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25. Sensory Modulation: Understanding Over Responsivity and Sensory Diets

In this episode of the podcast, we dive deep into the concept of sensory modulation, focusing on what we term as over responsive behaviour. We describe in detail the reasons behind over responsiveness, how we can understand it better, and the strategies we can use to work with children demonstrating these behaviours. Our discussion brings in multifaceted perspectives stemming from neuroscience, psychology, and therapeutic treatments that can help children with diverse sensory needs.



The Science and Art of Sensory Modulation:

Sensory modulation refers to the brain's management of incoming sensory information. The sensory modulation process may result in over responsiveness, with individuals reacting more intensely or for an extended time than typically expected. Understanding the nature of over responsiveness can guide us in offering more effective treatment for children struggling with these reactions.


In our discussion, we demystify the concept of sensory modulation, emphasizing our focus on over responsiveness. Over responsiveness is characterized by two contrasting aspects: one is the defensive reaction where the individual avoids unpleasant and intrusive sensory information, and the other is curious over responsiveness, where the individual finds the sensory input intriguing but still intense. The fundamental distinction is based on the 'valence' or the emotional value individuals associate with the sensory information.



Understanding Defensive Over Responsiveness:

In defensive over responsiveness, the individual perceives certain sensory experiences as threatening, leading to a fight, flight, or freeze reaction. Common defensive reactions include plugging ears in response to loud sounds or ripping off clothing due to uncomfortable textures. Some individuals may also exhibit gravitational insecurity, becoming excessively fearful of movement, although this condition is often less obvious and more manageable in everyday scenarios.



Understanding Curious Over Responsivity:

With curious over responsivity, an individual constantly over-responds to various stimuli without necessarily landing in engagement. For instance, a child might seem to jump from one interesting thing to another without maintaining a focus, failing to convert their interest into meaningful engagement. In such cases, there is a tendency to move from reactions to recovery, aiming for establishing safety, then fostering engagement, and transitioning into constructive activities.



Sensory Modulation in Everyday and Clinical Contexts:

While recognizing these nuances in sensory modulation, it's equally crucial to notice the interweaving of various factors such as neuroception (detecting safety and threats), detection of salience (how the stimulus stands out), and contextual or individual-specific factors like the child's current state, environment, and the availability of sensory discrimination processes. In therapeutic practice, therapists can use the STEP SI (Sensory, Task, Environment, Predictability, Playfulness, Interaction) mnemonic to strategically utilize sensory modulation as part of an integrative treatment plan.



Creating Effective Treatment Plans:

Creating an effective treatment plan involves assessing the child's sensory modulation patterns and understanding the associated positive or negative emotional values (valence). Based on the understanding, the plan can include regular rhythmic activities to provide a sense of safety or plan for novel activities that stimulate curiosity while controlling their intensity. Thus, the focus shifts from merely coping with the over responsiveness towards facilitating meaningful engagement, enhancing the child's ability to adapt and participate in their everyday life more effectively.



Understanding sensory modulation and its manifestations such as over responsiveness with more specificity can significantly enhance therapy planning and delivery. When equipped with this knowledge, therapists can better cater to children's diverse sensory responses, rightly supporting their neuro-physiological and emotional needs. As the science evolves, it’s crucial for us as therapists to continually refine our understanding and innovate our practices to enrich the lives of children navigating these sensory challenges.



[00:00:00] Cory: Here we go kicking it off again for another year with spirited conversations podcast. I wanted to let you all know that

The new cohort for the STEP2SI training has just begun. So if you are interested in that, get hold of DFX ASAP, we've got a link for you in the description. And if you have been holding out for the spirit model and taking that in a cohort form, which means you get to do the course with a group of people and actually meet live online in real time and discuss the model together. The new cohort will open in the Australian springtime and in fall for all of our American Listeners. If taking either of those courses in the cohort form just isn't going to work for you this time. Don't be discouraged because both courses are also available and will be available this whole year to Take an a self-paced version. So if you're keen to do that, jump onto the link and check it all out.

But without further ado, let's jump in to today.

[00:01:13] Michelle.: Oh, hey guys. We have had lots of listener questions. So we are going to do our usual thing. We'll be prompted by the listener questions, which is around sensory modulation and the language we use to describe that which, you know, reflects how we think about it. So someone has asked around. Um, sensory modulation, over responding and under responding. We've had questions around sensory diets. How do you use a sensory diet? And, we, want to think about that in terms of, how's it positioned in a broader context of our intervention planning. We've had questions around, arousal and autonomic functions and impact on sensory modulation.

And which comes first? So we are going to have a mismatch and trying to see if we can answer a few questions at the same time because they're somewhat all related. So here we go.

[00:02:12] Tracy: What when most of us say somebody's over responding or under responding, we're actually commenting on their behavior

[00:02:21] Michelle.: Yes.

[00:02:22] Tracy: and saying that it's sensory modulation, but it's not really sensory modulation. It's the behavioral outcome of the sensory modulation and regulatory functions, working. And so, that is really complicated the thing that's so interesting is that in the OT literature, when I went back and looked at the definitions from some of the key people who write about this from kind of an academic perspective,

they always To me, because my training in neuroscience was so specific in making sure that you knew the level of analysis that you were speaking about, and you guys have heard me talk about that before is a hard, hard, hard thing to do, but truthfully when I went back and reread People who I admire and respect, but I re read this morning and the actual definitions that they're using are Blending across levels of analysis and the definitions that they'll write will be something like hypo responsivity or Hyper responsivity as noted by this behavioral response.

[00:03:39] Michelle: mm

[00:03:40] Cory: right.

[00:03:41] Tracy: jumping from Level of the modulation response to the level of behavior, and I know that the only thing we can objectively see is behavior. We don't have

[00:03:52] tools for measuring what's

[00:03:54] Michelle: mm

[00:03:54] Tracy: and so I think that in my own mind, I'm thinking about the neurological definitions that are not from OT's, but from neuroscience, around

over and under responding and those are not the same as how an OT writer is writing it. And that confusion is a real confusion. And I was at a symposium recently where somebody that I admire greatly was talking about, kind of how the window of tolerance might function in a dynamic manner, but they were mixing autonomic functions, behavioral functions sensory modulation functions without differentiating them.

Michelle: um,

[00:04:43] Tracy: So, I, I think that in my own work, what I've been trying to do is help all of us to be a little bit more precise and differentiate these concepts. And for some people, that complexity is not welcome. It's not like an easy place to go. what we're wrestling with here is that terminology is complex and really, we don't have enough science in our OT field to fully translate.We're working in this translational space basically space between basic neuroscience and how kids develop, and it's really complicated, and I wouldn't, I'm not trying to claim that I have better understanding, I just have a different level of training from my own graduate training that was very specific in trying to get  the people in my field, of developmental neuroscience to think across levels of analysis.

And so that's something that I feel like I have tried to offer. So, it's confusing, and I think that for the sake of treatment, where I think our passions align, the three of us, and where we feel like this podcast really is relevant, is that if a therapist anywhere, so I recently, oh, I'm going to just insert this cute story here, because. I recently got the sweetest email from a therapist in Hong Kong who told me that in the last bit of time. Her team of 12 had just decided to listen to the podcast as they're continuing ed they gather as a group and they chat about it and they've become real fans of the information and like many people when listening to it, they're like, Whoa, wait a minute. I don't know if I know that, but it's cool to think about that. So the reason that we do this is because we love to talk about this stuff, but also it advances practice for people, and where the practice, related to sensory modulation gets tricky is that if your clinical reasoning isn't right, you'll do the wrong thing in treatment.

Michelle: Mm

Tracy: If a kid is over responsive because they're defensive, that treatment looks different than if they're over responsive because they're curious and engaged, but they can't land their orienting. into action plans and into the higher level processing. And that transcends sensory modulation into higher capacity.

So that's why we need a tool like the SPIRIT that helps us to make the connections between the sensory process itself and how it integrates into adaptive function. Because that sensory stuff matters if it's not connected and integrated. And so, the same is true with under responding,

Cory: Mmhmm,

Tracy: we, we may under respond because we're protecting ourselves and if we under respond, because we're protected and we're in a dorsal state. The treatment is not to bombard sensation. The treatment is not to create bigger intensity.Well, you can put somebody into farther shutdown, which happens to be death, right? Or catestrophic catatonia and really shutting off from the world and if you're under responsive

[00:08:29] Michelle: Mm,

[00:08:30] Tracy: because you are Your nervous system is slowed in the processing to create salience, but the salience is meaningful to you. You just have to have it at a slower pace or a different kind of salience pace. That's a different treatment plan. So Based we have to differentiate based on valence and our field really is doing a disservice if we don't start to identify sensory modulation issues based on this distinction.

And, and I just think that that's like, it's okay to just be clear about that and not be confrontational about it. But just to say, we can't keep saying over and under responding. It's not going to help us to be able to offer the life changing interventions that we can offer. And when we get it wrong, it can be catastrophic.

Cory: So we need better, definitions around the actual functions and separating that from the behavior. So the, like, that's a really key thing that I think you said earlier was that the definition involved both the neurological process and the behavior, but the actual Neurological theory is, is not embedded in the behavior. So it's really useful for me to have those two as, different pieces to see and evaluate.

Tracy: one of the things that I think we all can struggle with in a moment in a therapeutic assessment or in a moment in therapy or just even later in reflective work that we're doing is what is the sequence or and or when does sensory modulation do its work so that sensory discrimination can do its work and what comes first. It's sort of a chicken or the egg question, right?

[00:10:32] Cory: Yep.

[00:10:32] Tracy: So, sometimes with kids in the clinic, you can have a kiddo who looks quite avoidant and over responsive, let's say, to sensation. And can find it hard to help them find engagement. And that could be related not to sensation at all. It could be fully only related to autonomic neuroceptive processing that's telling them something's not safe. The sensation could be not safe, but it could be something else. It could be anything else. So, we as OTs often assume that it's sensory, when sometimes it isn't, and when it shows up in behavior, it's easy to code it as sensory, when maybe it could be different than that?

[00:11:17] Cory: I wanted to kind of bring us back to just the idea of whether I feel safe or not. That is the intervening factor around modulation. I think that's what you said. Or is that not quite right?

[00:11:37] Tracy: So if we think about neuroception as the detecting factor for safety and threat, that then helps to draw the resources of the whole system, but set the tone and the state of the autonomic nervous system. So the thing that is tricky here is, so yes, you said it right, but it's not just the safety threat, it's that activation deactivation related to So now the state is a reflection of what was detected by the neuroceptive functions. And neuroception is drawing from sensory modulation. Let's say there's novelty happening. There's somebody in the hallway that you're not recognizing the foot pattern of, you're unfamiliar.

[00:12:28] Your nervous system will say there's something afoot. There's something out there that needs to be more deeply detected and surveilled. And so let's mobilize some resources in that direction. And as it does that the sensory modulation function actually becomes sensitized. It's like, I need more information. Your whole nervous system needs more information and whatever your central nervous system. was engaged in. Let's say that you were writing a letter, or painting a picture, or cooking dinner, or harvesting your garden. Whatever the thing you were involved in doing that was drawing all of the rest of your resources, those are put into a non important category anymore, and the orienting responses are shifted away from that toward the thing that now has become salient. That shifting that's happening, that is happening across lots and lots and lots of different functions in your brain, not just sensory, it's, everything would shift. So your motor responses are shifted toward it, your language processing, your memory processing, your attention,

[00:13:44] Cory: I'm landing this on, like, literally just my actual experience, sorry to interrupt you Trace, of the last couple of days being slightly sick and lying on the couch feeling unwell. And obviously lacking in metabolic resources and whatever else is happening when you're sick. And, um, just having my eyes closed and listening to an audiobook and any slight banging of a door, which usually doesn't orient me in any particular way, growing up in a pretty rambunctious, loud kind of house.

[00:14:18] I was just complete, like full morrow, jumping, orienting, what was that? just because of the way my nervous system was in that state of feeling unwell. So I was like, oh yeah, it was because in a time when I'm well and I have the full capacity to be more fluid, I guess, in the way that my nervous system is just taking in and responding and my memory knows the sound of that. I don't need to worry about it. I can still attune to the audio book that I'm listening to. And I don't even really pick up the other noises. Yeah, it just was like, oh, that resonates so much right now with just having been sick. And socially, like I felt irritated at anybody that was shutting a door. I'm like, what are you, why are you shutting the door so loud? Like it's unnecessary. Like, even though normally it was just, that's exactly how that would always be shut. You know, so it's kind of interesting how that shifts everything.

[00:15:28] Tracy: It totally is. It also really shows that the sensory over response you were having in those moments was driven by the state. So the intervening variable of state was changing the stimulus response formula. And it also shows you that The sensory modulation response is not neutral. It is valence based. You were irritated.

[00:15:53] Cory: Yeah.

[00:15:54] Tracy: so we can, we can enjoy sensation. We can feel soothed by sensation. We can relish sensation. We can reject sensation. It has an affective tone to it. So sensory modulation, I think having the nosology that has been the SPD nosology being retired recently, one of the welcome pieces of that is just that this over under function is really not the right characterization neurologically because we know that at the foundation of sensory modulation there is an affective dual coding. And that is the valence of the sensation with the affective tone to it, and that is connected to neuroception. So how our sensory modulation contributes to our state is very intermingled there and you would be quite hard pressed to super separate it out at the level of behavior. It would almost be impossible to separate it at the level of behavioral observation.

[00:17:09] Am I seeing a sensory issue there? Am I seeing autonomic? Am I seeing affect? You're seeing it all. And then, through testing, observation, good clinical intuition. You might be able to figure out what's driving what so that you can get to the source for good treatment because if, in that, like, let's take your experience, Cory, that you just described to us and bring it to one of our clients and maybe we would call that like misophonia. They're really irritated by the sounds that human beings are making around them. So in that, is the solution to address it auditorily? Possibly. But there's more to it there, right? There's a lot around affective, physiological regulation, and getting into a ventral state so that you're not quite so triggerable in that irritation.

[00:18:07] And so if you're in a ventral state, those things that are triggering a negative sensory affective experience may no longer continue to trigger it. So then we wouldn't think of it as being driven by sensation, we would be think about it as being driven by state. Does that, is that all clicking for everybody?

[00:18:28] Michelle: mmmm.

[00:18:28] Cory: does for me. I do wonder about, um, maybe unpacking a little bit more, just in terms of the way people think about sensory modulation. I don't know, I'm just thinking about, for anybody that's using the words, they're over or under responsive, how do we help kind of update them. Like how do we give them the information that they need to come to think about that in a different way now? Especially if they've never heard before like positive and negative valence response

[00:19:02] Tracy: I have some new teammates here at DFX in Denver, and this question came up, you know, how do I explain, or how should I be thinking about? So, the first thing that I suggested was to honor exactly where they're at right now. Because, a starting spot is a good spot to be at. And so if the word you're using is over or under, then just use it. Until the curiosity that I want to plant in your mind is more crystallized. And that first level of curiosity would be to say, if you see a child having an over response, is it over In a approach way?

Or is it over in an avoid way? Is it over in a I'm curious and interested in and just can't get enough of that way? Or is it over in a that is awful and negative for me? Defensive

Cory: so clever, Tracy, bringing in the valence of the over or the under. Is that what you're kind of trying to do there is, is get the tone of the behavior. What's the tone in terms of a positive or negative valence?

[00:20:24] Tracy: That's exactly right, because defensive over responding is not at all the same as curious over responding.

[00:20:34] Cory: Mm

[00:20:35] Tracy: And how you would treat those two things actually would be very different from each other, right? Um, so,

[00:20:45] Cory: Should we give like an like actual child example of the classic defensive over responding? Automatic things that come to mind are just like clapping hands over ears, um, or ripping clothing off or hating socks and shoes, hating fingernail cutting or haircuts or any of that comes to mind am I missing any others, Michelle, that are helpful?

[00:21:12] Michelle: No, that auditory, tactile, um, defensive patterns are classic, I guess. They're the ones that it, um, impact on function the most as well and are harder to understand for educators and parents, I think. So, yeah. Good classic one.

[00:21:29] Tracy: Yeah, you could also think about defensiveness in the vestibular function with more like gravitational insecurity.

[00:21:37] Cory: yeah, under the radar more though. I feel like kids can work around that one much more readily, like in terms of if they've got enough kind of capacity or strengths. They can kind of figure out ways around the, it still crops up, but it just it like I feel like the tactile and auditory ones, um, parents will bring that to me more and I'll see the vestibular gravitational kind of issue from my clinical side that doesn't always show up in just observations from the everyday people around the

[00:22:13] Michelle: sometimes it's less problematic because they're actually just a bit more passive then. And so then they, they enjoy drawing and doing other things, which can be much easier to have a child doing passive play, um, then the opposite, you know, on the go or, or that auditory and tactile defensive that really, you can't miss in day to day life with getting dressed and, you know, traveling to school or preschool or whatever. Yeah,

[00:22:42] Cory: Okay, so that's more classic defensive over response. I'm quotation marking those. But then what, what was the- over response, but like approach,

[00:22:52] Tracy: yeah, but without a negative valence to it, really what it is, is it's that kid who is over oriented to every salient stimulus all around them constantly, but they don't really land it. So you see this, kind of like squirrel, squirrel, squirrel, squirrel, squirrel, squirrel, and it can happen visually, it can happen auditorily, It can happen tactilely, it can happen vestibularly and proprioceptively. So it's, what happens is that the sequence of processing should be that we constantly surveil and detect stimulus around us.

And as we detect the stimulus, then we have an orienting response that draws us into engagement. Or, if there's a negative response, we have a defensive response. So that's the valence, is you have a defensive response or an orienting response. Sensory modulation then should kindle that regulation, so that if you orient to that cool thing over there, that then that draws you in for the purpose of engagement, which is the outcome of sensory modulation.

And then we begin the praxis, sensory discrimination based functions that help our engagement to become really purposeful and skillful and higher level. So there is a little bit of a sequencing that happens there. Um, so we are drawn to the stimulus. So that over responding kid can be like a ping pong, ping, ping, ping, ping, ping, ping, ping, ping.

But they don't engage enough for that to become meaningful. And so they just continue to be over responsive instead of I respond and I engage. I respond and I land in habituation. So both of those functions are mediated by habituation and downregulation. If you orient, then you should settle into engagement.

If you have a defensive response, you should find protection and then move away from continuing to over respond. So over response shouldn't continue, it should be mediated by The response that is drawn from the resourcing of the response.

It also for me brings up that in my own kind of reading of the literature I feel like the OT interpretation of sensory modulation has been too focused on the response and not enough on the whole picture of how the response and the recovery connected to a purpose is working.

So if your nervous system over orients, over responds, And then the sensory modulation function isn't helping to create that ease of now land on what that information is and now put it to use. So there's a lot of micro inhibition that's happening right there. in the processing circuitry for a brain that can do that well. And for our kids, I think that is not working well. It's those little micro inhibitory or facilitory, depending, processes that are sensory affective in nature, and they're connected to the state that we're in, so it does vary a little bit, and we all know that to be true, that when we're working with kids with these so called sensory modulation issues, that there is variability based on their state.

I think that as the science progresses, we need to focus a whole lot more on the recovery and on those micro processes, at least on a science level. Now what we need to work on in treatment is differentiating what we've just described, which is basically, if you have a child, where you originally would have said, Oh my goodness, I see over responsivity here.

Characterize it as positive or negative valence based, right? Is it a defensive response or is it an over orientation that they're not turning into meaning? And then, that actually paints the picture for you for what your treatment plan should look like. Because if it's a defensive characterization, What you need to treat is how do we uncouple a negative response and help it to become a safe response.

So we're treating through safety. In the other side, we're treating through engagement and through building attention and participation. So that's, to me, a really important distinction. And I think that it does make us better clinicians. When we challenge ourselves to go to that level of definition, I don't think that's too much detail.

I think it's the right thing for treatment planning. Does that connect for you guys?

Michelle: Yeah, it really connects to me. I guess when I started working in pediatrics, sensory integration was the new thing for me. And so I started learning about children and profiles and behavior and, you know, trying to uncover or work out what I was seeing and why. From a sensory integration perspective. Which was fascinating and amazing and part of the piece. And then I did the DIR floor time that was like amped up. Oh, relating to this affective lens I was looking at. And I guess it's only been since understanding polyvagal theory or trying to get my head around that, that, I don't. go to sensation first necessarily.

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