Is It Sensory Processing Disorder or ADHD?
Distraction. Impulsivity. Lashing out. Sensory processing disorder and ADHD have striking similarities. So how do you distinguish symptoms in your child? Start here.
I remember the day I knew our daughter had a problem.
We were rushing to an appointment, hustling along a crowded sidewalk on a humid summer day. I was cautioning Elisabeth about something, dragging her behind me the way you sometimes do with an almost-4-year-old. The traffic was loud and smelled of exhaust, a kid on a bike was blowing a whistle, and the storefronts were bursting with bright vegetables and flowers.
Suddenly, my daughter stopped in her tracks and screamed — a long, loud scream of agony and frustration — prompting everyone around us to turn and glare. Later, when I asked her why she screamed, she said she didn’t know, she just couldn’t control the impulse.
There was more. Elisabeth was terrified of playground swings and of walking barefoot in grass. She hated crowds and washing her hair. But these I chalked up to developmental angst. I knew almost nothing about sensory processing disorder and ADHD. Only when Elisabeth was evaluated, at age 5, as having sensory processing disorder (SPD) by an occupational therapist trained in sensory integration (SI), did I begin to understand her perplexing behaviors.
I remember another day, too, about two years later. Sitting in our school district’s offices with the “special education committee” assigned to evaluate my daughter’s needs, I became furious as the psychologist — who had never seen my daughter — pronounced her symptoms as “clearly ADHD,” on the basis of a checklist she held in her hands. She was as dismissive of SPD (also known as SI dysfunction) as I was of ADHD, each of us refusing to entertain the possibility that the other’s diagnosis was correct.
As it turns out, my daughter has both. But it took another year or so for me to learn the similarities and differences in the two conditions, or comorbidities, and to accept treatment for ADHD. Examine their symptoms side by side, and you’ll see some striking parallels, as well as several disparities. The two conditions don’t necessarily go hand in hand, but they often do. “Many neurological problems overlap,” explains educator Carol Stock Kranowitz, author of The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder. “Often, a child who has dysfunction in one area will have dysfunction in others.”
The correlation of ADHD and SPD symptoms is shown by a new national study of children ages 2 to 21 done at the University of Colorado. Parents reported that, of children who showed symptoms of either ADHD or SPD, 40% displayed symptoms of both, according to Lucy Jane Miller, Ph.D., director of the Sensory Processing Treatment and Research (STAR) Center at the Children’s Hospital in Denver. When ADHD and SPD do coexist, however, it’s important to distinguish one from the other because their treatments are different.
What is SI?
Sensory integration is the process by which information from our senses (touch, sight, hearing, taste, smell, as well as balance) is interpreted by the brain so that we can respond appropriately to our environment. A child with good SI automatically filters the important from the unimportant stimuli as she makes her way through the world. At school, she sits alert at her desk without thinking about her posture. She pays attention to the teacher and filters out the noise of children in the hallway. On the street, she ignores the booming car radios and honking horns, and the itch of her wool sweater, but attends to the sound of the bus turning the corner, “telling” her to wait before crossing the street.
For some children with sensory processing disorder, information reaching the senses often feels like an assault of competing stimuli. To get the idea, imagine this scenario: Three children are telling you conflicting stories about who had the toy, the phone is ringing, and you suddenly smell the cake burning in the oven — and did I mention the itchy rash on your legs?
For others, outside stimuli are dulled, as if a shade has been pulled over the environment, muting sights, sounds, and touch. These children crave extra stimulation to arouse themselves — similar to needing the jolt of a wake-up shower after a sleepless night. These are the kids who love to spin and swing upside down. Most children with SPD display elements of both extremes, suffering from sensory overload at some times, seeking stimulation at others. It’s not difficult to see how the symptoms — distractibility, the need for intense activity, problems with social interactions — could seem like ADHD.
A child playing in a sandbox can ignore the sweat trickling down her face and neck because she loves the sandbox, and there’s a breeze to cool her off a little. A child with SPD cannot ignore anything — the sweat is distracting and irritating, and the wind makes her feel worse, not better. Lacking an inner ability to cope with these irritations, she may kick the sand in frustration and lash out at her playmates, ruining her playtime and her entire afternoon. The bad feelings stay with her long after the physical triggers are gone. Children with SPD can be frustrating to parents and teachers, but their behavior is most frustrating to the children themselves. A. Jean Ayres, the groundbreaking occupational therapist who first described SI dysfunction more than 40 years ago, likened it to having
“a traffic jam in the brain.”
Who’s at Risk?
Most people develop normal sensory functioning, but some experts believe that the process goes awry in as many as 10% of children. As with ADHD, the causes can be unclear and may be genetic, but there are extrinsic factors that may put children at particular risk for SPD. These include maternal deprivation, premature birth, prenatal malnutrition, and early institutional care. Bundling, minimal handling, and propping bottles for feeding deprive the infant of the kinds of stimulation that promote integration of the senses. Such factors may explain why the incidence of SPD is higher among children who were adopted from orphanages. Repeated ear infections before age 2 may also increase the risk factor.
How Do You Know For Sure?
Once you recognize the possibility of SPD in your child, the next step is to locate a knowledgeable professional, usually a trained occupational therapist, to evaluate him. Many kids with SPD never receive an accurate diagnosis. The condition can resemble other problems, and can be misdiagnosed as ADHD, a learning disability, or even pervasive developmental disorder. In some children, the symptoms are so subtle and so similar to developmental behaviors, that they can be mistaken for mere personality quirks. Friends and family may, with all good intentions, say, “She’s just a late bloomer. Uncle Fred was always a sensitive child, and look how successful he is.” Our first pediatrician suggested that Elisabeth’s resistance (to put it mildly) to haircutting and shampooing was simply one of the factors that make her a unique individual.
Another barrier to diagnosis is the nature of the disorder itself. Many children with SPD intelligently develop coping strategies — social withdrawal, ways to avoid certain activities and textures. The coping masks, but doesn’t eradicate, the condition. Some children have a small degree of dysfunction but crave the kinds of activities that help them cope and even excel. Thus, they find their own antidote and may not need diagnosis or formal treatment. I know a boy who is more attentive and cooperative in class after swinging on the monkey bars at recess. My daughter is more easygoing after swimming. Swinging and swimming are activities that regulate the brain pathways responsible for integrating the senses.
“Sometimes it’s just an immature sensory system, and a child will outgrow it,” says Stock Kranowitz. “Other times, a person doesn’t outgrow it, but grows into it.” As a person matures, she might, for instance, find an occupation that is comfortable. Consider the professor who is able to work in comfort behind the desk that “protects” her from the stimuli of classroom sights, sounds, and smells.
What Do Doctors Say?
The biggest barrier to recognizing and diagnosing SPD may be the skepticism of the health care community. Much of this doubt stems from the medical model of health and disease, which requires evidence. Thus far, SI problems have not been quantified, in part because symptoms are variable and often dissimilar from one child to the next. But more research is being conducted to clarify the specific physiology, symptoms, and effective treatment of SPD, says Dr. Miller, who suggests that SPD’s eventual inclusion in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders is probable — if not just over the horizon.
Until then, the coexisting symptoms of SPD and ADHD may be confusing. A child with ADHD can be inattentive (or hyperattentive — aware of too many things), distractible, easily frustrated, poorly organized, forgetful, fidgety, and impulsive. So can a child with SI problems. So a superficial description of a child with SPD will sound the same as a superficial description of a child with ADHD. But a closer examination of the child with SPD will reveal symptoms that likely will not be seen in the child with ADHD (unless he has both): an intense desire for or aversion to swinging and spinning, a terror of walking on grass or other unstable or bumpy surfaces, and extreme sensitivity to noise.
My daughter’s developmental psychiatrist has observed that for most of the children he has seen (all with ADHD), various treatments for SPD have not produced sustained improvements, and that makes him doubt the diagnosis. But for some, including Elisabeth, the therapies have produced long-term results.
What’s the Treatment?
The two disorders may present similarly, but the medication and behavior-modification therapies that work for ADHD do not work for SPD. SI treatment consists of working with an occupational therapist on a set of activities that help retrain the senses. The little I knew about it was baffling, but after seeing them in action, the strategies made complete sense. The basis of the therapy is a varied sensory “diet,” to stimulate all the senses. Since each child has his or her own sensory strengths and weaknesses, the sessions are tailored to the child, and change as she or he progresses. The earlier dysfunction is recognized and treated, the better.
Elisabeth spent a lot of time swinging — sitting up, lying on her stomach, on her back, and on a trapeze. She was encouraged to touch lots of different textures, she searched for buried “treasure” in containers of Play Doh, poured uncooked beans and dried peas from one container to another, finger-painted on mirrors with shaving cream, carried big jars of sand up a slanted surface, somersaulted down a soft incline, and jumped into piles of huge beanbags.
We began new activities for a few minutes at a time. Once she overcame her initial fears and aversions, Elisabeth began to seek out the kinds of activities that helped her — some of them the very ones she had avoided. Within about a month, she seemed less fearful, more cooperative, and physically stronger. She started to make friends on the playground, her play was more organized, and she stuck with activities for longer periods of time.
SI treatment is not a panacea and certainly not a quick fix. Although some children need less therapy than others, for many it’s a years-long proposition. By the time Elisabeth was 7 years old, it was clear that SPD could not account for all of her learning and attention problems, and she was diagnosed with ADHD. She now takes medication and receives behavior modification strategies at her school, along with occupational therapy. But the two conditions need to be differentiated, because, again, ADHD medication and behavior modification will not fix SPD, even if the conditions coexist.
Elisabeth still sometimes yells when I wash her hair, but she doesn’t scream anymore. She fusses about waistbands and sock seams that aren’t exactly right, but says it’s OK, “I’ll get used to it.” Best of all, she is making her way in the world, has lots of good friends, and is thriving at school and at home.
For more information about sensory integration and referrals to health care professionals trained to treat SPD, consult the following:
Sensory Integration International. SI information, workshops, therapists database, and more.
The KID Foundation’s SPD Network. Includes a national resource directory where parents can access local physicians, occupational therapists, mental health professionals, educators, facilities, community resources, and more. (Health care providers who work with SPD are encouraged to register here, as well.)
The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder, by Carol Stock Kranowitz. Excellent resources by the editor of S.I. Focus, a magazine about SI and SPD.
Making Sense of Sensory Integration, 2nd Edition (audio CD and booklet), by Jane Koomar.
Teachers Ask about Sensory Integration(audio CD), by Carol Stock Kranowitz.