Sensory or Behavior?

Sensory vs Behavior
By Patience Domowski, LCSW

How do I know if my child’s behavior is sensory-related or a behavioral problem? Parents wonder this all the time. The simple answer is that it's often hard to tell and sometimes the reasons overlap. Often the issues can be both.

Sensory issues are sensitivities related to the senses- see, hear, feel, taste, smell. People can be over-sensitive or under-sensitive to senses. Children can be sensory- seeking: they do certain things to get certain sensory stimulation, such as excessively rubbing a soft blanket, or sensory-avoidant: they do things to avoid sensations they cannot handle, such as covering their ears for loud sounds. Some behaviors that are sensory related can also be behaviors for other reasons, which makes this so difficult to figure out. Some children are both sensory seeking and sensory avoidant for different senses.

Some behaviors you might see in a sensory-seeking child: running around and crashing into furniture/items, desires tight hugs and squeezes often, chews/sucks on toys/fingers/etc, bites/scratches/squeezes  people or furniture, likes to feel various items and objects, fabrics, textures. These behaviors are  not to get something they want from another person, like a toy, or attention, but for sensory input into their body.

Some behaviors you might see in a sensory-avoidant child include: won’t touch or eat certain textures- wet or soft items often like pudding or yogurt, screams and covers ears/eyes in certain bright lights or loud noises (may seem normal lighting or sound to a non-sensory person however, but to a sensory kid it’s overwhelming), avoids certain fabrics/clothing.

If a child is screaming or running around, those are not obviously sensory related behaviors, so how do you know the difference? The way to figure it out is to try to figure out the function, or the WHY, of the behavior. Is the child running around because they are trying to get your attention? (Behavioral) Do they seem to be very hyper and struggle to sit still? (Could be Sensory) Is the child screaming to get what they want, get attention, or because other people are doing it? (Behavior) Or are they upset with no clear reason why? (Could be sensory) Would the child do the behavior if no one was in the room with them? One of the simpler ways to figure out if a behavior is for sensory purposes is if the behavior would occur without any other interaction from another person. If the child was alone in a room and would still do that behavior, it is likely sensory- because they are not trying to avoid something they don’t want to do, get attention, or get something from someone else (the other functions of behavior). [For more info on functions of behavior see my other article on this topic].

Many children do sensory-seeking behaviors that are not a major problem as most children like to run in circles, dance around, touch soft items, etc. because it feels good to them. It's only a sensory problem when the behaviors are disrupting the family or school setting, or causing distress or interference in the child’s life. To have your child diagnosed with a sensory disorder please seek an evaluation from an occupational Therapist (OT). OTs are available through Early Intervention (if your child is under age 5), the school system, or private agencies.

If the behavior is for any other reason than sensory-stimulation it's a behavioral issue, not a sensory issue. If a child is throwing a tantrum because they didn't get candy, that’s behavior. If they are melting down because the lights are too bright- that’s sensory. Sometimes it's hard to know why so trying to figure out when the behaviors occur, what set it off, and the environment is very helpful. If your child is verbal, ask them what the problem is if they can verbalize it. Sometimes taking data is helpful to see patterns and figure out what settings the behavior seems to occur in most often.

So what do we do about it? We want to treat the behavior differently based on the function (or WHY) of the behavior. If a child is screaming for attention purposes, we would likely want to ignore them and teach them a better way to get attention. But if the child is screaming to avoid a loud sound, we would want to help them protect their ears- such as providing headphones in noisy environments. If the child doesn't want to wear underwear to be difficult or in control that is much different than a child who is complaining the underwear is itchy. So once we figure out WHY the behavior is occurring, then we come up with a solution.

OTs help kids de-sensitize and meet their sensory needs in more appropriate ways. So a kid who cannot tolerate certain clothing would probably be brushed until they could tolerate it. They would have the child do sensory activities like jumping on a trampoline or crashing into cushions to meet those needs instead of grabbing people or running into walls. Behaviorally the child can be given rewards for making good choices- like using a sensory toy or strategy, such as biting a chew toy instead of mom’s arm.  We want the child to meet their needs in an appropriate way or get them to a point that they don't need that problematic behavior anymore.

Often the behaviors are both sensory and behavioral and they can feed each other, so sometimes a combined approach to treatment is helpful. Many children with ADHD, autism, and anxiety also have sensory issues. However a child can have sensory issues without a mental health diagnosis as well. Try to have your child evaluated by both a behavioral/mental health therapist and an OT to figure out the right diagnosis as that will be very helpful in coming up with a treatment plan.

Because sensory and behavior needs vary so much per child, and figuring out the function can be difficult sometimes, it is important to meet with an experienced professional to help figure out a plan specifically for your child. OTs and Behavioral Specialists/Therapists are the best professionals for this. Some Physical Therapists (PTs) can be helpful as well. Not all child therapists are familiar with sensory issues however, so find someone who knows something about sensory concerns and behavior.

• More information on Sensory Processing Disorder, including symptoms and treatment see: https://www.sensorysmarts.com/signs_of_spd.html https://www.sensorysmarts.com/sensory_diet_activities.html
• https://www.understood.org/en/learning-attention-issues/treatments-approaches/therapies/sensory-diet-treatment-what-you-need-to-know
• http://lemonlimeadventures.com/is-it-sensory-or-is-it-behavior/
• https://theanonymousot.com/2013/03/28/is-it-sensory-behavior-or-both/
• https://www.brainbalancecenters.com/blog/2014/11/sensory-meltdown-vs-temper-tantrum/
• http://suelarkey.com.au/wp-content/uploads/2015/05/Sensory_Meltdowns_vs_Behaviour_Meltdowns.pdf

Autism/Aspergers and teaching social skills at home

Autism/Aspergers

If you have a child on the autism spectrum you are probably realizing that parenting this child is extremely different that parenting neurotypical children.

[If you aren't sure if your child is on the autism spectrum have them evaluated by any of the following: their pediatrician, a developmental doctor, a licensed therapist, psychiatrist, Early Intervention evaluation team, child psychologist- either independent or at the child's school.

Signs of autism include at least some of the following symptoms -extreme difficulty with social interaction (including poor eye contact, difficulty understanding other person's tone or intent/meaning, struggles to make friends/initiate conversations, "tuned out", doesn't seek out others for interaction, doesn't understand emotions/how others feel), difficulty with communication (either not talking by age 2, barely talking, difficult to understand, difficulty with conversation skills/pragmatics/turn taking), repetitive behaviors/sensory problems (head banging, flapping, spinning in circles etc), restricted interests (will only play with dinosaurs, lines up cars, etc), other difficult behaviors (defiance, lack of focus, extreme inflexibility, difficulty transitioning between activities, needs a lot of help with basic life skills activities).] 

Children on the Spectrum need visual directions often, and help learning every behavior that most other kids will naturally pick up on without having to be specifically taught. I recommend find a good therapist and get them in a school/classroom that will meet their needs. Because autism is such a spectrum: from the severe nonverbal kids that might also have intellectual disability to the high functioning brilliant Asperger’s kids that your child’s treatment needs to be individualized and work best for their needs.

There is not really a one size fits all treatment for every kid on the spectrum but some basic tips include:

- use visual cues and directions

(social stories, picture schedules, show pictures or gesture/sign language of what you are asking them to do, write down reminders, instead of telling them what to do use picture cards or list the directions)

-don’t give long explanations just short, concise directions

With typical children explaining WHY is really helpful. With kids n the spectrum they often don’t care or don’t understand. Its usually just extra words they are confusing. SO just state what you want them to do in as a short a way as a possible. Example: “Put toys in box”- for autism child. For typical child you might say- “Please clean this room, because we are having guests visit tomorrow and I don’t want them to trip”.

-Teach and encourage your child to interact with peers.

Instead of expecting them to invite friends over to visit, you might need to take the initiative and invite the peers over and even teach/tell your child what they will play with. They might need some adult directives to play together instead of alone.

-teach them how to recognize and manage their own feelings as well as recognize and react to others feelings

Point out how you feel and how they feel so they start to recognize it.

Examples: “Mom is happy because you just gave me a hug! You can tell I’m happy because I’m smiling!” or “Dad is sad because you just kicked your brother. You can tell I’m sad because I’m frowning and shaking my head”.

“You seem so excited about going on vacation! I know you are happy because you are jumping up and down and smiling!” “You seem angry because your brother took your toy. I think you are angry because you have a mad face and are stomping your feet.”

-if they have sensory needs get them the sensory tools they need to help and a good O.T./therapy to help. [See sensory article] 

Matching Activities

Matching can teach learning and focus and are great for young kids with autism and typical preschoolers as well! 

There are many websites with printables to make these matching activities.

First/Then

First/Then

This strategy is really helpful for kids with autism but it can work with anyone! You make a card with two sections and put a picture/or write what you want the child to do first, and then the second part is something the child prefers. This is used for work, play, eating, going places, etc! 

Getting your child to talk about their day

Getting your child to talk to you about their day at school/camp/etc

If your child comes home from school and won't talk about their day, here are some suggestions...

1) Don't let them get away with "I dont know" or a shrug when you ask them about it. Keep asking, or don't let them move on until they give a response. Often they just dont want to think about it or hope you will just let it go. Once they learn they have to respond with something, they usually will! If they need some time to decompress after they come home, try asking them about it at dinner or bedtime instead of right off the bus.

2) Suggest options for them to pick from: "Which special did you have today? Music or Art?" , or give more closed-ended questions to get them thinking more specifically. "Who did you sit with on the bus?" ," What did you play at recess?" "Tell me something new/funny/etc that happened today?" If they are in preschool, for example, and the teacher sends home a paper/note daily to tell parents about the child's day, use that as a jumping off point to discuss. "I see your teacher said you played with playdough today, tell me about that?" or "Oh you had gym today, what did you play in gym class?"

3) Everyone in the family has to share something about their day at dinner. With parents and older siblings modeling this, younger children will often soon learn how to join in. It just becomes the expectation to discuss. This could be done at bedtime alternatively.

4) Let the child draw a picture of something that happened that day, or write down a response if they are not verbal learners or have difficulty with communication (often this will work better with kids with Aspergers)

5) I made up a form that I have used with some clients to have them write a little something or draw something about their day. In therapy I have used "I don't know" tickets. I give the child 5 tickets for example in therapy and when I ask them questions if they say " I don't know" I take away a ticket. When they run out of tickets (may be for a few different questions, not all at once) then they have to respond. Kids usually catch on quick and don't want to lose the tickets so will answer! Even if the tickets don't mean anything! They also will often not need the tickets after a few sessions, because they learn that I won't just drop it and they get used to responding to me.

6) Consider that your child might legitimately not know due to memory issues, too young to process, or they can't think about what happens in different settings when not in that setting. Try suggestion number 2 above and if that's unsuccessful, they may just not be able to respond at this time (until they are older or more advanced in learning/cognitive skills).

Feeding problems

Eating/Feeding concerns and how to address them (Picky Eaters)

This is for picky eaters, kids with autism, sensory food avoidance, etc...

This is an idea of how to introduce new foods that I have come up with based on observing different interventions teachers, OTs, therapists, parents, etc have used with kids. I cannot and will not guarantee this will work, but its just a suggestion to try.
The basic idea is to offer/present or insist on trying the new food BEFORE they get the food they want. Do not even show them their preferred food when presenting the new food. New foods must be offered SEVERAL times on different occasions for kids to try to see if they will like it/eat it. Don't give up after just one attempt!!  
Also often children will eat more/different foods at school, or with peers/siblings/friends/cousins/etc MORE OFTEN than just with mom/dad at home, so try sending in different food options to school, invite kids over at home to all eat foods, etc. 
When I talk about "New or Different" foods I mean normal kid food that the child refuses, nothing that is usually an acquired taste like some different cultural or "ethnic" foods, sushi for example if family is not Asian, certain vegetables like Asparagus most kids don't prefer for example. Ask/observe other kids to find out what is "normal" kid foods in your area/culture. 

Using a "First/Then" chart card may be helpful for visual learners (most autistic kids).

Feeding Behavior Protocol

Present new food daily, or at least several times/week. Child must do Step (below) first, then receive preferred foods.  Once the Step (that you are on) has been successful for 5 consecutive days, move on to next step in sequence. If unsuccessful, go back to previous successful step. Don’t pressure child or make it feel like a punishment. Make it relaxed. Model eating different foods for child, offer child to eat off parents plates, have peers/siblings model eating the new food as well (if possible). Keep trying new and different foods. Research shows child may need to be presented with new foods 20 times before will eat/try it. Skip Steps below if your child is already past that stage (don’t go backwards if unnecessary)

(** Note - most kids will be at step # 3, 4, or 5 to start. Some kids may need pre step or steps 1-2 to start)

Pre-steps: (Use if child is avoidant of touching certain textures like pudding for example)

– Have child first touch food with one finger (or touch food with a plastic glove on, or in a plastic bag)

-Have child put hands in food, then wash off /remove quickly

-Move to step 1:

• Step 1: Touch food to mouth
• Step 2: Lick food
• Step 3: Take a tiny bite “mouse bite”
• Step 4: Take a larger bite “elephant bite”
• Step 5: Eat new food (1)
• Step 6: Eat full serving of new food
• Step 7: Try another new food!! Repeat Steps 1-7 as needed

Teaching Language skills

Using Language to Communicate to Get what you want

Kids (especially Autistic children) have to be taught to communicate (whether its verbally, with sign language, picture exchange, or tech device). They will often use the least amount of effort to get what they want.
Even typical (non autistic/non special needs) kids will often cry or whine for something if they are not made to communicate properly if that behavior will still get them what they want.

Problem example:
Child wants milk. He whines. Mom knows what he wants, so she gives him the milk.
Child wants to eat. He cries. Mom fixes him dinner.
Child wants a toy. He points to it and grunts. Dad hands him the toy.
Child wants something at a store. He throws a tantrum. Mom/Dad buy the toy.

Even if you know what your child wants, other people may not, and you want your child to learn to communicate (usually verbally) instead of making noises (grunts), pointing (in some cases), crying, or tantrumming to get what they want/need.

Here's what you can do. "Friendly Sabotage": Hold the object/item the child wants, or put it just out of reach and DO NOT give it to the child until they communicate appropriately (whatever is acceptable and Possible for that child whether its talking, using pictures, signs/gestures, etc).
For example. Child wants drink. He points to cup and whines. Mom holds the cup and says "Drink. Do you want drink?" Child nods. Mom waits. Mom repeats "Drink. I want Drink". (Either says what the child should repeat, or waits for child to make request). Child says "Drink/I want Drink" Mom gives him/her the drink.

Another example. Teacher/Therapist/etc is doing a craft with the child. Teacher/therapist withholds the tools needed (markers, glue, scissors) and tells the child to do a task. "Write your name on the paper". When child realizes they need a tool to complete the task, they must ask for the tool first. "I need marker please!" Teacher/Therapist can hold the marker/glue/etc or say the word for child to repeat. "Do you need marker? Ask for the marker/ I want marker, please."

If child cannot talk then use sign language, or picture exchange (your child's therapists/teachers should come up with the best communication system for your child in consultation with parents and observing child's preferred way of learning and his/her abilities already) - consult with your child's speech therapist and special education teacher, as well as with behavioral therapists for more ideas and suggestions and ways to teach this skill.

Sensory

Some children have Sensory issues which can be causing behavior. To find out- have them evaluated by an Occupational Therapist (OT) at school or outpatient. Sensory behavior may include avoiding certain textures- food, touch, clothes; or sensory seeking like crashing into walls, craving tight hugs, jumping excessively, etc. Children with autism and ADHD often have sensory issues. Some children without any mental health issues have sensory concerns too. 

A "sensory diet" is helpful for kids with sensory needs. This doesn't mean food but rather activities. Consult with your child's OT, PT, special education teacher, etc to make one. Here are some links with more information. 

http://www.playathomemomllc.com/2013/05/bouncy-ball-basics/
http://www.sinetwork.org/about-sensory-processing-disorder.html
http://sensorysmarts.com/sensory_diet_activities.html
http://www.autismfile.com/treatment-therapy/keep-your-cool