When Washington, D.C., mom Sara Durkin's son was 3, she got a call one day from his preschool. "They said he wasn't sitting in circle time, he wasn't sharing as much as he should, and he liked to be the center of attention," she recalls. There were other issues as well. He didn't like group activities, although he did like to play one-on-one with other children. He was busy and physical, but he didn't want to ride a bike and seemed a bit clumsy.
The school suggested that Durkin take her son to see an occupational therapist. "They said that he might have sensory processing disorder or something like that," she recalls. Occupational therapy (OT) helps adults do better at their job and daily tasks. OT helps children be more comfortable and successful at play and in school.
Durkin and her husband thought he was just being a 3-year-old boy, and that in some ways -- such as seeking the company of adults and enjoying the limelight -- he was simply taking after his father, a national TV news correspondent. They elected to skip OT.
Then within a few months she heard from several other D.C. families. Their sons, all around the same age, had also been referred for occupational therapy (by different schools) with the suggestion that they might have sensory processing (or integration) disorder (SPD) or attention deficit hyperactivity disorder (ADHD). "I have one neighbor who's a speech pathologist and another who's an audiologist, and they both told me [SPD] is one of the most over-diagnosed disorders these days," Durkin says.
SPD: Real Disorder or Trend?
What's going on here? Is there something really wrong with our kids -- especially little boys? Or is "sensory processing disorder" the new ADHD --that is, a diagnosis of the moment that may well apply to certain kids who truly need professional help, but could also be over-applied to interpret typical young-child behavior as an illness?
It's true that behavioral and developmental disorders are on the rise among America's children. One in every six children now has been diagnosed with a developmental disability, such as autism, ADHD, or learning disabilities, according to research from the Centers for Disease Control and Prevention. That's 1.8 million more children than were diagnosed with similar conditions in the late 1990s. And nearly twice as many boys as girls have these conditions.
But what's not entirely clear is how much of this rise is due to a real increase in behavioral problems, and how much can be attributed to greater willingness to diagnose children who seem more active or distracted than others, but who in the past might not have received a "behavioral disorder" label.
"Schools often make these calls with good intentions; often they want to find out what's going on with a child who isn't 'fitting in' with the regular model of schooling," says Maureen Healy, MBA, a child development expert who has advised public school programs in New York, Connecticut, California, and North Carolina.
Unrealistic Expectations for Boys
This phenomenon may be occurring partly because we ask much more of preschool-age children than in previous decades. "We've compressed the curriculum more and more over the years, to the degree that what we're expecting of younger children is developmentally inappropriate," says John Schinnerer, PhD, a former school psychologist now in private practice in California and the author of Guide to Self: The Beginner's Guide To Managing Emotion and Thought.
"Not being able to sit in circle time for 20 minutes or resist touching the person sitting 6 inches away from them? That's totally normal for a 4- or 5-year-old boy. I'd say that for probably more than half of young boys, school just isn't made for them."
And why are parents of boys getting most of these phone calls? That may have to do with how boys' brains are wired. The prefrontal cortex -- the brain's "CEO," which helps us to make decisions, organize, analyze, and resist impulsive behavior -- matures more slowly in boys than girls.
"Boys are just antsy and full of energy, and part of that is because the 'brakes' in their brain aren't fully wired yet," says Ahsan Shaikh, MD, a child and adolescent psychiatrist for EMQ FamiliesFirst, a mental health and social services agency with offices throughout California.
What Is SPD?
Sensory processing disorder has been compared to a "neurological traffic jam," in which sensory signals received by the brain -- about everything from the taste and texture of a food to the intensity of a touch -- become garbled and disorganized. People with SPD may be oversensitive (or undersensitive) to stimulation of any of the five senses.
Some examples: A typical child may cover their ears when the train with its loud whistle rockets by; a child with SPD may fall into hysterical fits of terror. A typical child may wrinkle his nose and say that Grandma's perfume is stinky, but a child with SPD might refuse to play at someone else's house because they think they all smell yucky. (The Sensory Processing Disorder Foundation has a checklist of symptoms on its web site.)
The concept of SPD has been around for a long time -- it was first described in the 1960s by occupational therapist A. Jean Ayres, PhD -- but the diagnosis gained traction in the late 1990s with the publication of The Out-of-Sync Child, by educator Carol Stock Kranowitz. The Sensory Processing Disorder Foundation claims that as many as 1 in every 20 people -- both children and adults -- in the United States is affected by the condition. It often seems to be worse in children, though.
"Sensory dysregulation tends to get better with neurological maturation, but in many cases, it does not go away altogether," says Allison Kawa, PsyD, a Los Angeles child psychologist. "Most people learn coping strategies as they grow up. For example, people with sensitivity to light often find fluorescent lights irritating. As adults, they might choose to bring floor lamps into their office to avoid having to use them.
"Remember, we all engage in sensory seeking behavior (such as tapping a pencil or chewing a pen cap while concentrating) and sensory avoidance (I personally hate touching cold, mushy things like raw meat). It is when these needs or aversions interfere with our functioning and cause dysregulation that we have a disorder," Kawa adds.
But not everyone is convinced that SPD is a distinct disorder at all -- many suggest it is only a symptom related to other behavioral or developmental disorders, like autism and ADHD. Even those who do think it exists are cautious about applying the SPD label.
"I see it all the time in kids, and I do refer for further evaluation by occupational therapists," says Kawa. "But it does not yet appear in any of our diagnostic manuals, and it's not something like depression that has been well researched and defined with a large body of evidence."
"It can be a legitimate diagnosis," Healy adds, "but I also think that a lot of highly sensitive kids get lumped with a label that's not to their benefit. In extreme cases, it's clear there's a problem that needs help. But in milder situations, it's very unclear if it makes sense to label these kids."
Helping a Child With SPD
What if you realize that the school might be on to something? A referral to an occupational therapist can pretty much never hurt, says Shaikh. "This isn't medication. It doesn't have side effects," he says. "There are a lot of adaptive, common-sense things that a good occupational therapist can do to help a child with sensory issues."
For example, perhaps your son has been fighting a lot at recess. The occupational therapist may find that they have a problem with knowing where their body is in space, so when another child bumps into them, they lashes out.
"A good OT will give him exercises to better develop that positional sense," says Shaikh. "In general, with young kids, the more 'nonmedical' work -- teaching and training -- that can occur, the better off you are."
But you shouldn't take a referral from a school straight to an occupational therapist, advises Melanie Fernandez, PhD, a clinical psychologist and director of The Parent-Child Interaction Therapy Program at New York City's Child Mind Institute. Instead, consult your pediatrician, and perhaps seek an evaluation from a child psychologist or psychiatrist.
"That diagnosis will help identify the most effective approach," she says. "For example, the real issue might turn out to be ADHD, which occupational therapy doesn't treat. An evaluation may also be a way to establish what the condition isn't -- ruling out SPD or ADHD, but still identifying support that can take place in the classroom to help your child."
Getting Professional Help for SPD
Many providers, such as child psychiatrists or psychologists, may be willing to do a short "second opinion" consultation over the phone, says Kawa. "You can tell them that the school has brought up x, y, and z concerns about your child, and ask what they think. They may say that it sounds like you need an ADHD evaluation, or that it's 'typical boy stuff' and suggest waiting a few months to see if it's still a problem. Or they may tell you to come right in because it sounds like your child is really struggling."
To find a qualified child psychologist or psychiatrist, contact the nearest major medical center or use the search tool provided by the American Academy of Child and Adolescent Psychiatry (www.aacap.org).
Since occupational therapy can cost thousands of dollars out of pocket, you're more likely to get insurance coverage for it if the referral comes from a pediatrician or a child psychologist or psychiatrist.
If your child does have sensory issues, Shaikh says, identifying them and intervening at an early age can be enormously helpful. "One child was just slamming into people, and [his parents] realized that he just needs to feel things pushing up against him," he recalls.
"Every once in a while, the school has him crawl through plastic tunnels back and forth on his hands and knees, to get that need for stimulus out of him, and then he goes back into class and does fine. If you're a kid who struggles with this, every part of the day can be a bit irritating. Getting his needs met by modifying his day can make a world of difference."
Durkin's son started a new school last fall, one that seems to be a better fit for his personality. But his year at the old school ended well, and the teachers didn't mention occupational therapy again.
"I know they had his best interests at heart," she says. "Some of the things they complained about early on, he'd already stopped doing. I think in a lot of kids, it's just a question of maturity. They don't all mature at the same pace, and that doesn't always mean there's anything wrong."
Does Your Child Need an SPD Diagnosis?
Maybe, maybe not. First, consider taking one or more of these steps to help them adjust to a school environment.
Discuss alternate activities. "You might just have a kid who isn't developmentally ready for a 20-minute circle time," says Kawa. "After 10 minutes, perhaps he can be allowed to go to a beanbag chair and look at a book."
Hold your child back from kindergarten. "Don't start him early, especially if he has a late summer or early fall birthday," Schinnerer advises. "Hold him out a year, let him be a kid and develop socially, mentally, and emotionally."
Look at simple things like nutrition, sleep, vision, and hearing. Evaluating these areas may help you identify an easily correctable problem that might be causing behavioral issues. "My own son was a very wiggly little guy, and was even more so when he would eat sugary breakfast cereals," says Shaikh. "When we started giving him more protein in the morning, a lot of his behaviors went away." Note, however, that sugar doesn't necessarily cause heightened activity in kids.
Consider changing schools. "A lot of kids are sensitive, but that doesn't mean they have sensory integration disorder," says Healy. "They may just do better in a different school -- for example, a more open-ended, nontraditional environment." Research different schools in your area and one that may be able to accommodate your and your child’s needs better.
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