Learn more about the differences between sensory processing disorder (SPD) and attention-deficit disorder (ADHD) by reading this article by Center for Connection clinician, Dr. Jaime Chavas, OTD, OTR/L, SWC.
The Center for Connection (CFC) recently added another office, 1021 E Walnut St., Suite 200, Pasadena, 91106, in order to accommodate our ever-growing staff and better serve our clients. With more space, more equipment, and more therapists come more opportunities, more potential for therapeutic progress, and more collaboration.
The educational therapy team now located at the Walnut office includes two part-time Educational Specialists, Tami Millard and Tiffanie Hoang, who are both seasoned educators working toward completion of requirements to become Educational Therapists, and Debra Hori, who is an experienced full-time Educational Therapist for CFC. In addition, Janel Umfress serves as a consultant to CFC for matters relating to educational therapy, school support, and speech/language pathology. We also have two full-time Occupational Therapists at the Walnut office, Dr. Jamie Chaves, and Justin Waring-Crane. Dr. Chaves has her state certification in feeding and swallowing.
At the center of the new space is our full sensory gym, rich in a variety of climbing components, swings, tactile experiences, chalkboard wall, and ample space to move around. Not to mention it is surrounded by windows to give a gorgeous view of the mountains and abundant natural light. Because the sensory gym serves as the central hub, our educational therapists and speech therapists can utilize the space in order to regulate clients before or during their sessions. This puts clients in a better state of mind for learning, allows them to be open to new challenges, and facilitates improved focus—all of which result in more productive sessions. Our occupational therapists find the new space to be more conducive to a sensory integration approach and the wide assortment of sensory-based activities allows them to tailor a “just right challenge” to children of many abilities and ages. Listed below are several of the most utilized pieces of equipment in our sensory gym and a brief description of how they might be used in therapy.
In addition, the Walnut space is equipped with a full kitchen that has ample space for feeding therapy. Kids can engage in making new food creations, constructing food houses and food faces, or simply having a picnic. The kitchen is quiet and exclusive so children can remain regulated and feel in control as they explore the world of new tastes, temperatures, and textures.
Please stop by to see our new office!
Food is such an integral part of our society and a necessary component to our health. A well-balanced diet, including a variety of foods from each of the food groups (grains, dairy, fruits, vegetables, proteins), gives energy, boosts the immune system, helps with growth, and protects from certain diseases. But eating is more than just food. Mealtimes often dictate gatherings with family, friends, and colleagues. Gathering around a table facilitates conversations, laughter, and shared memories.
For a child who is a picky eater (defined as eating less than 20 foods), mealtimes are often a struggle for a variety of reasons: they must be distracted in order to eat, they must have their food prepared in a very specific way, restaurants do not offer the kind of food they like, the possibility of gagging or vomiting with any slight change of texture, sitting for a meal seems impossible, the entire process takes 45+ minutes, to name a few. Caregivers may hear phrases such as, “it’s not the kind I like”, “it looks funny”, “why does it smell so bad?”, “I’m not hungry”. Rather than turning the dinner table into a battlefield at the cost of precious calories, it is much easier to present the same 6 foods the child likes on a rotating basis while crossing fingers that each food stays in the rotation.
So why is it that some kids are such terribly picky eaters? Quite simply, it is more of a matter of “cannot”, not “will not”. Medical issues aside (e.g., reflux, hypertonia, hypotonia, food allergies/intolerances, pneumonia), sensory processing challenges oftentimes negatively impact the entire mealtime experience. People usually think about how food tastes and smells when eating, but the reality is that there are many more senses at play. If any one of the senses is not processing information about the food appropriately it can wreak havoc—the more often this happens the more the negative response is reinforced and the more the child will refuse to try anything new.
Understanding how a child’s sensory challenges are impacting eating is the first step in the journey to expanding a child’s diet. Once these sensory challenges are identified, then effective interventions, such as occupational therapy, can be initiated. It’s essential to realize that these eating problems won’t just magically disappear—early recognition of the need for therapeutic intervention is important. Here’s a breakdown of each sensory system and how it impacts the process of eating in order to help you identify possible sensory-related challenges in your picky eater.
The Vestibular System: [provides information about our balance, coordination, and relationship to gravity]
Most cultures sit to eat—whether in a chair, on the floor, or atop a stool. This alone is critical at mealtime in order to maintain a safe position and open airway. Our vestibular system helps to promote an upright seated posture with our head in a neutral position. Some children lack the postural stability to maintain a position in a chair or on the floor, while others lack the small postural adjustments not to fall out of the chair or off the stool. Some children crave movement so much they just cannot calm their body long enough to fully partake in a meal. This may result in “drive-by” eating, eating quickly, or leaning on someone nearby—none of which are very functional.
In addition, the process of eating takes a lot of oral coordination. Our jaw moves in a rotary motion in order to transfer food from one side of our mouth to the other. Our tongue facilitates the movement of food in conjunction with the jaw movement, and then coordinates with the cheeks in order to produce a swallow. Children who have a difficult time with motor planning and coordination, as a result of decreased vestibular processing (and decreased proprioceptive processing), may present with immature chewing patterns that negatively impact the types of food that are safe for them to eat. Soft, pureed, or meltable foods are preferred because they dissolve easily with saliva without needing a mature chewing pattern. They might push their tongue out of their mouth to move food to the back of the mouth because coordinating tongue elevation with cheek compression is too challenging. Limiting their diet to certain foods is not a choice, it’s a necessity.
The Proprioceptive System: [provides information about our body position and muscle engagement]
Each bite we take requires us to evaluate how much pressure to exert from our jaw muscles—biting a carrot will take considerable more force than biting a banana. As we progress in our chewing and the food breaks down, we need less and less force from our jaws. If we want to hold a piece of food between our teeth, we must do so at exactly the right force so as not to drop it or crush it. These are all the proprioceptive system at work. Ever have that feeling that you put too much food in your mouth? Again, the proprioceptive system at work. We also need to avoid biting our tongue and cheeks when chewing, which means we need to know where they are at in relationship to our teeth. Some children overstuff their mouths because they enjoy the sensation they get from it; others may repeatedly bite their tongue during a meal. Biting a carrot might seem impossible for a child who is not consistently exerting enough force. All are signs that their proprioceptive system is not receiving or interpreting the input accurately.
The Tactile (Touch) System:
Our lips and tongues are loaded with touch receptors. They provide important information to the brain about the where our food is in our mouth, about the size of food, about the temperature of the food, and about the texture of the food. When we eat a messy ice cream cone, our lips detect that we need to lick the remains or wipe them with a napkin. As we chew, our tongue detects where the food is in our mouth. And when our tongue detects that a piece of food is small enough, then we can swallow it. We all have food temperatures and textures that are more favorable than others. However, in general, people have a wide range of hot, cold, warm, crunchy, chewy, smooth, mushy, chunky, meltable foods they eat. Some children become overwhelmed by the feeling of cold or hot food, so they wait until food is room temperature. Some children crave the calming sensation of munching on popcorn or chewing on granola bars. And some other children get completely overstimulated (at times to the point of gagging or vomiting) with mushy foods like mashed potatoes or cottage cheese, or foods that “pop” in their mouth like grapes or blueberries.
When we eat a mixed-texture food, such as yogurt with granola, our tongue must differentiate between the hard granola that must be chewed and the smooth yogurt that must be swallowed. The tongue moves the granola in between the teeth to breakdown the granola into pieces that can be swallowed along with the yogurt. While this discrimination happens all the time subconsciously, there are some children who lack these discrimination skills for safe eating. Most of the time these children limit their diets to foods they can trust (including particular brands), investigate their food carefully before consuming, and/or only eat single-textured foods. They cannot trust their tongue’s tactile discrimination abilities so they employ their own safety mechanisms.
The Gustatory (Taste) System:
Food taste can be categorized as sweet, sour, bitter, salty, or umami (i.e. savory). Saliva helps to not only breakdown our food in order to be swallowed, but also increases the temperature of our food in order to release flavors from the chemicals in food. In general, the more taste buds one has, the more intense their taste experiences. Our taste buds continue to mature until the age of 16 years—so don’t be surprised if as an adult you now like tomatoes that you hated as a child. Bitter foods, like many vegetables, generally take more time to accept because of our biological design to avoid ingesting harmful substances. It is recommended that infants start with vegetable purees before fruit purees for that reason. Some children are understimulated by food, and seem bored or inattentive when eating, until flavors like curry, chili, lemon, vinegar, or saffron are added to their food. While other children respond to these flavors like someone washing out their mouth with soap; one blackberry in their smoothie can make it seem like they’re drinking lemon juice. Bland foods are safe and predictable. As a note, children who have a history of repeated ear infections may prefer more savory, fatty, creamy foods because a branch of a cranial nerve runs from the middle ear to the anterior and middle tongue thus impacting what tastes they experience.
The Olfactory (Smell) System:
Smells of certain foods evoke such strong memories that we can almost taste the food without even taking a bite: grandma’s fresh apple pie, dad’s homemade biscuits, Aunt Carron’s savory lasagna. That’s because about 80-90% of the taste of food can be attributed to its smell. Everyone knows the trick of plugging your nose when eating something off-putting in order to diminish the taste. This works because it blocks “retronasal olfaction” – a fancy name for the passage of air from the back of the oral cavity into the nasal passage—that enhances the smell of food when eating. Our brain identifies this smell as coming from our mouth (which it does) and therefore associates it to taste rather than smell. For some children it is the smell of food that elicits a gag reflex or avoidance of many flavorful foods; odorless foods are preferred because overstimulation does not occur. Other children crave smell and repeatedly bring their food to their nose in order to enhance its taste.
NOTE: Children and adults who have anosmia (i.e. loss of smell) lack the cues from the olfactory system about the taste, and to a degree the texture, of food and may therefore activate their gag reflexes more quickly with unfamiliar foods.
The Visual System:
Presentation of food can make or break your mealtime experience. It sets up expectations for whether or not the food is fresh, and whether or not the food is cooked thoroughly (but not too thoroughly!). Eating with your eyes closed can dramatically change a meal because our visual system gives us a lot of information about our food before it even enters our mouth. We can see if there are croutons in our tomato bisque or whipped cream on top of our pancakes. How often do children decline trying a new food before they’ve tried it—just because of the way it looks? Some children cannot get past the visual cues from their food so they want it to look the same each time, they want to see the box or package it came from, they want to inspect each French fry to make sure it has no crispy parts, and/or they want to watch their food being prepared. The look of unfamiliar or undesired food triggers a part of the brain to become too overstimulated with the thought of how it might taste or feel in the mouth. That’s why repeated exposure of food (10-15 presentations!) is so important with children—familiarity is half the battle.
The Auditory (Sound) System:
Of the sensory systems with which we’re most familiar, this is often the least considered when it comes to eating. We generally do not attend to the sound of our food when we’re eating—probably because we’re busy attending to the conversation around the table. Some children cannot tolerate the sound of crunchy food as it’s being chewed because they have such extreme auditory sensitivity. This sensitivity may cause such dysregulation that the thought of eating evokes anxiety.
NOTE: Misophonia is a specific diagnosis associated with an extreme sensitivity to the sound of people chewing or smacking their lips, along with certain other sounds.
For those of you who weren’t counting, that’s seven senses that combine to make eating possible—3 to 5 times per day! Parents want their children to thrive in all areas, including participating in mealtime and eating a well-balanced diet. For children who are picky eaters, eating can be overstimulating, dysregulating, or disengaging. They may miss out or opt out of social opportunities around eating. Helping to address associated sensory processing challenges can open the doors to new mealtime experiences for the child and decrease the level of anxiety/stress/frustration at mealtime for the caregivers. If you have or know a child who is a picky eater (not due to medical issues), a comprehensive sensory evaluation by an occupational therapist certified in swallowing and feeding is recommended.
by Dr. Jamie Chaves, OTD, OTR/L, SWC
It is amazing that we can even write at all. Handwriting requires the integration of almost every sensory system in order to create a legible, organized product. When a breakdown occurs in any or several sensory systems, handwriting is generally negatively impacted. It is therefore important that when exploring the best therapeutic options for a child with dysgraphia or poor handwriting that a comprehensive sensorimotor occupational therapy evaluation be conducted. This includes exploring how a child responds to vestibular, proprioceptive, tactile, and visual inputs, as well as the child’s postural stability and praxis. (NOTE: postural stability and praxis essentially require the integration of the vestibular, proprioceptive, and tactile systems.) Here’s a glimpse at what needs to happen in order for handwriting to be successful.
Sitting upright in a chair: requires the integration of the vestibular, proprioceptive, and tactile systems in order to maintain postural stability and modulation of tactile input from the seat of the chair. “Proximal stability equals distal mobility” is a commonly used, and very foundational, catch phrase. This means that in order for us to effectively move our wrists and fingers we must first establish stability in our shoulders and core muscles. Children with poor postural stability (those who lean on other people or objects, prefer to lie down, have difficulty sitting in a chair) notoriously have poor handwriting. It is integral to all other aspects of handwriting, so I won’t continue to list it. Also, if a child is sensitive to tactile input and is sitting on a wooden chair or a chair with a textured seat, he or she may be too distracted by that feeling to stay attentive to writing.
Holding a pencil: requires modulation of tactile input from the writing tool on the fingers, discrimination of proprioceptive input to use the right amount of force, tactile discrimination and praxis to move each finger in a distinct position on the pencil, and vestibular discrimination to hold the pencil up against gravity. For children who don’t like the feeling of the pencil, grip the pencil too tightly (or loosely), position their fingers incorrectly on the pencil, or fatigue easily when holding a pencil, it is important to further investigate the corresponding sensory systems.
Manipulating a pencil: requires praxis to move the fingers apart from the rest of the hand and arm, discrimination of proprioceptive input to know how much pressure to use on the paper, and vestibular discrimination to know which direction to move the pencil. When we write our fingers do the majority of the work and must move on their own to be more efficient. Children who tire easily with handwriting may be engaging too many muscles to complete the task or may be pushing too hard on the paper. Or they may be using so much effort to isolate the movement of their fingers because their motor planning is off. Detecting up, down, forward, and backward is really important for moving the pencil in the direction needed to form shapes and letters.
Forming shapes and letters: requires praxis to remember the necessary motor pattern, body awareness (proprioceptive and vestibular integration) to understand laterality, visuo-vestibular integration so the eyes and hand can move in a coordinated manner, and visual modulation as to not get overwhelmed (or underwhelmed) with the visual input on the paper. As we progress in our handwriting skills we don’t even need to think about how to form each letter - it just happens because of praxis. When we learn a new symbol or form of writing we must concentrate more because our praxis is not yet automatic (this is what some children must do every time they write!). At the same time, being well acquainted with our body in relationship to itself must occur so we can understand our body in relationship to the writing tool being manipulated. This means we must consistently differentiate our right from our left (i.e., laterality) so we can differentiate letters facing right versus left. The visual and vestibular systems work very closely together to inform each other of where to keep our eyes oriented on the paper and where to form the letters. If these two systems are out of sync, which happens quite often in children with sensory processing disorder, then the head and eyes can have a difficult time remaining stable while the hand is moving. For children who get overwhelmed by visual input, the lines on the paper, amount of writing, or colors on the paper may be too much. Many children nowadays, however, have the opposite problem and are so underwhelmed with the mundane nature of gray pencil on white paper in contrast to fast-paced, colorful video screens.
It is important to mention several areas of visual-perceptual that also influence handwriting, such as visual attention, visual memory, visual spatial skills, and visual form. These are higher level cognitive processes that interpret visual information. While they can be assessed and addressed by an occupational therapist, they are not in and of themselves a sensory processing disorder. Similarly, occulomotor skills, such as visual tracking, visual saccades, and visual convergence can be screened by an occupational therapist to determine if a full evaluation by a developmental optometrist is warranted.
There you have it. Now you can see why handwriting is such a complex process, and why dysgraphia cannot effectively be remediated by simply practicing writing over and over (although some practice is necessary). Educators, parents, and other professionals can have a profound role in recognizing handwriting problems early and recommending a comprehensive sensorimotor evaluation by an occupational therapist to get at the root of the issue.
Here's a great interview with the CFC's very own Annalise Kordell. Take a listen!
by Dr. Jamie Chaves, OTD, OTR/L, SWC
Sleep is a daily occupation in which all of us participate. Some better than others. When sleep is disrupted this is a red flag for occupational therapists, and should be for parents and other professionals as well. Sleep plays a critical role in restoration of brain cells, supporting brain plasticity, resting muscles and joints, and regulating our circadian rhythm. Poor sleep negatively impacts almost every area of functioning and development. Here’s a list of indicators of poor sleep patterns (for children and adolescents):
*Requires longer than 30-45 minutes to settle before preparing to falling asleep
*Takes longer than 15-20 minutes to fall asleep
*Requires someone present in the room, next to the bed, or lying in bed in order to fall asleep
*Restlessness or frequent changing of positions
*Getting up or waking up at night on a regular basis
*Inconsistent sleep patterns (e.g. sleeps 6 hours one night and 10 hours the next night)
*Gets less than 8 hours of sleep for 3-5 year olds or less than 7 hours of sleep for 6-13 year olds (numbers according to the National Sleep Foundation)
Poor sleep can be an indicator of sensory processing disorder (SPD) for myriad reasons. Different subtypes of SPD impact sleep differently. Sometimes the bedtime routine leading up to bedtime is dysregulating, which consequently impacts the quality of sleep. Sometimes the child is so overstimulated from the day that settling to sleep can be challenging. Sometimes the overstimulation from the day is so exhausting to your child that he wants to nap after school which disrupts his sleep at night. Sometimes the events of the day were so understimulating that the body was essentially in sleep mode all day long. It’s important to note that children with unaddressed sensory processing modulation disorder have a difficult time self-regulating because they do not yet have the strategies to do so. Therefore co-regulation, adaptive strategies, and use of external sensory inputs will be necessary until they can internalize the strategies provided by their occupational therapist. Don’t be quick to brush off requests or complaints from a child as “behavioral” or a means to “escape bedtime”.
If your child…
· Doesn’t like the feeling of pajamas (or other specific clothes)
o He/She may be over-responsive to tactile input
o Try sleeping naked, wearing a compression shirt to bed, or wearing an oversized t-shirt to bed
· Doesn’t like the feeling of sheets
o He/She may be over-responsive to tactile input
o Try lycra sheets (“Skweezrs”), using a weighted blanket (7-10% of child’s body weight)
· Gets upset when bathing or showering
o He/She may be over-responsive to tactile input
o Try bathing or showering in the morning, bathing or showering before dinner, switching from a shower to a bath
· Wants to sleep next to someone
o He/She may be seeking or under-responsive to proprioceptive input
o Try moving the bed to a corner, buying a body pillow
· Wants stuffed animals or pillows piled on top
o He/She may be seeking or under-responsive to proprioceptive input
o Try sleeping under or on top of a bean bag, using a weighted blanket (7-10% of child’s body weight)
· Changes positions throughout the night
o He/She may be seeking or under-responsive to vestibular or proprioceptive input OR over-responsive to tactile input (i.e. the movement is response to discomfort from pajamas/sheets)
o Try moving the bed to a corner, sleeping under or on top of a bean bag, using a weighted blanket (7-10% of child’s body weight), lycra sheets (“Skweezrs”), wearing a compression shirt to bed, wearing an oversized t-shirt to bed
· Falls out of the bed
o He/She may be seeking or under-responsive to vestibular input
o Try moving the bed to a corner, sleeping under or on top of a bean bag, using a weighted blanket (7-10% of child’s body weight)
· Must have complete silence when falling asleep
o He/She may be over-responsive to auditory input
o Try using a sound machine or white noise machine, wearing noise-cancelling headphones
· Dislikes the taste of toothpaste
o He/She may be over-responsive to oral (taste/smell) input
o Try brushing without toothpaste at night, using an electric toothbrush, flavored toothpaste (not peppermint or cinnamon)
· Snacks right before bedtime
o He/She may be seeking oral input
o Try only giving chewy or crunchy foods before bedtime and/or at dinner
· Uses a bottle at bedtime
o He/She may be seeking oral input
o Try giving a piece of candy to suck on when reading in bed, keeping a cup of water next to the bed, using an electric toothbrush
· Looks around room when falling asleep
o He/She may be seeking visual input
o Try putting in a nightlight, hanging blue or green tube lights, using a moving fishtank toy
· Complains the room is too bright (even with the lights off)
o He/She may be over-responsive to visual input
o Try facing the bed away from the windows, getting heavy curtains for the windows, using a sleep mask
Poor sleep may also exacerbate sensory processing to the point that child appears to have SPD. Think about a time you were tired in a meeting or presentation—what did you do? Oftentimes adults get up to move, swivel in the chair, bite nails, chew on a pen, drink or eat something, fidget with an object, doodle on the paper. All of these are sensory strategies to stay awake and alert. Now think about a time you didn’t sleep well—how did you function the next day? Did you get up more frequently from your desk? Did you have more difficulty multi-tasking or remembering details? Did you notice your tolerance of people around you dropped?
Consider a child who chronically sleeps poorly. Her tiredness may manifest by constantly jumping or skipping around in an attempt to stay awake. He could “zone out”. Chewing on his sweatshirt or nails may help him focus. She might be more reactive towards peers. His frustration tolerance might be limited or he might give up easily. Spinning in circle could give him more stimulation. Any strategy to say “wake up, body!” is likely. And anything that tests an already short fuse will lead to a “zero to sixty” response.
While all children are different in their sleep routine preferences there are a few things I regularly recommend.
1) Eat dinner early—about 2 ½ hours before bedtime. This will allow for digestion.
2) Play hard for about 45 minutes before you start the quiet bedtime routine.
3) Transition to the calming routine by dimming the lights and playing classical instrumental music.
4) Brush teeth. This is usually not a favorite for most kids, so doing it first will allow for the other activities to re-regulate him/her.
5) Take a warm bath. Showers can be very stimulating because each stream can feel like a pin prick.
6) Read 2-3 books together in bed.
7) Sing 1-2 songs.
8) Hug and kisses.
9) Lights out.
It’s important to make slow changes to the bedtime routine and to try each strategy for 1-2 weeks before giving up. Change is hard so it may be met with initial resistance. Try to get your child involved as much as possible in making decisions, such as picking the color of the lycra sheets or deciding where the nightlight should be placed. No matter what, keep your sleep at the forefront of your conversations until you find a manageable solution!