Sock Bump Anxiety Disorder? Understanding Children with Sensory Over-responsiveness

In the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry there is an article, with an accompanying commentary, that encourages me to think that perhaps the discipline of psychiatry is making moves from the "what" to the "why" of mental illness. Alice Carter, a brilliant researcher at UMass Boston, has an article entitled Sensory Over-Responsivity, Psychopathology, and Family Impairment in School-Aged Children.

In their editorial in the same issue Cynthia Rogers and Joan Luby write:

This work suggests that developmental scientists and mental health clinicians should recognize sensorimotor processing as an important independent developmental domain and key area of challenge in early childhood that has tangible implications for behavioral and emotional functioning.

Interestingly Joan Luby has written about the validity of diagnosing major depressive disorder in preschool children, an idea about which I have grave concerns. I wrote, in a response in the Boston Globe when her work on this subject was first published:

My sense is that these children process the world differently. One mother described carrying her screaming son for hours until she realized that he didn't want to be held. Another mother said her daughter was "not cuddly" and difficult to feed. As they become toddlers, the issues change. I hear about what I call "sock bump anxiety," where many changes of socks are required to find the one with the right seam in the toes. "Fun" family outings to a county fair can end in disaster as kids become overwhelmed by all of the sights and sounds. Intense tantrums and meltdowns are frequent.

Now I wonder if Luby an I are more on the same page than I had thought. The question, in my opinion, should be not "what is the disorder" but rather "what is the expereince of this particular child and family?" Unfortunately, as Dan Carlat states in his book Unhinged: the Trouble with Psychiatry

The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in ‘why’ and more interested in ‘what’.

My clinical experience is consistent with Dr. Carter's findings. I see young children with a wide range of behavioral concerns. Sometimes they have symptoms of anxiety. Others are "explosive" or "hyperactive and impulsive" Still others have rigid rituals, and teachers have raised concern about autism spectrum disorder. In almost every story, there are symptoms of sensory over-responsiveness. These symptoms are inevitably accomapied by problems of self-regulation and in fact have been called "regulatory disorders" in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood–Revised(DC:0-3R). And as Dr. Carter describes, these symptoms are very disruptive to family functioning. Often siblings are the most dramatically affected when their needs are relegated to the back burner, as families struggle to avoid and then manage the frequent meltdowns that inevitably accompany these sensory difficulties.

I have wondered what it is that makes one child with sensory over-responsiveness and concurrent problems of self-regulation develop depressive symptoms, other autistic symptoms and yet another hyperactivity and attention problems. I suspect we will find that the gene(s) responsible for sensory processing are associated with different genetic vulnerabilities, and so the symptom takes a different path.

Occupational therapists have long recognized the significance of these problems, and many have advocated for adding a diagnosis of "sensory integration disorder" to the DSM list. Rather than debate whether sensory over-responsiveness is a disorder in and of itself, it is in my opinion, enough to recognize, as Dr. Carter has done, that it can be a significant problem for a child and family. Then primary care clinicians, mental health care providers as well as friends and family can offer the validation and support these families need. Waiting for a DSM defined diagnosis to emerge may narrow thinking and cloud our view of the complexity of the family's experience (Such a label maybe necessary, unfortunately, to bill insurance for services.) As I have said before on this blog, these "problems" of sensory over-responsiveness may be transformed into adaptive assets when children, validated and understood by their caregivers, develop the language skills and capacity for self-regulation that come with growing up.