My thoughts about sensory diets have shifted gradually over the last many years. My initial “a-ha” moment happened a couple of years ago, when I was working with a 7 year old boy who had been referred to me by the STAR Institute. He had global sensory processing disorder but no other diagnoses. As I think back on my work with this client, aside from my memory of being nervous because of who referred him and the fact that I wanted to do a good job, what I remember most is my client’s mom. She was constantly frustrated, and so was I. We were frustrated because she kept asking for information and suggestions and I thought I was giving them but she’d end up coming back asking for more, yet I didn’t see what I had already recommended being implemented.

When this mom finally came to me near the end of this client’s treatment and said, “I just need a plan. I just need to know what to do with him.” My immediate thought was What do you mean?! I’ve told you what to do with him. You’ve been in every session! I’ve been giving you things every single week–handouts, information, links and resources. I’ve shown you what I do and what I want you to do and I’ve sent activities home with you. How can you possibly NOT know what to do with him? I felt I had done my job, but this mom wasn’t getting what she needed. And when I stopped to really think about it, neither was my client. I was missing something.

Coincidentally, this case occurred alongside a time of increased sharing on social media of lots of treatment activity ideas and “sensory diet information.” This sharing in and of itself was and is not bad. Ideas can be very helpful to many people, therapists included. Yet, what I realized as I watched this global, and amped-up, sharing of activities to meet sensory needs, is that what I was missing and what I didn’t see being shared was the “how”; HOW to implement these strategies in the context of a child’s day. HOW to discern which strategies were suitable or not in the moment based on child responses (aka attunement) and HOW to implement them in the context of relationship (a neural super-power)! I also didn’t see anyone sharing with therapists about HOW they could explain it all to parents. All I saw was activities and strategies, out of context and that’s what I had been providing this parent.

Mistakes I Made

I gave my client information and strategies but I didn’t share HOW or why it could work for her son specifically (my bad) or HOW to implement the strategies in THEIR days vs. just how they “should be done.” I hadn’t considered the unique nature of their relationship, where she expected him to be independent and wasn’t and how she thus approached him worried and anxious herself. I neglected to consider the impact that could have on her thought process or his receptivity or the overall efficacy of the strategy to influence his nervous system. I was leaving her to her own devices once I had shared and shown and made the pretty handouts.  I hadn’t shared in a way that helped her to develop some reasoning skills based on her own cognitive and emotional status. I simply assumed she had the reasoning she needed (she was a very informed and knowledgeable parent). But knowledge isn’t reasoning and it certainly isn’t a guarantee of a nervous system being ready to support regulation in her son’s nervous system. I hadn’t shared in a way that made it make sense to her or that supported her in her nervous system.

Obviously there are other factors that played into this case, but it brought to light some thoughts I was having around how we use and teach the use of sensory strategies. I have since refined my approach and conceptualized two types of “sensory diets”: Prescriptive and Intuitive. I have also boldly suggested we change the name from “sensory diet” to “sensory support plan”. More about these suggested changes are covered in my “Re-thinking Sensory Diets” Webinar and I’ll be sharing more in coming months through various posts. This is also the framework I share when I mentor other OTs and in The Sensory Collective Membership and Group Coaching program I offer for sensory OTs. In refining my approach however, I have also done more research into polyvagal theory and I believe we can learn some things and do what we already do as OT’s but to do them even better by using a polyvagal lens!

What is a “Glimmer” and 3 Ways to Present Sensory Strategies to Children

Deb Dana, a prominent psychologist and author who has written “The Polyvagal Theory in Therapy” defines glimmers as “cues of safety arising from a ventral vagal state of health, growth, and restoration” (Dana, 2018). Dana asserts that multiple micro-moments [glimmers] may become significant enough to create an autonomic shift.

This concept of glimmers is significant to our work as sensory OTs, because it not only emphasizes the importance of the potential for sensory strategies to make neurological change but, it reminds us that our work is not just about the sensory stuff or the sensory strategy. It reminds us that we might gain more therapeutic traction and more benefit for our clients if we use relationship. We can incorporate relationship into our sensory approach when we: 1) connect & join our client or child during use of the strategy, 2) embed sensory supports into daily activities, and 3) make supports sustainable and feasible for caregivers.

  1. Connect and join as we implement a strategy. This means find a way to make the item and the process of using it meaningful, engaging and to use it yourself (assuming it’s not a negative experience for you to do so) along WITH the child. If wanting the child to try and use a weighted blanket for example, don’t just hand the blanket to the child and say, “Here. Try this.” Pick up the blanket and stroke it to show how soft it is. You might try making a pleasing sighing sound as you do so (even older children know what it sounds like when someone relaxes into a completely cozy space or sensation). Wrap it around yourself and show them with your face how relaxing it is–closing eyes, putting a soft sleepy smile on your lips, resting your head back against the couch or on a pillow…cue the drama and secret actor inside of you. Cover up a beloved stuffed animal with the blanket and make a “shhh” sound with your pointer finger over your lips to “pretend their stuffy is taking a nap” as you gently pat the stuffy’s head affectionately and in a nurturing way (engaging their sense of imaginary play and inherent nurturing we all have and want…engage THEIR sense of drama). Lastly, you can place the blanket beside them or on their lap as you read to them or as they play LEGOs with you, or as you snuggle in for a movie with a giant bowl of popcorn. Your relationship is a powerful influence for your client or your child. Being able to appeal to their stage of development and being able to use true back and forth relationship in a tuned in way, can change the entire experience of trying something new.
    • When YOU share in the experience and model the result you hope for it creates a context for the child and a desire to follow your lead.
    • When you present it gradually, it allows them the opportunity to become familiar with this new thing (new and novel things are perceived as a potential threat to many children with sensory challenges). Those with touch sensitivities are especially inclined to be resistant to new fabrics and touch sensations, of which a new blanket is an example.
    • Children with sensory challenges often desire greater amounts of control than typically developing children, in theory because their bodies feel out of their control. Thus they may be inclined to refuse the weighted blanket, simply because they want control over a new experience. Their initial refusal may have nothing to do with the blanket itself, but when we present the blanket as though it’s all about the blanket, we inadvertently allow them (and their nervous system) to make it all about the blanket too, which decreases the odds of acceptance. Let’s make it about pairing the blanket with a positive feeling. Keep in mind this is an example of introducing a weighted blanket. These concepts apply to use of any sensory item or strategy; think other tactile items like a z-vibe wand, using an adaptive cup, joint compressions, or even movement strategies like a swing.
  1. Embed into daily activities and routines. While autonomic shifts are possible when completed outside of typical routines and environments using sensory strategies as part of a routine has more potential for meaning and interaction with the world and more potential to make positive emotional connections and cues with the environment. Some examples of embedding sensory strategies into routine might be, having a child march or jump instead of walking, carrying a backpack and walking to school instead of a driving, using a bite-n-suck straw water bottle or using a vibrating toothbrush. All of these strategies provide enhanced input during an activity that is getting done anyway and an activity that needs to be done regardless of how it gets done. Some reasons this approach is helpful are:
    • Relying solely on use of prescribed exercises that have nothing to do with routines, makes the sensory support an “extra” and for young children (and even parents) who are stressed extra things to do may be perceived as challenging.
    • Doing things outside of inherent routines could provide less contextual cues for meaning and thus the strategy may feel more imposed. Remember that need for control? Imposed items/strategies may increase a sense of threat and thus a higher need for control vs. engagement). I should state this is only one way of providing a sensory input and for some children needs to be balanced with other methods and interventions.
    • Children with sensory challenges are often hyper-vigilant to the inputs within their environment and when we create opportunity for them to get inputs that feel good or positive to them and when we do this throughout their day, they are more likely to look forward to the upcoming activity vs. guard against it and the hope is that anticipatory anxiety about what’s coming next is reduced.
    • Additionally, young children are typically doing daily activities alongside their parents anyway, and thus when we embed enhanced supports within daily tasks, we are inherently including the parent as a supportive factor.
    • Lastly, when we embed sensory strategies into a child’s day, it means it’s happening within the context of their typical environment and thus the opportunity for repeat practice (and repeat glimmers) exists. More frequent repetitions leads to more frequent practice of new neural patterns.
  1. Make supports sustainable and feasible for parents or the setting (i.e. it’s not helpful to recommend vestibular input if the family doesn’t have a swing or if we don’t give, show, and trial ideas for vestibular play that the family is able to do at home). We also can’t expect a family to take their child to a park if there is no park close by and the family doesn’t have transportation or if a parent is highly rigid and overwhelmed by mess and we want to recommend tactile messy play. This may seem obvious and I don’t mean to imply that OTs don’t already consider these kinds of variables. What I am suggesting is that we need to remember the uniqueness of each family and their resources (personal, financial, environmental, temporal, health etc.) and to consider parent needs and resources as part of the plan vs. just sharing activities that might help based on what we know about sensory. Too often we develop or share a printed list of things that a child might need and present a list or visuals for parents or children to choose from, without regard for how a parent will feel if they aren’t able to implement a large portion of that list. The same goes for a classroom environment. Just because a child needs a certain input does not mean it’s appropriate or even possible to give it to the child at school. We need to consider these things when recommending one treatment model over another and when suggesting certain activities for home or school, so that we set caregivers up for success.

There is not much evidence, if any, supporting positive outcomes with use of a “sensory diet” (Pengale et. al, 2019). Yet use of sensory strategies to support change in autonomic state is used frequently as occupational therapy intervention. Additional research is needed to provide evidence of best practice when it comes to use of sensory support plans, but until such evidence exists, incorporating frameworks such as polyvagal theory, that are based in brain science, is an evidence informed approach to refining our practice.

 


References

Dana D. (2018). The Polyvagal Theory in Therapy. WW Norton & Co. NY, USA

Harvard University, Center on the Developing Child (2017) Brain Architecture. Retrieved online 10/7/19 https://developingchild.harvard.edu/science/key-concepts/executive-function/

Porges, Stephen W. & Dana, Deb A. (2018). Clinical Applications of the Polyvagal Theory: The Emergence of Polyvagal-Informed Therapies (Norton Series on Interpersonal Neurobiology) 1st Edition. W.W. Norton & Company. NY USA.

Vidya Pingale, Tina Fletcher & Catherine Candler (2019) The Effects of Sensory Diets on Children’s Classroom Behaviors, Journal of Occupational Therapy, Schools, & Early Intervention, 12:2, 225-238, DOI: 10.1080/19411243.2019.1592054

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