflexive postural reactions help you recover when you are bumped, jostled, or otherwise knocked off balance. And, perhaps most complex of all, motor coordination relies on the combination of good posture and movement.
Postural skills are largely subconscious, meaning you probably do not pay much attention to them. However, you rely heavily on your posture to complete every day tasks such as brushing your teeth or typing at a computer. Holding yourself up against gravity and coordinating your movements actually requires integration of multiple sensory systems. The sensory systems that contribute most to posture include your: proprioceptive (muscles and joints), vestibular (equilibrium and balance), tactile (touch), and visual (sight) systems.
So, what qualifies a posture problem as a Sensory-Based Motor Disorder? Just like all sensory disorders, a sensory-based posture disorder is caused by brain wiring differences that are developmental (present from birth). Therefore, poor posture due to injury, disease, poor physical fitness, or health problems would not be considered a sensory-based condition.
Symptoms of a postural disorder may include:
Chronic muscle tension in the neck, shoulders, and back
Unusually loose or tight muscles at rest
Poor control of movements (i.e., clumsiness, poor body awareness)
Core muscle imbalance, resulting in rounded or slouched posture
Slow reflexes/reactions when knocked off balance (for example, you may not be able to catch yourself when tripping or falling)
Inefficient or excessive/extraneous movements (such as motor overflow) resulting in fatigue
Motor praxis is perhaps even more complex than postural control. In sensory integration theory, the term “praxis” encompasses all of the processes involved in performing skilled movements. Briefly stated, praxis includes:
Ideation–coming up with ideas; problem-solving; using the imagination to “mime” actions without objects (for example, pretending to brush your teeth without an actual toothbrush)
Planning–deciding what to do
Sequencing–logically ordering actions from “Where should I start?” to “How I know I’m finished”
Execution–carrying out your plan of action
Feedback–reflecting on how well a plan of action worked (as well as feedforward, which is how well a plan of action is working in the moment)
When a professional is assessing praxis abilities, some of the areas that may be examined are:
Constructional praxis–building or copying configurations of materials or shapes from a model or instructions
Oral motor praxis–coordinating the muscles of the mouth and jaw for speech production and facial expressions
Imitation of movements–watching a demonstration of a complex movement or a series of motions before doing the same movement/motions
Motor patterns–sustaining repetitive movement patterns (such as a rhythmic clapping pattern)
When praxis is optimal, it has three main functions:
Coming up with ideas, making plans, thinking of ways to get organized, and problem-solving for actions you will take in the future. This includes reflecting on recent experiences and processing what you thought went well (and what you wish had happened differently). These processes happen in the top and front area of the brain, primarily in the frontal lobe of the cerebral cortex.
Monitoring your performance in the moment to sustain actions, or make adjustments to improve your accuracy or speed. This process combines cortical functions throughout the cerebral cortex as well as more automatic or reflexive functions that occur in the subcortical region of the brain.
Completing motor tasks automatically, often using the same pattern of movements without much thought. For example, you may shower or fix breakfast the same way every day without making any decisions about what action to take next. You just “go through the motions.” This automaticity of movements saves a lot of mental energy, which frees up energy for your brain to use on newer, more interesting functions. This process occurs at the base of the brain in the subcortical region and is more a result of good praxis than an actual function of praxis.
When praxis skills are not fully functional, one or more of the above processes are impaired. This impairment is called dyspraxia. The literal definition of dyspraxia is “bad” or “difficult” action. Some people use the term dyspraxia interchangeably with, or prefer other terms, such as apraxia (which is literally defined as “without” action), developmental coordination disorder, or motor planning problems. In the United States, occupational therapists commonly use the term dyspraxia as an umbrella term for developmental praxis problems and apraxia is reserved for praxis challenges brought on by illness or injury.
Praxis abilities are based on the sensory processing functions of modulation and discrimination of inputs, the cortical functions of planning and sequencing, as well as the cerebellar functions of sequencing and rhythmicity. Dyspraxia, as categorized under Sensory-Based Motor Disorder, is developmental in nature (as in developmental coordination disorder), and not caused by illness or injury (such as a head injury or stroke). Again, in the United States, rehabilitation professionals tend to prefer the term apraxia for praxis challenges brought on by illness or injury.
Some symptoms of dyspraxia are:
Poor coordination, especially for complex tasks involving multiple body parts
Difficulty learning complex motor skills, such as driving a car
Struggling to come up with ideas or becoming distressed when answering simple open-ended questions, like, “What do you want to eat tonight?”
Difficulty with multi-tasking
Having trouble following multi-step instructions
Always doing things “the hard way” or in an illogical or inefficient way
Having trouble planning ahead
Difficulty managing time
Being overly rigid with plans and routines
As you can see, Sensory-Based Motor Disorder can be quite complex and affect many different aspects of daily life. Currently, best practice for addressing posture and praxis challenges is to work on bottom-up (body- and sensory-based) strategies in combination with top-down (cognitive) strategies to manage symptoms and improve quality of life.
Your nervous system is a complex network of signals connecting your brain and your body. There are eight major systems that connect your sensory organs through collections of nerve endings that gather sensory information to send to your central nervous system (brain and spinal cord). These systems give your brain information about your body and the world around you.
The “Foundational” Senses
Your foundational or proximal sensory systems give you information about your body and are some of the earliest to begin developing in utero. They include:
Tactile (touch)– located in your skin, touch receptors provide information about the world and specifically about the shape, size and texture of objects. Your skin is your body boundary and helps you understand your surroundings, to feel safe or alert you to danger, and to bond with loved ones.
Vestibular (head position and movement) – located in your inner ear, your vestibular system provides information about movement, balance, and your relationship to gravity. It lets you know if you are right side up or upside down. It also communicates if you are moving or still, as well as how quickly and in what direction you are moving.
Proprioception (joint and muscle activation) – located within each of your muscles and joints, your proprioceptive system provides information about the weight and resistance of objects, muscle relaxation, muscle contraction, stretch, and other movements of your body.
Interoception (internal sensations) – with receptors in each of your internal organs, your interoceptive system provides information about your bodily functions and is linked with how you feel emotion. Examples of interoception are hunger, thirst, breathlessness, pain, temperature, heartbeat, muscle tension, and bladder/bowel pressure.
The “Functional” Senses
The functional or distal sensory systems give you information about the world around you. They include:
Auditory (hearing) – located within your middle ears, your auditory system gives you information about what you hear.
Vision (sight) – located within your eyes, your visual system gives you information about what you see.
Gustatory (taste) – located within your mouth, your gustatory system gives you information about what you taste.
Olfactory (smell) – located within your nose, your olfactory system gives you information about what you smell.
Want to know more? Check out What is Sensory Processing? if you missed it! Also, stay tuned for Sensory-based Motor Disorders and Why You Should Care About Sensory Processing.
In simple terms, sensory processing and integration are the ways your brain detects, prioritizes, and remembers:
External sensations from the environment around you
Internal sensations from within your bodies, and
Interactive experiences with the people and objects you encounter.
Differences in the way your brain has developed gives you a unique set of filters through which you process the sensations you experience. Everyone has subtle differences in the way they process sensations, which are known as your sensory preferences. Here’s a quick overview of how sensory processing works.
Sensory modulation is how your nervous system regulates your brain’s response to sensory stimuli. It is what allows you to perceive a sensation as being too much, too little, or just right. Sensory modulation is related to sensory gating, which is how your brain decides if something is worth paying attention to or not.
When functioning appropriately, sensory modulation alerts you to important information and helps you respond to dangerous situations quickly. However, problems with sensory modulation can lead to a wide variety of challenges.
Sensory over-responsiveness (SOR) is also sometimes referred to as sensory sensitivity or being highly sensitive to sensations. An over-responsive reaction to sensations may cause you to easily startle or become overwhelmed by sensations. Sensory over-responsiveness can affect individual sensory systems or the nervous system as a whole.
Sensory under-responsiveness (SUR) is also referred to as low registration of sensory input. When you are under-responsive to sensations, you easily miss sensory information unless it is substantial enough to be noticed. Sensory under-responsiveness can affect individual sensory systems or the nervous system as a whole.
Sensory craving (SC) is often confused with sensory seeking (which is usually an adaptive behavior and not a problem). Sensory craving is more mal-adaptive (addictive or risk-taking) in nature. When your brain cannot detect what or how much sensory input is needed, you are driven to seek out increasing amounts of input, even if doing so leads to negative consequences.
Sensory discrimination is how you filter and categorize sensations. It helps you identify what a sensation is (for example, a sound), determine its qualities (a quiet whisper to my left), and compare and contrast it to other sensations with refined detail (that sounds like my Aunt Mabel).
When functioning well, sensory discrimination allows you to pay attention to and process your experiences. It allows you to discard irrelevant information, catalog things of interest, and remember important details and their attached meanings. Sensory discrimination relies on efficient and reliable sensory modulation abilities, so when you have difficulties with sensory modulation, chances are you have some challenges with sensory discrimination as well.
Here are a few examples of sensory discrimination challenges:
May not notice how much is “too much” until too late—you may be overly rough with others, use too much force and break things, or over-stuff your mouth when eating. You may be slow to catch yourself when you trip and fall, talk too loud, or be unable to tell if food is spoiled or not. You may tend to overeat, wait until the last minute to use the bathroom, or not notice signs of hunger or thirst. You may overexert during exercise or yard work, talk excessively, or accidentally overfill containers.
May be unable to tell when something is “not enough“—you may tend to run out of things completely before buying more, not clean thoroughly, or use too little pressure when hugging or shaking hands. You may talk too softly, drop things often, or misjudge how much of something is needed when planning ahead or preparing a meal. You may not offer adequate information when communicating with others, not notice when a room is becoming too dark to see, or misjudge how much time it will take to complete a task.
May need extra time to form conclusions or come up with questions when learning something new—You may comprehend information on a surface level but have “aha” moments much later. You may ask someone to repeat themselves only to figure it out before the other person finishes repeating what they said. You may not fully understand the meaning of something until a later time. You may not appear to be listening but then surprise others when you say or do something later that demonstrates you were listening after all.
These challenges, along with other similar difficulties with processing sensations are referred to collectively as sensory discrimination disorder (SDD). What is puzzling is that if you have SDD, you may often (though not always) be perceptive of details, but seem to have a hard time making meaning of the information taken in. It can seem like the “filter” in your sensory funnel is clogged. You take in information, and may even comprehend what you are perceiving, but you need time to form conclusions or questions about what you have learned. If you are required to take in too much information for too long, you may experience a form of shutdown that appears as though you are under-responsive to sensations. SDD may cause you to have difficulty prioritizing your responses to sensations, often missing or ignoring your body’s signals until the sensations become intense enough to register as urgent.
Want to know more? Check out The Eight Sensory Systems(that’s right–Eight!). Also, stay tuned for Sensory-Based Motor Disorders, and Why You Should Care About Sensory Processing.
In a stressful world, all of us find ourselves in moments that are too much for us to handle. We start to “lose it” — our confidence, our cool, our train of thought. The good news is there are some easy ways to get re-regulated and get back in control. Read on to learn more about regulation and how to use sensory strategies to improve your life.
The most basic definition of arousal regulation refers to your energy levels and your ability to change your level of energy to match the situation you are in. A low arousal state (see Figure 1) occurs when you are tired, bored, and are either not able or not required to exert much energy. A high arousal stateoccurs when you are stressed, upset, and are exerting a lot of mental and/or physical energy. There are appropriate times to be in low arousal (first thing in the morning, late at night when it is time for bed). There are also times where it is appropriate to be in high arousal (in high-performance or dangerous, life-threatening situations).
However, when you drop into a low arousal state at the wrong time, such as during an important meeting or exam, you need to shift your arousal level to a more alert or regulated state. And, when you find your arousal getting too high at the wrong time, such as during a conversation with your partner, you need to know how to calm down and get re-regulated before you “lose it.”
Finding the right sensory hacks takes time and practice. The best way to explore if the sensory strategies below are helpful is to try them when you are already fairly calm and relaxed. Some strategies may shift your arousal state right away. Some may have a delayed effect. You may need to try some of them several times to decide if they work for you. As you experiment, notice if the strategy tends to raise (increase) your arousal, lower (decrease) your arousal, or if it can do both depending on the situation. You may find that you already use some of the strategies below.
Hack #1: Get your head lower than your heart This strategy works by initially increasing blood flow to the head, which signals your body to lower your blood pressure. This, in turn, is a hack to calm your nervous system and lower your arousal level.
Important Note: Do not attempt this strategy if you have high blood pressure. Keep your neck safe and protected and do not apply pressure through your head if you have neck problems. Stop immediately if you experience nausea, dizziness, light-headedness, or pain.
Some ideas: standing forward fold, inversions, child’s pose (from yoga); headstands, handstands, kneeling on the ground and touching your forehead to the floor; lying in prone (on your stomach) or supine (on your back) over a large exercise ball and shifting your weight forward onto your head and/or hands.
Bonus tip: If it’s not an appropriate time to get your head below your heart, try putting some gentle downward pressure on the top of your head or along your forehead, especially near the upper bridge of your nose, right above your eyebrow line.Both strategies tap into powerful bundles of nerves that send calming signals to the brain.
Hack #2: Hum Humming, especially non-melodic, long, and low sounds produced deep in your throat creates strong vibrations that work to internally massage and soothe your nerves.
Hack #3: Bean bag tapping Any soft, small, weighted object will work for this strategy. A sock filled with rice, a TY Beanie Baby, or a cornhole bean bag all work well.
Hold the bean bag (or other soft, weighted object) in your right hand and gently but firmly tap from your left upper back/ shoulder, down the outside of your left arm, up the inside of your left arm, across your collarbones/ upper chest, then switch hands. Repeat the process across your right upper back/ shoulder, down the outside of your right arm, and up the inside of your right arm. You can continue this cycle back and forth or move to your lower body.
To tap your lower body, hold the bean bag (or other soft, weighted object) in your right hand and gently but firmly tap from your left hip down the outside of your left leg, across the top of your left foot, and up the inside of your left leg. Switch hands, and repeat the process beginning at your right hip, down the outside of your right left, and up the inside of your right leg. You may find it helpful to tap along your lower back and buttocks one side at a time, or, hold a weighted object in each hand while standing, twisting side-to-side, allowing the weight of the objects in your hands to alternately tap your lower back and buttocks as you twist.
Hack #4: Put pressure on the “button” on the roof of your mouth There is another powerful bundle of nerves on the roof of your mouth. You can press on the roof of your mouth or increase the pressure on the inside of your mouth by sucking while pressing upward with the tongue. A small, hard candy, such as a mint or lollipop can help you apply even more pressure, but is not necessary. This is why many young children find thumb-sucking or sucking on a pacifier so soothing.
Hack #5: Acupressure Acupressure has traditionally been used as a healing methodology provided by trained practitioners. It usually involves applying sustained pressure to sensitive points along the energy meridians of the body. However, sustained pressure in any tender spot of the body (especially the hands and feet) can be a powerful way to ground you in your sensations and calm racing thoughts. Self-administered acupressure has also shown promise as a way to reduce deliberate self harm in some patients.
To do acupressure on yourself, you can either use a variety of self-massage tools or simply use your thumb(s) and/or finger(s) to apply pressure. The key to using acupressure is to feel around until you find a tender spot and then apply gentle but firm pressure to that spot for several seconds. Some spots to try:
1. The soft space between your thumb and first finger, about a half-inch into your palm. 2. The nail bed and/or cuticle of your fingers and toes. 3. The webbed spaces between your fingers and toes. 4. The base of your thumb where it meets your wrist. 5. The middle of your forearm about three fingers-widths away from your wrist. 6. The back of the neck where your skull connects to your spine. 7. The ears.
Hack #6. Exercise. This “hack” is probably not a surprise. Exercise has been shown to be an excellent way to boost your mood or recover from stress. But what you might not know is how much intensity matters. What I am referring to is not the amount of calories you burn, but the strength of the sensation(s) provided by various forms of exercise.
When the intent of exercising is to change your arousal level, you will find that engaging in exercise that provides you with strong, enjoyable sensory input has the most impact on your regulation. Some examples of forms of exercise that can provide a lot of body-based sensory input are:
1. Chin-ups, monkey bars, or hanging on a bar or door frame from your hands 2. Leg presses, lunges, or squats 3. Lat pull downs, rowing, or butterflies/pec flies 4. High-intensity interval training, CrossFit, or Orange Theory routines 5. Hot and Yin-style yoga classes 6. Running, swimming, or cycling
Bonus Sensory Hacks There are many ways you can use your body to tell your brain you are okay. Below are several more ideas of ways to tap into sensations to adjust your arousal throughout the day.