Abstract
Sensory processing is a personal trait that can contribute to challenging behavior. Protective factors, such as resiliency, can support children in managing their behavior, yet little research has addressed the contribution of sensory processing to protective factors. Therefore, in this cross-sectional study we aimed to determine the contribution of sensory processing (using the Sensory Profile–2) to challenging behavior and protective factors (using the Behavior Assessment System for Children, 2nd ed., Parent Rating Scales) in a sample of 51 children ages 6–11 yr from the general U.S. population. The results indicated that sensory avoiding predicts externalizing behaviors, depression, resiliency, and adaptability. In addition, sensory seeking is related to depression and resiliency, whereas sensory sensitivity is related to externalizing behaviors. Implications for occupational therapy research and practice are discussed.
Sensory processing describes the interface between a person’s neurological function and the environment. Interactions between the environment and person are at the heart of modern conceptualizations of health and can affect participation (World Health Organization, 2007). Across disciplines, sensory processing has been related to aspects of temperament (Aron & Aron, 1997; Aron, Aron, & Jagiellowicz, 2012), including externalizing (Franklin, Deitz, Jirikowic, & Astley, 2008; O’Donnell, Deitz, Kartin, Nalty, & Dawson, 2012; Pérez-Robles et al., 2012) and internalizing (Ben-Sasson et al., 2008; DeSantis, Harkins, Tronick, Kaplan, & Beeghly, 2011) behaviors. Whereas previous studies have largely focused on children with particular conditions (e.g., autism spectrum disorder [ASD], developmental disabilities), we have limited evidence of how sensory processing patterns are related to challenging behaviors as well as protective factors in children with and without such conditions (Dunn, Little, Dean, Robertson, & Evans, 2016). Therefore, we investigated the extent to which sensory processing patterns predicted challenging behaviors and protective factors in a sample of children from the general U.S. population.
Multidisciplinary Perspectives of Sensory Processing
Dunn’s (2014) Sensory Processing Framework (DSPF) theorizes sensory processing as two continua of responses to environmental stimuli. People respond differently to sensory information on the basis of how soon they detect (threshold) and how they manage (self-regulation) sensory stimuli. According to DSPF, threshold ranges from high (slow to detect) to low (quick to detect), and self-regulation ranges from passive (reacts to stimuli as they happen) to active (plans reaction to stimuli). These two continua interact to create four sensory processing patterns: (1) registration (high threshold and passive self-regulation), (2) seeking (high threshold and active self-regulation, (3) sensitivity (low threshold and passive self-regulation), and (4) avoiding (low threshold and active self-regulation).
In personality research, sensory processing has been shown to be related to, yet distinct from, emotion and self-regulation (Gouze, Lavigne, Hopkins, Bryant, & Lebailly, 2012). In addition, some psychology studies have considered sensory processing sensitivity (SPS) as a temperament, or personality, trait (Aron & Aron, 1997; Aron et al., 2012) and have defined SPS on a continuum of responsivity to environmental stimuli. Responses from more sensitive people are related to strong emotional reactions and include being more sensitive to subtle stimuli, pausing to make observations in novel situations, and using complex self-regulation strategies for planning responses and learning from situations. Both SPS and DSPF consider sensory processing a personal characteristic that allows a person to make sense of the environment. However, only DSPF accounts for the role of a neurological threshold, allowing consideration of the full interaction between threshold and responsiveness.
From a broad, developmental perspective, sensory processing has been considered an innate biological trait. From this viewpoint, specific aspects of sensory processing have evolutionary benefits (Wolf, van Doorn, & Weissing, 2008, 2011). In particular, society needs responsive people who notice and respond to subtle changes in the environment as well as other people who do not notice subtle changes and can calm the group. For example, if there is a threat, someone with a low threshold for sensory information will notice the threat early and respond. However, society may become unstable if people always act as though a threat were present. After the threat is understood or dealt with, people with a high threshold will quickly return to a calmer state and support others to do the same. The range of sensory processing observed through research suggests the adaptability of our species as a collective.
Sensory Processing and Behavior
The above-mentioned multidisciplinary perspectives contribute to our understanding of sensory processing as a continuum of response that is characterized by great variability and heterogeneity across the population. Research has largely focused on the extent to which sensory processing, as related to over- and underresponding, is associated with challenging behaviors, such as internalizing and externalizing. This section highlights research that has associated sensory processing with challenging behavior. In addition, although little research has studied the relation between sensory processing and protective factors, such as adaptability and resiliency, this section highlights the evidence that is available.
Internalizing
Internalizing behaviors, such as anxiety and depression, have been associated with sensory processing across the lifespan; for example, Lane, Reynolds, and Dumenci (2012) found a small, positive relationship with sensory sensitivity and anxiety in children ages 6–10 yr with ASD, attention deficit hyperactivity disorder (ADHD), and typical development. Similarly, typically developing adults who are more sensitive to environmental stimuli also display higher levels of stress (Bakker & Moulding, 2012; Benham, 2006), anxiety (Hofmann & Bitran, 2007; Kinnealey, Koenig, & Smith, 2011), and pain catastrophizing (Engel-Yeger & Dunn, 2011; Meredith, Rappel, Strong, & Bailey, 2015). Children with ASD (Watson et al., 2011), as well as typically developing children (Evans, Nelson, & Porter, 2012) who show increased sensory sensitivity, also display lower levels of adaptive social behaviors. Toddlers with ASD who demonstrate a higher frequency of sensory-related behaviors (i.e., underresponsivity, overresponsivity, or sensory seeking) also exhibit more negative emotionality, depression, and anxiety (Ben-Sasson et al., 2008). Finally, preschoolers with ASD who demonstrate a higher frequency of sensory seeking behaviors have been shown to have more difficulty with receptive language and adaptive behavior (Tomchek, Little, & Dunn, 2015).
Externalizing
In regard to externalizing behaviors, Chuang, Tseng, Lu, and Shieh (2012) found that children with autism who were more sensitive to sensory input showed a higher intensity of reaction to sensory stimuli (which is characteristic of externalizing behaviors). Similarly, aggression has been related to self-regulation (White, Jarrett, & Ollendick, 2013) and a low threshold for sensory stimuli (Crick & Dodge, 1996). Although only a limited amount of research has investigated the relationship between sensory processing and externalizing behaviors, these studies suggest a possible relationship between them. More research is needed to add to this literature base.
Protective Factors
Although the aforementioned studies have considered how sensory processing patterns relate to challenging behavior, emerging evidence suggests that specific sensory features may be related to children’s and adults’ interactions with their environment. For example, enhanced perception (i.e., a hyperacuity or hyperfocus on the sensory elements of activities) is positively associated with activity participation of young children with ASD (Little, Ausderau, Sideris, & Baranek, 2015) as well as adults with ASD (Baron-Cohen, Ashwin, Ashwin, Tavassoli, & Chakrabarti, 2009; Mottron, Dawson, & Soulières, 2009). In the adult general population, researchers have also found relationships between sensory seeking behaviors and active coping strategies, such as increasing activity and ignoring pain (Meredith et al., 2015). Given this evidence, sensory processing patterns may be positively related to protective factors (i.e., resilience and adaptability).
Evidence indicates that sensory processing is associated with behavior, but much of the research has used either participants with specific conditions (i.e., ASD) or typically developing adults. The aim of this study was to examine the extent to which sensory processing patterns predicted challenging behavior (i.e., externalizing, internalizing) and protective factors (i.e., resilience, adaptability) in the general population of children ages 6–11 yr.
Method
Design
This study had a cross-sectional design with a national sample so that we could determine the relation between parent-reported sensory processing patterns and behavioral characteristics of children ages 6–11 yr.
Participants
We recruited participants from the general population, stratified on the basis of diagnosis, across the United States for the Child Sensory Profile 2 (CSP–2; Dunn, 2014) standardization study. See Dunn (2014) for more detail on the recruitment and stratification methods of the sample. The sample for this study included 51 children, ages 6–11 yr, whose parents completed both the CSP–2 and the second edition of the Behavior Assessment System for Children, Parent Rating Scales (BASC–2; Reynolds & Kamphaus, 2004) assessments. Forty-four of the participants had no diagnosis, 5 had ADHD, and 2 had ASD (Table 1).
Age, Gender, and Diagnoses of Sample
Note. ADHD = attention deficit hyperactivity disorder; ASD = autism spectrum disorder.
Measures
The CSP–2 is an 86-item parent-report measure of a child’s sensory processing characteristics. It provides scores on sensory systems (i.e., auditory, visual, movement, body position, and touch), behaviors related to sensory processing (i.e., attention, conduct, and social emotional), and sensory processing patterns associated with the DSPF (i.e., registration, seeking, sensitivity, and avoiding), which was described previously (see Table 2 for further descriptions of the sensory processing patterns). An important change from the original Sensory Profile (Dunn, 1999) is that items on the CSP–2 are rated on a Likert scale ranging from 0 (not applicable) to 5 (almost always). Therefore, low scores on the CSP–2 indicate low frequency of behaviors, whereas higher scores represent higher frequency of behaviors. The CSP–2 was standardized on a large national sample (n = 697) and demonstrates strong psychometric properties (Dunn, 2014). An important change between the original Child Sensory Profile (Dunn, 1999) and the CSP–2 is that the item scoring was reversed.
CSP–2 Sensory Processing Pattern Scale
Note. CSP–2 = Child Sensory Profile 2.
The BASC–2 is a parent-report assessment that measures how frequently children engage in both adaptive and maladaptive behaviors. To measure challenging behavior, we used the Externalizing and Internalizing composite scores. The Externalizing score consists of the Aggression, Hyperactivity, and Conduct Problems subscales, and the Internalizing score consists of the Depression, Anxiety, and Somatization subscales. To measure protective factors, we used the Adaptability and Resilience scales. The data in Table 3 describe the BASC–2 scales we used. Higher scores on the BASC–2 indicate higher frequency of behavior.
BASC–2
Note. BASC–2 = Behavior Assessment System for Children (2nd ed.), Parent Rating Scales.
Higher scores indicate more difficulty.
Higher scores indicate more ability.
Analysis
We used four multiple linear regression models on four behavior scores (as measured by the BASC–2; i.e., Externalizing, Internalizing, Adaptability, and Resiliency) to determine how sensory processing patterns (as measured by the CSP–2) predict adaptive and maladaptive behavior. We entered the independent variables (i.e., avoiding, sensitivity, seeking, and registration) simultaneously into the regression models so that we could determine the relative contribution of each pattern. Additionally, for Internalizing, we ran regression models based on the component scores (i.e., Anxiety, Depression, Somatization).
For all models, we controlled for diagnosis by creating a dichotomous variable and entering it into the model before the other predictors. This allowed us to remove the variance that may be associated with the conditions of the children in the study.
Results
The data in Table 4 show the percentage of variance that was accounted for in each of the regression models. Given the number of regressions we conducted for this study and the limited sample size, we reported the more conservative adjusted R 2 coefficient. All of the models were significant and ranged from 40% to 69% in percentage of variance accounted for (see Table 4).
Multiple Linear Regression Models Using Sensory Processing Patterns as Predictors
For Internalizing, the overall model was significant; however, no specific sensory processing pattern was a significant predictor. The Internalizing subscales (Anxiety, Depression, and Somatization) demonstrated different relationships among the predictors. Similar to the Internalizing composite, the overall model for Anxiety was significant, adjusted R 2 = 0.22, F(5, 45) = 3.76, p = .006, but no sensory processing pattern score was a significant predictor. For Depression, adjusted R 2 = 0.65, F(5, 45) = 19.39, p < .001, both Avoiding, β = 0.998, p < .001, and Seeking, β = −0.406, p = .008, were significant predictors. The overall model for Somatization was not significant, adjusted R 2 = 0.05, F(5, 45) = 1.47, p = .217. In addition, Diagnosis and Avoiding predicted Adaptability (see Table 4), and Avoiding and Seeking predicted Resiliency (see Table 4).
Discussion
In the current study we investigated the predictive value of sensory processing patterns in regard to both challenging behavior and protective factors in children in the general population, including those with and without sensory processing conditions. Our approach, which has drawn from other disciplines, considers sensory processing a continuum in the general population. Our research is novel in that our sample included children from the general population (including representative numbers of children with varying conditions known to show differences in sensory processing. We included children with and without disabilities in recognition of the fact that occupational therapists who design interventions in natural settings (i.e., schools, stores, museums, homes) must consider the sensory processing patterns of all children.
We controlled for diagnosis in our models, to remove any condition-specific variance. Diagnosis was not a significant predictor in three of the four models. Adaptability was the exception. Adaptability, as measured by the BASC–2, refers to a child’s ability to adjust to changes in routine, shift from one task to another, and play well with others. In addition to the Avoiding subscale, which predicted Adaptability, occupational therapy practitioners should consider factors other than sensory processing when promoting adaptability among children with conditions. For example, a child’s cognition, developmental status, and psychosocial features, or environmental familiarity and task complexity, could also contribute to adaptability.
Challenging Behavior
Our research suggests that when avoiding behaviors are more frequent, externalizing behaviors (i.e., hyperactivity, aggression, and conduct problems) are more frequent as well; yet, when we considered avoiding and sensitivity together we noted that more frequent sensitivity behaviors were associated with less frequent externalizing behaviors. In other words, children with increased avoiding behaviors showed increased externalizing, whereas increased sensitivity was associated with decreased externalizing. Perhaps passive regulation, as associated with sensitivity, is more effective in helping children regulate responses that are viewed as externalizing. Interventions focused on teaching children to notice their response to sensory stimuli and to internally plan a reaction may be helpful in reducing externalizing behaviors. For example, Bakker and Moulding (2012) found that adults with more frequent low-threshold behaviors who also demonstrate more mindfulness showed lower levels of anxiety and stress. Additionally, Barnes, Vogel, Beck, Schoenfeld, and Owen (2008) found, in a sample of children with emotional disturbance, that a program teaching strategies to recognize their level of arousal and reactions to sensory stimuli resulted in increased self-regulation skills.
No sensory processing pattern significantly predicted internalizing behaviors (i.e., depression, anxiety, somatization). This finding is contrary to previous research showing a relationship between sensory processing and internalizing (Ben-Sasson, Carter, & Briggs-Gowan, 2009; Ben-Sasson et al., 2008). One reason for the difference may be that the children in our sample did not exhibit enough internalizing behaviors for the parent raters to notice. Another possibility is that our sample did not have a high enough incidence of internalizing problems (high frequency of internalizing behaviors) to detect an association.
Previous research has shown that parents of children who do not show behavioral problems tend to report fewer internalizing behaviors than the children report (Smith, 2007). Given that low levels of internalizing behaviors may be difficult to measure through caregiver report, future research into sensory processing and behavior in the general population may consider child report measures of internalizing behavior. Our analysis of the Internalizing subscales, however, demonstrated different contributions of sensory processing in each of the scales. No sensory processing pattern predicted anxiety, yet the overall model was significant and accounted for 29% of the variance. This could mean that sensory processing in general influences anxiety but that no one pattern is dominant. Previous research has reported that low-threshold responses are related to anxiety (Kinnealey et al., 2011; Lane et al., 2012). It may be, however, that overall differences in sensory processing relate to anxiety.
Avoiding and seeking were significant predictors of depression. When avoiding was taken into account, seeking predicted depression in a negative direction, indicating that the more seeking behaviors a child exhibits, the less frequently the child demonstrates behaviors associated with depression. This finding is supported by those of Meredith and colleagues (2015), who found that seeking in adults was related to active coping mechanisms in adults. A key component of the seeking pattern is engagement with the environment. The finding that seeking was negatively associated with depression could also indicate that when children are sufficiently interested in activities to fully engage in the environment, they cope better and display fewer depressive behaviors. Another hypothesis is that in environments where a child’s sensory patterns are supported, they engage more in the environment. Further research is needed to understand how seeking supports internalizing behaviors such as depression.
Resiliency and Adaptability
We found that avoiding was a negative predictor of resiliency, yet, seeking was a positive predictor of resiliency when entered into the model with avoiding. Perhaps children who engage in sensory seeking behaviors are exercising active regulation strategies to counteract their aversions, or avoidance. Resiliency, as measured by the BASC–2, refers to a personal trait that reflects resourcefulness and flexibility of functioning (Block & Block, 1980). Our findings suggest that children who engage more actively in their environment (i.e., seeking) show increased resilient behaviors. Given previous research relating seeking patterns to repetitive behaviors in children with ASD, such as Boyd, McBee, Holtzclaw, Baranek, and Bodfish’s (2009) study, our finding relating seeking to resiliency may cast a new light on behaviors considered maladaptive in the ASD population. Perhaps their behaviors are adaptive in the sense that the children are trying to manage overwhelming situations for them.
Overall, scores on the Avoiding subscale increased all challenging behavior scores and decreased scores on the Adaptive subscale, indicating that children who have a low threshold for sensory stimuli and have active self-regulation strategies need more support to manage their behavior. Children who show increased avoiding behaviors may benefit from intervention to help them develop self-regulation strategies that are viewed as more appropriate to their peers, parents, and teachers. In addition, if avoiding behaviors increase challenging behavior and decrease adaptive behavior, occupational therapy practitioners can support children by creating or adapting environments and routines to limit the amount of sensory information. For example, children may benefit from going to playgrounds at less crowded times. Also, occupational therapy practitioners may work with families to create morning and evening routines that are predictable and allow the child to control the amount of sensory input they receive (i.e., decide when to turn the lights on in the morning, the taste and texture of their toothpaste, or how many errands to run after school). Creating environments in which children’s need for predictability and control (which is characteristic of avoiding behaviors) is met may reduce challenging behaviors.
There were several limitations to this study. First, the sample size was small for the amount and type of data analyses performed. This limited the conclusions we could make. Additionally, it is possible that some sensory processing patterns that were not significant in our study would have been significant in a study with a larger sample size. Future research should consider the relationship between sensory processing and behavior or participation using a larger sample size to allow researchers to draw more definitive conclusions. However, the large regression coefficients and small p values obtained in our analysis give us confidence that the relationships we noted are reliable. Finally, we did not correct for the number of comparisons made in the analysis.
Implications for Occupational Therapy Practice
We found specific relationships between sensory processing patterns and behavior, particularly with regard to challenging and adaptive behaviors in the general population. Certain sensory patterns predicted externalizing behaviors, depression, resiliency, and adaptability. The findings of this study have the following implications for occupational therapy intervention:
Sensory processing differences affect children’s behavior.
Sensory characteristics of the environment are important considerations for all children.
Occupational therapy practitioners can collaborate with parents and other professionals to modify environments that support positive behavior and participation for all children.
Further studies are needed to understand the adaptive qualities of sensory processing behaviors.
Conclusion
This research connects sensory processing and behavioral characteristics in a general population of children. Most research on relationships between sensory processing and behavior has examined specific diagnostic groups, mainly ASD. In this study we used a sample of children from the general population, which allows us to think about sensory processing as a relevant feature for understanding all children’s behaviors.