Academy Society Spotlight: Sensory Processing Sensitivities: Pediatric Orthotic Considerations
March 2019 Issue
Sensory processing has been defined as "the neurological process that organizes sensation from one's own body and from the environment and makes it possible to use the body effectively within the environment".1 These nuances, different for every child, were first described nearly 50 years ago by Ayres.2
A 1997 article by Aron and Aron defined sensory processing disorder (SPD) as "a greater sensitivity to subtleties,"3 and Thomas and Chess described sensory processing sensitivities (SPS) as a "fundamental individual difference."4 Boterberg concluded that "individuals with high SPS are believed to be easily overstimulated by external stimuli because they have a lower perceptual threshold, and process stimuli cognitively deeper than most other people."5 As many orthotists can attest, and specifically those whose work is focused within the pediatric population, sensory issues are an ever-present, constant, and at times, poorly understood battle.
In 2012, the American Academy of Pediatrics (AAP) released an official statement recommending that SPD not be utilized as a primary diagnosis, and that other disorders, including "autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorder, and anxiety disorder" should be considered and thoroughly evaluated when SPS are present.6 A 2012 study found that while SPS may occur independently of other diagnoses, it often occurs in conjunction with a primary, recognized diagnosis.7 With respect to contemporary research and the AAP's statement, and for the purpose of this article, the term SPS will be used. For the purpose of this article, SPS will be defined as a lower than typical sensory threshold.
Sensory sensitivity has been associated with social and emotional issues,8,9 behavioral problems,10,11 obsessive compulsive disorder and ritualism,13,14 as well as "impaired emotional regulation, less adaptive social behavior, and seems to be more frequently present in children with clinically significant anxiety."14Anecdotal references in contemporary literature have drawn relationships between SPS and idiopathic toe walking as a method of sensory avoidance, however there appears to be no recent research on the relationship between orthotic acceptance and SPS.15-17
Research on the efficacy of sensory integration therapy is "limited and inconclusive."6 That being said, therapists and orthotists are acutely aware of the implications associated with SPS. The available research on this topic is limited, if nonexistent, with regard to lower-extremity orthotic management in the pediatric population. It is through trial and error that many have found success in the orthotic management of pediatric patients with SPS.
Careful consideration should be taken when evaluating and orthotically treating children with SPS, bearing in mind that their reactions may be different than those of other children. Aron and Aron wrote that "there is reasonable evidence for some kind (or a variety of kinds) of greater sensory-processing sensitivity and depth of discrimination in a large minority of individuals. If this sensitivity exists, it would be expected to manifest itself as low sociability and high negative emotionality in some sensitive individuals—the former as a strategy to avoid overstimulation, and the latter as the result of an interaction of the trait with aversive or socially unsupported early experiences involving novel stimuli."3
While not always feasible, whenever possible, an orthotic "preview" may be helpful in raising awareness and increasing acceptance of orthotic management in pediatric patients with SPS. Product samples that patients can handle, and in some cases, try on, are helpful for clinicians and therapists alike in determining long-term orthotic compliance.
Bear in mind that while clinicians often have a clearly delineated schedule for the day, your pediatric patient with SPS does not. Gunnar et al. wrote that "for those whom we call sensitive children, a novel experience is startling and requires checking out but leads to a sense of threat and fearfulness when the child senses inadequate social resources."18 Consider allowing extra time for these appointments to ensure that your patient doesn't feel rushed or anxious. Recognize that orthotic break-in periods may also take additional time to ensure orthotic acceptance and compliance. C. Leigh Davis, MSPO, CPO, FAAOP, recommends, "A structured wean-in process is helpful. Working up to wearing the orthoses at all waking hours may be more successful than a part-time wear schedule. With part-time wear it may be difficult to fully integrate the braces into their lifestyle—they are essentially constantly weaning in."19
If they can communicate well, ask your patient's caregivers or your patient whether there are any material sensitivities that you should be aware of. These may include sensitivities to or preferences for materials that may be described as smooth, soft, scratchy, or flexible. Special consideration should be given for material selection when designing orthoses for a patient with SPS. Examples may include, but are not limited to:
- Thickness of structure (plastic or carbon composite), straps, and padding
- Density and compressibility of straps and padding
- Soft linings versus rigid plastics and composites
Weight and Proprioception
For certain pediatric individuals, a lighter orthosis may be preferred as it may be less noticeable (and therefore, more tolerable) for the wearer. For others, a heavier orthosis may improve proprioceptive awareness.
Compression is not always tolerated but may be welcomed in some cases. Carefully consider trim lines, areas of contact, overall compressive forces, and adjustability (if applicable) of the orthosis.
While often unavoidable, some children struggle with sounds that are associated with materials commonly used within the field of orthotics, including Velcro. Take care to trim loose strap ends to avoid Velcro or similar materials catching against clothing. Consider adding bumpers to plantarflexion stops to reduce noise. "A child who is hyper-responsive to their sense of sound may be ‘easily distracted by noise.'"20
While easy to overlook, the overall feeling of a material against the wearer should not be taken for granted. "A child who is hyper-responsive (over-responsive) to touch may be bothered by certain fabrics, textures or clothes," "desire deep pressure," and "have an innate desire to touch all textures. Children who are over-responsive to sensory input are more sensitive to sensory stimulation than most people. Their bodies feel sensation too easily or too intensely."20
While research is limited regarding orthotic acceptance in pediatric patients with SPS, this may be partly related to the challenges associated with collecting the data necessary to draw meaningful conclusions. "We have very little understanding of the effect of orthotic treatment on these pathologies. For example, can bracing exacerbate or calm sensory processing disorders? The trouble with this question is that it probably varies greatly from person to person and from brace to brace. The biggest challenge in research in this topic is the variability from patient to patient."19 There is, however, a clear need for further understanding in this area. A 2016 study found an association between individuals with an overreaction to stimuli and problems in their daily functioning.5 Lane, Reynolds, and Dumenci wrote that children with SPS "demonstrate defensive or exaggerated avoidant responses to everyday sensations that people with more typical sensory processing do not find bothersome."21 Finally, Sher wrote, "Children with sensory processing disorder (SPD) can be so affected by their sensory preferences that it interferes with normal everyday functioning. Children with hypersensitivity to sensory input may exhibit fearful responses to touch, textures, noise, crowds, lights, and smells, even when these inputs seem benign to others."20
Heather Willets, MPO, CO, is a pediatric-focused orthotist, prosthetic resident, and the American Academy of Orthotists and Prosthetists (the Academy) Gait Society Chair. She is based in the Denver area.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.
1. Ayres A, J. 1972. Improving Academic Scores Through Sensory Integration. Journal of Learning Disabilities 5: 338-43.
2. Ayres, A. J. 1970. Sensory Integration and the Child. Western Psychological Services.
3. Aron E. N, A. Aron. 1997. Sensory-Processing Sensitivity and Its Relation to Introversion and Emotionality. Journal of Personality and Social Psychology 73(2): 345-68.
4. Thomas A, S. Ches. 1977. Temperament and development. Psychology.
5. Boterberg S, P. Warreyn. 2016. Making sense of it all: The impact of sensory processing sensitivity on daily functioning of children. Personality and Individual Differences 92: 8-86.
6. American Academy of Pediatrics. American Academy of Pediatrics Urges Improvement in Teen Vaccination Rates https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Urges-Improvement-in-Teen-Vaccination-Rates.aspx (accessed November 28, 2018).
7. Van Hulle, C. A., N. L. Schmidt, H. H. Goldsmith. 2012. Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis. Journal of Child Psychology and Psychiatry 53(1): 64-72.
8. Smith A. M., S. Roux, N. T. Naidoo, D. J. Venter DJ. 2005. Food choice of tactile defensive children. Nutrition 21(1):14-9
9. Stephens C. L., C. B. Royeen. 2006. Investigation of tactile defensiveness and self-esteem in typically developing children. Occupational Therapy International 5(4): 273-80
10. Reynolds S., S. J. Lane, L. Thacker. 2011. Sensory processing, psychological stress, and sleep behaviors in children with and without autism spectrum disorder. OTJR 31: 246-57.
11. Shochat T., O. Tzischinsky, B. Engel-Yeger. 2009. Sensory hypersensitivity as a contributing factor in the relation between sleep and behavioral disorders in normal schoolchildren. Behavioral Sleep Medicine 7(1): 53-62.
12. Dar R., D. T. Kahn, R. Carmeli. 2012. The relationship between sensory processing, childhood rituals and obsessive-compulsive symptoms. Journal of Behavior Therapy and Experimental Psychiatry 43(1): 679-84.
13. Ben-Sasson A., A. S. Carter, M. J. Briggs-Gowan. 2009. Sensory over-responsivity in elementary school: prevalence and social-emotional correlates. Journal of Abnormal Child Psychology 5: 705-16.
14. Conelea C. A., A. C. Carter, and J. B. Freeman. 2014. Sensory over-responsivity in a sample of children seeking treatment for anxiety. Journal of Developmental and Behavioral Pediatrics 35(8): 510-21.
15. Kranowitz C. S. 1998. The out-of-sync child - Recognizing and coping with sensory integration dysfunction. New York: The Berkley Publishing Group.
16. Herrin, K, M. Geil. 2016. A comparison of orthoses in the treatment of idiopathic toe walking: A randomized controlled trial. Prosthetics Orthotics International 2: 262-9.
17. WilliamsC. M., P. Tinley P, M. Curtin. 2010. Idiopathic toe walking and sensory processing dysfunction. Journal of Foot and Ankle Research 3:16.
18. Gunner, M. R. 1994. Psychoendocrine studies of temperament and stress in early childhood: Expanding current models. In J. E. Bates and T. D. Wachs (Eds.) Temperament: Individual differences at the interface of biology and behavior 175-98. Washington, DC: American Psychological Association.
19. Davis C. L. Email, 2018.
20. Sher, B. 2016. Everyday Games for Sensory Processing Disorder. Althea Press.
21. Lane S. J., S. Reynolds, L. Dumenci. 2012. Sensory Overresponsivity and Anxiety in Typically Developing Children and Children with Autism and Attention Deficit Disorder: Cause or Coexistence? American Journal of Occupational Therapy 66(5) 595-603.