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Is “Sensory Processing Disorder” a real condition?

I recently saw a young patient and her parents for a second opinion regarding the diagnosis of “Sensory Processing Disorder” (also called “Sensory Integration Disorder"). They wanted to know more about it and more importantly how to treat it.

Sensory processing or integration refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound, and gravity. The diagnosis of SPD is typically made by occupational therapists and is generally not recognized by mainstream medicine. Children diagnosed with SPD tend to exhibit unusual or exaggerated sensitivity to various sensory stimuli. They complain about textures of food or clothing. They may be oversensitive to loud noises. They may also have behavioral issues or delays in motor skills.

It is clear that children with sensory issues do exist, but the more important question is whether SPD is a distinct medical syndrome and whether the treatment typically given has any effect on the child’s short or long term functioning.

SPD was first described by A. Jean Ayres, PhD in 1968. She was both a psychologist and occupational therapist. She sold her clinic in 1984, but stayed on at the successor practice as a consultant. However, that practice was sued at least 15 times, for issues relating to its business practices, and in 2007 the California Superior Court issued an injunction that shut down the practice.

Proponents of SPD believe that it is a developmental disorder amenable to therapy and that treatment can improve developmental outcomes. However, the prevailing medical opinion is that SPD does NOT meet the usual standards required to qualify as a diagnosis. It is interesting to note that SPD is not included in the universally recognized Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), despite campaigning by occupational therapists to have it included.

Certainly many children who go on to be later diagnosed with Autism Spectrum Disorder (ASD) have a history of sensory issues. Similar issues can be seen in children with Attention Deficit Hyperactivity Disorder and anxiety disorders.

Therapy for SPD recommended and provided by occupational therapists includes brushing the skin, using weighted clothing, special shoes, and various excercises to improvive coordination ("vesitubular training”). These techniques are claimed to desensitize the patient’s nervous system. These therapy sessions are expensive and involve months to years of weekly or more frequent sessions.

In 2005, experts at the University of Rochester concluded that there had been no adequate controlled studies either supporting the existence of SPD or demonstrating that that its treatment is more effective than no treatment at all. In 2012, the American Academy of Pediatrics issued a policy statement that stated that SPD should not be diagnosed, and that “parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive.”

The bottom line is that most children with sensory issues improve their behavior spontaneously. It is reasonable to question whether costly interventions are really necessary for what are most likely self-limiting problems of neurodevelopmental immaturity and anxiety.

Please feel free to contact with me any questions you may have.

Dr. Katz recently returned from the ASD meetings in Boston and wanted to share some information regarding ASD.

What is ASD? Autism Spectrum Disorder (ASD) is a developmental disorder characterized by problems with social communication, unusual behaviors such as fixed interests, being inflexible, having repetitive behaviors, or abnormal responses to sensations. Communication problems include difficulty understanding and responding to social cues and nonverbal communication such as gesture and tone of voice, which can result in challenges in making or keeping friends. Although people with ASD may want to make friends, difficulties in understanding social norms or correctly interpreting language and facial expressions can get in the way.

In recent years, it has become clear that individuals with ASD, despite sharing some behavioral challenges, can be quite different from one another. Some people with ASD may be very intelligent, while others may have advanced vocabularies and others may speak very little or not at all. Thus, people in the same family with autism or who share the same genetic risk factor(s) can end up with very different symptoms and outcomes.

While there is no “cure” for ASD, there is medication available that can help with the host of other difficulties that can as problematic as the symptoms of ASD itself. Anxiety, mood instability, impulsivity, hyperactivity, sleep problems, and even aggression and self-injurious behavior can occur in some people with ASD. Medication may be helpful in treating the symptoms of some of these associated conditions. Unfortunately, no medication has shown to offer clear improvement for the social communication impairment or restricted, repetitive behaviors that make up the core issues of patients with ASD.

Sitting down with Dr. Katz to discuss whether it is a good idea to try medication for certain troublesome symptoms in the patient with ASD is always a good idea.

Many parents ask me about what accommodations would be appropriate for a 504 plan for their child’s classroom. Here are some principles that a 504 plan should be designed around along with specific accommodations. An individual student may not require all these accommodations, but these should give you an idea of what might be reasonable. I think you will find them useful.

Mitchel G. Katz, MD
Connecticut & Gulf Coast ADHD Associates

Manage Impulsivity in the Classroom

For a child who speaks out of turn:
> Seat him front and center, near the teacher, and away from distractions
> Discuss the behavior in private rather than calling him out in front of the class
> Have him sit next to a well-behaved role model  
> Increase the distance between desks, if possible  
> For younger students, mark an area with tape around his desk in which he can move freely

Help for Half-Done or Incomplete Assignments

> Allow extra time to complete assigned work
> Break long assignments into smaller segments, each with a deadline
> Shorten assignments or work periods
> Pair written instructions with oral instructions
> Set a timer for 10-minute intervals and have the student get up and show the teacher her work

Help Classroom Focus

If your child doesn’t participate, drifts off when taking notes, or turns in work with mistakes:
> Have a peer assist him in note taking
> Have the teacher ask questions to encourage participation
> Enlist him to help present the lesson
> Cue him to stay on task with a private signal—a gentle tap on the shoulder
> Schedule a five-minute period for him to check over work before turning in assignments

To End Disruptive Classroom Behavior

> Have the teacher ignore minor inappropriate behavior
> Allow the student to play with paper clips or doodle
> Designate a place in advance where to let off steam
> Adjust assignments so that they are not too long or too hard
> Develop a behavior contract with the student and parents (share info about what works at home or vice versa)

For the Daydreamer in Class:

> Have the teacher use clear verbal signals, such as “Freeze,” “This is important,” or “One, two, three…eyes on me”
> Allow the student to earn the right to daydream for 5-10 minutes by completing her assignment
> Use a flashlight or a laser pointer to illuminate objects or words to pay attention to
> Illustrate vocabulary words and science concepts with small drawings or stick figures

Settle Fidgety, Restless Behaviors

If your child taps his foot or pencil nervously in class or gets up out of his seat a lot:   
> Allow him to run errands, to hand out papers to students, clean off bookshelves, or to stand at times while working
> Give him a fidget toy in class to increase concentration  
> Slot in short exercise breaks between assignments  
> Give him a standing desk or an air-filled rubber disk to sit on so he can wiggle around

Keep Track of Homework and Books

If your child forgets to bring home homework assignments or books, return papers to school, or to put his name on his paper:    
> Use an assignment notebook/student planner
> Allow students to dictate assignments into a Memo Minder, a small three-minute tape recorder
> Staple the teacher’s weekly lesson plan in the student’s planner
> Reduce the number of papers that are sent home to be signed
> Appoint monitors to make sure that students write down homework assignments
> Allow student to keep a second set of books at home

Put Time on His Side

If your child has trouble with due dates and deadlines:
> Give advanced notice about upcoming projects and reports
> Stand next to the student to make sure that the assigned task is begun quickly
> Present all assignments and due dates verbally and visually
> Use timers to mark transitions—putting materials away before starting a new subject or project

Expand Her Social Network

If your child is clueless about social cues, doesn’t work well with others, or isn’t respected by peers:  
> Set up social-behavior goals with her and implement a reward program
> Request that the school establish a social skills group
> Encourage cooperative learning tasks
> Assign her special responsibilities or a leadership role
> Compliment positive behavior and work
> Acknowledge appropriate behavior and good work frequently 

Take the Fear Out of Writing

If your child is challenged by written assignments:  
> Allow more time for written assignments and essay questions
> Shorten reports or assignments
> Allow students to print; don’t require cursive writing
> Allow the option of a recorded or oral report in lieu of writing
> Encourage students to use a computer for written work
> Allow the use of spell check and grammar check software

Reduce Math Anxiety

If your child does not finish math tests, is slow to finish homework, or has problems with multi-step problems:  
> Photocopy pages for students so they do not have to rewrite math problems
> Keep sample math problems on the board
> Allow use of a calculator for class- and homework
> Give review summaries for math exams
> Give extended time on tests

Attention deficit hyperactivity disorder (ADHD), a disorder that is most often diagnosed in childhood, is characterized by trouble paying attention, impulsiveness, excessive activity, and problems controlling behavior that isn’t age-appropriate. It’s a disorder that parents may be hesitant to consider because its symptoms are easily attributed to a child acting like a child. But if symptoms persist, or increase, it is something that parents should definitely talk to their child’s pediatrician about.

If you think that your child may have ADHD, your pediatrician will likely refer you to a mental health specialist for a diagnosis, unless he or she has experience with ADHD.

How and When is ADHD Diagnosed?

The first thing your doctor or mental health professional will do is assess your child’s behavior. This should be done comprehensively – by talking to you, observing your child, reviewing medical records, talking with your child’s teachers (or at the minimum having them complete standardized evaluation forms about your child’s behavior), and possibly talking with other adults who are part of your child’s life.

Your child’s doctor may decide to perform a non-invasive brain scan to assist in the diagnosis. The scan measures theta and beta brain waves, which tend to have a higher ratio in children and adolescents with ADHD than in those without it. This scan is approved for use on children between the ages of 6 and 17 years-old. The scan itself is not definitive in diagnosing ADHD, it should be used in conjunction with medical and behavioral observations and reporting.

It’s difficult to determine if children under 6 suffer from ADHD because the behavior of children that young can look like ADHD and yet be completely normal. In order for your child to be diagnosed with ADHD, symptoms must be present for a certain period of time, and they must be affecting your child’s life (school, home, recreational activities, etc.). That’s not an easy thing to evaluate in very young children, so most diagnoses of ADHD occur sometime after children hit the 6 years-old benchmark.

ADHD is a treatable disorder that you and your child’s doctor can manage. It is most commonly treated with a combination of medication and behavioral therapies, but there are also some things that you can do at home to help your child. Following a routine every day, praising and using positive reinforcement, making sure your child gets enough sleep and eats a healthy diet, and most of all, modeling good behavior, are all things that are beneficial to children with ADHD.

All preschoolers can be challenging, but some parents of ADHD preschoolers feel lost about how to handle things. However, you can see immediate results with these five easy parenting tips for ADHD preschoolers.

1: Be consistent

One of the most important things that parents of ADHD children must do is to determine what behavior is acceptable and what behavior is unacceptable early on. Like neurotypical children, ADHD children benefit from consistency--punishing them for certain behaviors one day and then ignoring those behaviors the next day prevents them from understanding the importance of avoiding that behavior.

2: Develop a Points System

Conversely, it's important to notice and reward good behavior in order to instill positive modification. One of the ways to make this system of positive and negative reinforcement concrete is to develop a "points" system in which children earn points for good behavior. You can then allow them to redeem these points for fun activities such as playing video games or watching television.

3: Offer structured choices

While the aforementioned boundaries are important, it is equally important to give ADHD children enough time to actually make the right decision. A simple way to get them in the habit of good behavior is to offer structured choices--that is, they get their choice of two or three things that need to be done. For example, if you ask a child if they want to do their homework, they may honestly answer "no." However, if you frame the question as whether they would like to complete their math or science homework first, you help to steer them towards positive choices.

3: The Power of Positive Attention

Children with ADHD crave lots of positive attention. You can use this to promote good behavior by going out of your way to notice and praise the child's good behavior. For instance, as the child works on their homework, go out of your way to encourage them by noting their hard work and how close to completion they are. 

4: Accentuate the Positive, Ignore the Negative

By paying more attention to good behavior and less attention to negative behavior, you can use your child's desire for positive attention to help modify behavior. Remember that younger children will respond more positively to touch, while all ADHD children will benefit from you noticing and praising their strengths on a daily basis.

5: Be Flexible

These rules, like those you set for your own child, should be considered flexible. While consistency and rules are crucial for any child, those with ADHD don't always adapt to changes as quickly as neurotypical children. If you are too strict, too soon, it may keep them from learning.

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