Is it sensory or behavior?

I saw this question posed recently in an online group for occupational therapists. To be honest, I’m really surprised that this is a question that OTs still ask because I thought most people knew by now that they are not mutually exclusive. I think the question that they really want to know is whether the behavior is something that OT should be addressing or not because a lot of people still see OT as addressing behaviors only when they are related to sensory processing. I also see in these online groups that it isn’t uncommon for OTs to feel pressure from educators to address behaviors because they believe the issue is sensory-related. 

This Question Has Been Around a Long Time

This is a question that came up a lot in my early years as an occupational therapist (and I’ve been an OT for over 25 years). Sensory and behavior are not mutually exclusive and when supporting a child at school the school teams need to gather a variety of information and use a self regulation lens. Over time the understanding about behavior has shifted and we now know that there are a lot of factors that may affect self regulation and behavior. When considering this, we can look at a bigger picture to understand all of the factors that contribute to how a child is regulating. Sensory processing is only a small piece of that and is typically a symptom of something else, not a diagnosis of its own.

Using a Self-Regulation Lens

Although my role in evaluating a student in schools is often limited to sensory processing, there are so many other factors that need to be considered, and often should be part of an evaluation when behavior is of concern. 

Executive Functioning

In schools this is most commonly assessed by the school psychologist, but is something I regularly assess in private practice when self-regulation is an issue. 

Language

A language delay can have a significant effect on a child’s ability to follow directions and understand what is happening around them, and with their ability to ask for help.

Academic Levels

A child who is academically gifted may be acting out because they are bored. One who has reading delays may not want their peers to see them struggle and may have a behavioral response to avoid reading in front of peers. 

Observations

There are many areas to observe, particularly in schools. Is the child being bothered by another child? Do they feel unsupported by the adults in their classroom? Are they on task? Can they follow multi-step directions? Do they disengage when they encounter a problem or do they attempt to solve it or get help?

Health and Medical

Maybe the child has an undiagnosed vision or hearing problem. Do they have adequate nutrition and sleep?  Is there an undiagnosed medical issue, such as an allergy or diabetes? Or possibly ADHD that is not yet diagnosed? Do they have pain? 

Trauma

Is there a history of trauma or is the child currently experiencing trauma?

Input from the Child 

There are just some things we can’t know because we don’t feel the internal experiences of the child. That is one of the main benefits to using The Stress Detective Clue Cards. The child’s team can get a better understanding of what issues the child is perceiving to be a problem so that can be addressed more specifically. This helps find the right people and strategies to support that child.  

When we use a self-regulation lens we can better identify and address the issues children are facing that cause them to have difficulty self-regulating. Sensory processing is not always a factor, but even when it is it is usually only a piece of the puzzle. In my evaluation reports I have a blurb that indicates that there are many factors that affect self-regulation and that not all of them can be assessed by an occupational therapist. I try to communicate this to educators and parents. 

Addressing Self-Regulation in Schools

How this is addressed in schools will vary by school and by child. So many sensory tools and strategies are mainstream now that they really don’t require the skills of an occupational therapist to provide (e.g., fidgets, wiggle cushions). I address self-regulation on a consultation basis most of the time. However, I will work directly with children in some situations:

1. When interoception-related issues affect self-regulation. For example, I worked with a child who had a lot of behaviors related to wanting food and snacks. He could not identify feelings of hunger and fullness well and confused the feelings of thirst and hunger. This is an area that other school specialists are not usually trained in.
   
   

2. When the child has poor awareness of their own energy levels and their need to move interferes with social participation and staying focused in class. Typically, the children and I work together to identify their energy level and find strategies that will help them. In schools they have usually already tried chair bands, wiggle cushions, and fidgets, but these were not enough to support the student. We usually use The Alert Program.
   
   

3. When the school team feels they need more support or lacks the training, tools, or experience to provide support. For example, some special ed teachers have a compliance-focused lens that does not factor in the student’s mental health, or they are limited in their repertoire of strategies.
   
   

4. When sensory processing is a really big factor affecting their performance at school. This is often when it’s more than just needing to move or being distracted or overly sensitive to sounds and things they see. There are usually multiple specific issues that need to be addressed, and often anxiety is a factor too.
   
   

In conclusion, sometimes there are sensory issues, but even when a standardized sensory questionnaire, such as the Sensory Profile (SP) or Sensory Processing Measure (SPM-2), reveals significant sensory processing differences, it does not mean they require occupational therapy interventions. In fact, I have evaluated numerous students whose SPM-2 results indicate significant sensory processing differences, but the student has not needed any occupational therapy interventions, even when we have added consultation to the child’s Individualized Education Program (IEP). What the majority of them needed most often was connection with a trusted adult they saw daily to help them feel safe at school and/or predictability and routine so they knew what to expect in their day.