Could sensory integration disorder be the primary problem?

As in an Escher Print, there may be a completely different way to see this issue from that offered in a new policy statement from the American Academy of Pediatrics on the role of sensory integration therapies for children with developmental and behavioral disorders. The statement cautions against using the diagnosis of "sensory processing disorder," because these are most likely symptoms of some other disorder such as autism or anxiety.

But I wonder if, as we learn more about the genetics and neuroscience of mental illness, we will find that the sensory processing issue is primary, and we simply organize the range of symptoms that may result from this problem into categories, in the form of diagnoses such as autism, OCD, anxiety and depression. These may in fact all be regulatory sensory processing disorders.

Sensory processing is intimately tied to emotional regulation, and our  ability to manage ourselves in a complex social environment. The world may feel soft and inviting, or harsh and dangerous. In taking detailed histories from families of children with a range of behavioral and emotional problems, I have found that there is almost always some problem of sensory processing, often from birth.

Consider this poignant description from Daphne Merkin, in a New York Times Magazine piece about her life-long struggle with depression:

It is an affliction that often starts young and goes unheeded — younger than would seem possible, as if in exiting the womb I was enveloped in a gray and itchy wool blanket instead of a soft, pastel-colored bunting.

One little boy (identifying information as always have been changed to protect privacy) I recently saw in my behavioral pediatrics practice carried a diagnosis of selective mutism, a form of social anxiety. He was able to tell his parents, once they became curious about experience of the world, rather than just trying to get him to talk, that he saw colors as sounds. This is a variation of sensory processing known as "synesthesia" where two sensations are combined into one. Certainly it alters a child's perception of the world. These qualities may be associated with great talents, particularly musical. But for a young child who does not have the words to express or make sense of his experience, it can be overwhelming.

Consider another little girl of three who I saw  "because she didn't play with other kids in school." Detailed history revealed that she was highly attuned to all the sights and sounds at school and intensely curious about her surroundings, at this point more so than in the other kids. There was a strong family history of similar traits. She also became easily overwhelmed by loud noise, such as fireworks. At home her social interactions were normal. Yet a question of autism was being raised. Kids with similar sensory processing challenges may become very disorganized in the school setting and receive a diagnosis of ADHD. Again the sensory issue may be the underlying problem.

I wonder if we should we abandon altogether the search for a "disorder," and instead focus on understanding a child's experience of the world and helping him to make sense of and manage that experience. As I have said many times on this blog and in my book, Keeping Your Child in Mind, children do well when the people who care for them understand them, and can see the world from their point of view. If we stay focused on this task, then a label with a "disorder" becomes necessary only  for the insurance company.

In my behavioral pediatrics practice at Newton Wellesley Hospital, where I children under age 6 with a variety of emotional and behavioral concerns, almost every child has sensory processing issues.  Many sound like Merkin's baby in a grey wool blanket. They may cry all the time and not sleep. In toddlerhood and beyond these issues take different forms, including  difficulties with daily tasks such as dressing and bathing.

I am not saying that all of these children should have "brushing therapy." The AAP statement points to the lack of evidence for sensory integration therapy. But there is a wide range in quality of these therapies. The essential element is that these problems exist in a caregiving relationship. For example, having a baby who does not like to be held and cries all the time can be a devastating experience for a parent. Feelings of inadequacy or even depression may occur. It is essential to address the sensory processing problem in the context of this relationship, and not simply treat the child. Stanley Greenspan's DIR Floortime model is the prototype of this kind of work.

I am looking to add an occupational therapist to my practice who is well versed in the field of infant mental health and understands how to work in relationships in this way. We need to bring the body into the treatment as early as possible to help children regulate their emotions. Helping them to feel comfortable in their body and manage their sensory experience, and to use the body for self-regulation, are essential elements of the treatment of any behavioral or emotional concern in a young child.