By Maude Le Roux, OTR/L, SIPT, RCTC, DIR® Expert Trainer at A Total Approach 

At A Total Approach, I support many children who are working through a sensory processing disorder (SPD) and learning to self-regulate their emotions. Many are picky eaters and may also demonstrate extreme sensory, emotional and behavioral responses to the taste, smell, sound and texture of foods when eating. 

Research shows that from birth to age eight, 20 percent of all children struggle with feeding challenges. As parents and as occupational therapists, we must be aware that eating a meal is a complex sensory experience. It involves the ambience of the dining room and the family dynamics during dinnertime such as conversation, cooking sounds and other distractions in addition to the qualities of different foods. Children also engage their motor planning skills when learning to sit at the table and to use forks, spoons and other utensils when eating.

Who Is The Picky Eater?

For a picky eater -and their parents- mealtimes can be stressful events. The picky eater can complain that foods taste or smell funny while the parents are constantly negotiating with them to eat what’s on the table. 

The picky eater may only eat certain foods like bread, pasta, crackers and white cheese -what’s known as a “white diet”. They may show signs of nutritional deficiencies due to these limited food choices as a result, such as being overly moody or sensitive, lacking vitality or looking unhealthy. 

Children with SPD may struggle to deal with all the sensory messages of mealtime. They may not want different foods to touch on their plates or to eat the same meal as the rest of the family. They may eat very few foods and avoid trying new foods. SPD can produce symptoms similar to eating disorders, which can lead to poor nutrition, significant weight loss or obesity.

Feeding as Nurture

For children and their parents, feeding is part of nurturing and nurturing is part of feeding. Many parents show love for their children through food. When feeding is not going well:

• Mealtime becomes a source of conflict
• The opportunity for bonding is lost
• Both parents and children put up barriers to attachment

The goal is to develop equilibrium and balance with feeding, which starts in infancy. Successful feeding depends on:

• Mother and child maintaining a calm, alert state during feeding.
• The coordination of sucking, swallowing and breathing during breast- and bottle-feeding.
• The orientation of the mother’s body and baby’s mouth towards the nipple.
• The ability of the child to signal hunger and satiation and the ability of the mother to read the cues and respond.
• Mother and child tolerating the body contact of feeding.

Source of Worry

Feeding is a huge source of worry for parents. Babies can pick up on a parent’s anxiety and may become resistant to feeding. If the child is experiencing modulation or regulation difficulties, they might not distinguish between feelings of hunger and satiation. The parents may resort to feeding the child to console them, which can start a cycle of needing to be fed when distressed. 

Biological factors can also come into play, such as malabsorption of food, tactile hypersensitivities and reflux, causing feeding to be a painful experience for the child. 

In our collective experience as occupational therapists, the following parental interventions can cause more harm than good:

• Forcing the child to eat food by placing it in their mouth.
• Putting food in front of the child’s mouth or on their lips until they eat it.
• Making the child take more bites after they have gagged on or vomited a food.
• Bribing the child to eat.
• Ignoring the emotional upset of the child when eating.
• Shaming or punishing the child for not eating.
• Staying away from the child until they eat.
• Making no eye contact or interacting with the child until they start eating.

Guiding Principles To Help Parents with Picky Eaters

Follow the child’s lead when it comes to them tolerating the food on the table. Expose them slowly to the smell, taste and touch of a food. If the child is pushing back or fighting about eating food, look for other options to get them to eat. It is also important to consider to first work on regulating the autonomic nervous system before the child will let go of the external need for control through picky eating due to not feeling in control on the inside. For this work you would need to work with your occupational therapist. 

You could try food chaining, which enables the child to try new foods that are similar to foods they currently enjoy and eat consistently. Use books about food during story time. Ask them why they like the foods they like and foods they don’t like. See if they can explain why they won’t eat a variety of foods. Help them by asking how the food tastes and feels in their mouth, what food flavors and textures do they prefer – salty, sweet, crunchy, creamy? Ask them if eating food makes their tummy hurt or makes them feel sick. 

Serve foods you want to eat as a family, establishing feeding rituals and predictable mealtime routines. Compare the child’s behavior only to themselves rather than to a sibling’s or even a parent’s behavior. 

Incorporate playful activities into eating like licking food, blowing bubbles in the food or spitting the food into a bowl or garbage can. Have them join in on meal prep in the kitchen, touching foods with their hands. Encourage the exploration of food and expect a mess. 

If the child may have a food allergy, medical condition or has difficulty chewing, seek the advice of a medical professional. Avoid any therapy occupational or otherwise that does not build relationships.

Sensory Integration Therapy from A Total Approach

Over the years of working in the field of developmental delay and sensory processing difficulties, we have witnessed many children struggle with picky eating and to make sense of their emotional responses.

Here are a few clinical interventions that could help: 

Tomatis Sound Training – This intervention is delivered through an electronic ear, a device that modifies music in a way that is stimulating to both sympathetic arousal and parasympathetic inhibition to impact the discrimination of different central nervous system pathways. 

DIR/Floortime Therapy – A comprehensive, developmentally-based model for assessment and intervention for children with special needs that empowers the parent to validate and support the child’s social, emotional and physical growth. 

Interactive Metronome Training – This is the only program that uses a patented auditory guidance system and a musical metronome plus interactive exercises to improve the foundational skills essential for learning and development by accurately measuring, assessing and improving rhythm and timing. 

Sandplay Therapy – Play is the language of children and the sand tray provides a safe medium for expression, free from judgment. When unable to effectively communicate needs, Sandplay therapy gives expression to non-verbalized emotional issues.

Learn More About How to Help A Picky Eater

If you’d like to learn more about how to help a picky eater, schedule a free phone consultation with one of our therapists who can give specific insight into our approach.

By Maude Le Roux, OTR/L, SIPT, RCTC, DIR® Expert Trainer at A Total Approach

For most children, sensory modulation develops during the course of ordinary childhood activities. If this process is somehow disrupted, a child may develop sensory modulation disorders (SMD) that interfere with their behavior, learning ability, social skills and self-esteem. They will also have trouble with emotional regulation.

The inconsistent responses of a child with SMD to sensory stimuli are less about willful behavior and more about how their system adapts and the coping strategies available to them at any given moment.

An important influence for a SMD child’s inconsistent performance is how they are sleeping. 

Adequate amounts of restful sleep give us the foundation for our best participation and engagement in daily life. When we work with children who exhibit developmental delays, first we explore the impact of sleep habits on the child and the family to determine their ability to function effectively during the day. 

Definition of Sleep

Physician Robert MacNish, who wrote The Philosophy of Sleep in 1830, describes sleep as a “suspension of sensorial power”, an altered state with a natural lessening of conscious awareness of the external world. The sleep state is transient, periodic and physiological, characterized by reduced responsiveness to environmental stimuli. It is also reversible, meaning people awake from sleep, which differentiates it from death or coma. 

Sleep is regulated by a homeostatic process and a circadian process that interact to determine sleepiness and alertness. These two processes are described scientifically as follows: 

A homeostatic sleep debt process refers to the drive for sleep that increases as a saturating exponential when we stay awake and decreases exponentially when we sleep, and a circadian process refers to the internal oscillatory rhythm that runs about 24 hours and can be reset by the environmental light.

Theories On Why We Need Sleep

Philosophers and scientists have been studying why people sleep since the dawn of medicine. Adaptive and instinctive, sleep:

• restores and repairs our bodies, creating metabolic homeostasis
• conserves our energy
• strengthens the integrity of our synaptic and neuronal network
• clears our minds of extraneous thoughts and consolidates our memories
• regulates our body temperature
• improves endocrine regulation of our immune systems

The Impact of Sleep Deprivation

Sleep also affects our emotions. Research shows people who sleep poorly or aren’t sleeping enough find it more difficult to recognize expressions of emotion like anger or happiness. Lack of sleep can also limit their social skills. 

Sleep deprivation is so prevalent in our society, it’s become an unmet public health problem. According to a report funded by the National Institutes of Health, an estimated 70 million Americans chronically suffer from a sleep disorder that hinders daily function and adversely affects health and longevity. 

When children are sleep deprived, it manifests through emotional and behavioral symptoms that include aggressive or delinquent behavior, reduced attention spans and a variety of social difficulties. Children can also experience sleep disorders associated more with adults such as insomnia, narcolepsy, sleep apnea and others. 

When a child comes to us with a sensory modulation difficulty, our first course of action that initiates any intervention program is to explore their sleep habits. Using sleep questionnaires, we help families make systematic changes in bedtime routines and suggest calming activities and other routines to facilitate sleep that do not burden the family and can be carried out consistently.

Tips To Create a Bedtime Routine That Promotes Healthy Sleep

• Select a specific bedtime for each child based on their age and schedule.
• Get your child relaxed and ready for bed with a predictable, regular sequence of events.
• Reinforce the bedtime routine with your child by explaining the routine step-by-step, then remind them of what’s coming, like, “First we eat dinner, then we play, then we’ll take a bath and put on our pajamas. Then we read a story and then get into bed to go to sleep.”
• Begin the relax-and-ready routine about a half hour before bedtime.
• If your child wants a drink, try a glass of warm milk, which is scientifically linked to improved sleep.
• Avoid having your child drink too much liquid before bedtime, however.
• Offer your child a light snack of foods high in tryptophan, such as bananas and cheese, to help them feel drowsy.
• Encourage your child to be part of the process. Ask them what step of the routine comes next, for example.
• Have your child pick up and put away toys.
• Turn off the TV and play soothing music during the bedtime routine.
• Prepare your child’s bedroom for healthy sleep. Keep the lights low and the temperature cool.
• Have your child take a warm bath, adding lavender or Epsom Salts to the bathwater.
• Offer your child choices of books to read and music to listen to or songs to sing.
• Suggest that your child take a favorite doll or stuffed animal or a favorite blanket to bed with them.
• Be consistent with bedtimes during the week, on weekends and even during vacations.

Tips for Increasing Your Child’s Comfort at Bedtime

• Check your child’s sensory experiences at bedtime. Are their pajamas or bed blankets itchy? Do the fabrics breathe? Is the room too warm? Too cool? Do the window coverings let in too much light?
• If your child expresses a fear of the dark, help them overcome the fear in a safe, supported environment. Make statements such as: “I believe in you,” or “I know you can do it”.
• Incorporate supportive actions into the bedroom routine, like checking the closet or under the bed for danger.
• Switching on a nightlight in your child’s room can help reduce their fear of the dark. Avoid lights with a blue or green cast as they inhibit the production of melatonin in the brain and can prevent your child from feeling drowsy at bedtime.

Learn More About Sensory Integration Therapy

If you’d like to learn more about the different methods we use for sensory modulation and emotional regulation, such as Tomatis sound therapy, Interactive Metronome therapy and others, I recommend scheduling a free phone consultation with one of our therapists who can give specific insight about you and your child’s situation.

By Maude Le Roux, OTR/L, SIPT, RCTC, DIR® Expert Trainer at A Total Approach

When we study a child’s development, we look at it through a sensory lens and an emotional lens. That’s because sensory modulation and emotional regulation work together to form a whole picture of the child’s behavior. Without one or the other, any therapeutic intervention may not give the results we’re looking for.

No discussion on the emotional triggers of regulation is complete without first talking about the sense of self that develops at an early age and the difference between temperament and personality.

Some call temperament the “why” behind personality and it is, in many ways. While personality arises within an individual and is made up of certain characteristics, temperament is the inherited style of an individual, often referred to as their natural instinct or emotional constitution.

Parents can nurture a child’s temperament, which gives clues about their strengths and weaknesses. Personality develops over the years and can be influenced by education, social status and the stress of life events. The characteristics of personality are consistent but can be expressed in a multitude of ways.

What is Emotional Self-Regulation?

During his lifelong study of emotion regulation, Dr. Stuart Shanker has observed that every time children are confronted with stress, their brains respond with processes that consume energy, followed by restorative processes to recover from the energy expenditure. Therefore, he defines emotional self-regulation as how effectively a child responds to environmental stressors in the moment and how efficiently they recover from the effort.

A child who merely misbehaves in any given situation will realize they could have acted differently, that they are perfectly capable of acting differently. Whereas a child who demonstrates stress behavior is not fully aware of their actions or the reason for their actions. They have limited capacity to act differently in a stressful situation.

The challenge for parents and occupational therapists in helping the child learn how to regulate their emotions is understanding why certain levels of stress stop the child from an effective, efficient response.

Dr. Shanker’s Five Domains of Stress

To help reduce a child’s stress level that is affecting their behavior, first recognize and identify the stressors across five domains:

1) Biological Stressors – Noises, crowds, too much visual stimulation, not enough exercise, lack of sleep, eating junk food

This domain refers to the physiological process of burning energy and restoring it. It involves sensorimotor challenges and sensory adaptive responses influenced by nutrition, sleep and exercise.

2) Emotional Stressors – Strong emotions, both positive and negative

This domain taps into the child’s understanding and management of their emotions and what to do when they are overwhelmed. Have they developed language to express their feelings in the moment? Temperament plays a role here. The emotional domain can also impact the biological domain.

3) Cognitive Stressors – Difficulty processing certain kinds of information

This domain engages the memory, information processing, reasoning, problem-solving, shifting and sustaining attention, self-awareness and thought sequencing- how to plan and carry out steps to achieve a goal.

4) Social Stressors – Difficulty picking up on social cues or understanding the effect behavior has on others

This domain accesses relationship skills and the ability to adapt behavior in social situations like making friendships that last, taking turns in conversation, picking up on social and non-verbal cues and understanding how emotions affect other people’s behavior.

5) Prosocial Stressors – Difficulty coping with other people’s stress

This domain relates to spiritual, aesthetic, humanitarian and intellectual development and internal standards and values. It brings into play empathy, selflessness, social responsibility, connecting with others within group dynamics and the smooth shift from me-centered to we-centered thinking.

All of these stressors influence a child’s ability to regulate their emotions. If they can’t make sense of an emotion that they’re experiencing in a physiological way with the right adaptive response, how can they self-regulate?

Hierarchy – Levels of Regulation

I use these levels of intervention when treating children with developmental delays as related to sensory processing and self-regulation:

Level 1: Sensory Modulation coupled with Emotional Regulation

• Depends on the emotional co-regulation of the parent-child bonding process

Level 2: Sensory Discrimination

• Registering and processing information in an adequate speed and pace
• Accurately grade sensory information to match the intended intensity from auditory, visual, touch, movement, deep pressure, smell and taste stimuli

Level 3: Praxis

• Series of exams to measure anxiety-related to performance demands
• Performance anxiety due to not performing exactly as my brain wants to cognitively dictate

Level 4: Timing

• Sequencing and bilateral integration includes the ability to regulate time, handling the passage of time, pacing self through activity

 Level 5: Executive Skills

• Cognitive skills used to plan, organize and execute a task, make decisions, shift between situations or thoughts, control emotions and impulsivity, be an active problem-solver and learn from past mistakes
• Requires the regulation of timing between all systems to impact interhemispheric function and attention regulation

To bring about emotional self-control requires secondary structures early in life. Detecting, monitoring and evaluating dynamic affective-state changes is impacted by registration and discrimination challenges. Inhibiting or modifying emotional reactions is impacted by the ability to inhibit over-arousal as well as excite under-arousal. Assuring automatic self-control over time is impacted by praxis, sequencing and timing.

Our occupational therapists can help your child’s emotional regulation skills by working on focusing attention, filtering distractions, controlling impulses and coping and calming behaviors to improve self-regulation. 

Learn More About Emotional Regulation

If you’d like to learn more sensory modulation and self-regulating emotions, schedule a free phone consultation with one of our therapists who can give specific insight into our approach.

In today’s world of medicine and education, the tendency to label a child’s behavior as a “behavior disorder” or to file it in a diagnostic category is a common practice. As a result, the child’s parents shift back and forth from one professional opinion to the other, starting a therapy treatment for the child’s disorder only to let it go, while the child starts to feel more and more helpless and out of control, which can become evident in their behavior.

As a subtype of sensory processing disorder and from an occupational therapy perspective, sensory modulation is the ability of a person’s autonomic nervous system (ANS) to regulate the activity between the sympathetic (arousal) and parasympathetic (inhibition) systems, allowing them to increase or decrease activity so that the desired outcome of activity creates harmony in all functions of the central nervous system (Ayres 1979).

In sensory modulation disorder (SMD), a regulatory imbalance often causes difficulties in a child’s behavior while anxiety levels rise. The child often is labeled as “having behavior problems” and also is blamed for them, even though it is a developmental delay and a neurobiological condition.

Sensory modulation disorder has long-term impact on a child’s development. If a child has a developmental delay, whether visual, auditory or otherwise, sensory modulation often impacts how these different sensory systems register information in order to process them. It really supports the ‘entry point of information’. If there is a disorder in this function, it’s a disconnect between what’s coming in externally from the context of the environment and the person’s internal experience of that same environment. That alters what we call the adaptive response.

Understanding A Child’s Behavior 

A child’s response to sensory input is dictated by their central nervous system. Each person has unique thresholds of response that cause a nerve cell or a system to activate. Children with a low threshold notice and respond to stimuli often, and their systems are frequently activated. Children with a high threshold miss stimuli that others notice and need stronger stimuli to activate. 

The hallmark of sensory modulation is that the child does not have consistent performance. It depends on how they slept. It depends on what they ate. It depends on how their system is adapting. It depends on how many coping strategies are available to them at any given moment. It’s not willful behavior.

The Four Patterns of Self-Regulation

Self-regulation is a behavioral construct of Dunn’s Model of Sensory Processing. According to Dr. Dunn, people either have a passive strategy or an active strategy for reacting to things that happen around them. She sites these examples: 

When a passive strategy for self-regulation intersects with an active strategy, four basic patterns of sensory processing emerge that involve the relationship among thresholds, self-regulation and sensory processing patterns:

Sensation Seeking – high thresholds with active self-regulation

• Enjoy sensory experiences and input
• Move more, hum during the day
• Jump up and down, rub hands together often
• May be distracted by new sensory experiences
• May have more difficulty completing tasks
• May lose track of daily life tasks

Sensation Avoiding – low thresholds with active self-regulation

• Notice things much more than others
• Like quiet environments, to be more isolated or alone
• Get anxious more quickly
• Withdraw from challenging environments 

Sensory Sensitivity – low thresholds with passive self-regulation

• Detect sensory events more frequently
• Get distracted more easily
• Get upset by seemingly unnoticeable things
• Notice more details in life
• Notice changes in setting or moods more quickly
• Get interrupted from completing tasks

Low Registration – high threshold with passive self-regulation

• Miss more cues than others
• Fail to notice details
• May be more easy going
• Take no notice when called
• Drift away during activities
• Find it hard to get tasks completed in a timely manner

Self-regulation is the basis upon which we build all our functions. This is why we see so many kids wanting to be controlling. They are acting out of a subconscious need for self-protection. They want to control others externally so that they can feel in control internally.

For example, a child may continue to sit amidst other children during play and become irritable because of all the random sounds in the play area. It is a passive self-regulation strategy to remain in this noisy play area even when the child feels uncomfortable from all the sounds. At the other end of the continuum, persons utilize an active strategy … For example, the same child playing amidst other children would crawl to a quieter place when the sound got overwhelming. It is an active self-regulation strategy to adjust one’s position to get a more manageable amount of sensory input. 

Link Between Childhood Trauma and Sensory Modulation Disorder

Chronic traumatic stress such as abuse and neglect creates changes in a child’s brain that trigger their fear response automatically, which is called a state of “hyperarousal.” Physiological changes during hyperarousal influence thinking, feeling and acting, which indicate a neurogenic response rather than a behavioral reaction. 

You cannot treat sensory modulation through a behavior program. You are going to fail. The neurological system will have to be reset. We want kids to think and then do and then feel. Children with sensory modulation disorder feel first, then they do, then they think.

Some successful neurogenic treatments for sensory modulation disorder include programs that strengthen interoception and the awareness of self. 

Interoception, one of the newest buzzwords in occupational therapy circles, allows people to “feel” internal organs and skin while providing a status report on the internal condition of the body. Interoception involves a variety of general, localized feelings such as pain, body temperature, itchiness, sexual arousal, hunger, thirst, heart rate, breathing rate, muscle tension, pleasant touch, sleepiness and bathroom urges as well as warmth or coldness, tickling or shivering, tension or relaxation, constriction or expansion, sinking or lifting, trembling or steadiness. These feelings are a key component of emotional experience and the basis for how people feel emotions. Often called “the eighth sensory system,” interoception can help a child calm down and self-regulate as a result of being more aware of the feelings within their bodies.

Interoception, combined with the awareness of self, form a social foundation for how people behave and interact with their surroundings and allow the development of a first-person perspective that connects thoughts, feelings, intentions and the body. When a child starts to understand themselves and develops a healthy self-awareness, only then can they move on to understanding others and the environment they live in.