Make peace with sensory battles

By the time I figured out what was going on, my daughter had been going “commando” for several weeks. It was a new stage in what I now think of as The Underwear War, and the enemy – the delicately wired nervous system in my young daughter’s body – had silently, secretly gained the upper hand.

In truth, the same battles had been fought before, only on different turf: the Great Sunscreen Stand-Off of 2002, the Stiff Blue Jeans Clash of 2003 and the Socks-and-Sweaters Conflict of the winter of 2004. I had already engaged in an Underwear Skirmish in 2005, securing peace only when a city-wide search turned up enough Hello Kitty briefs, size 8, to satisfy the treaty.

My bright, sweet, spirited daughter has always been sensitive to certain sensations, especially regarding the texture of her clothes. Over time, I realized that her refusal to wear certain clothing was not willfulness or stubbornness but a physical imperative she could not ignore, no matter how much she wanted to comply with our requests. By the time she was an otherwise thriving 6-year-old, we had accepted that her clothing had to be soft and loose, without any scratchy or clingy material, but not so loose as to require constant adjustment.

Despite efforts to buy clothes she would find comfortable, we continued to have problems dressing her. Eventually, I consulted our pediatrician and learned that children who repeatedly exhibit this sort of sensitivity could be struggling with Sensory Integration Dysfunction, now more commonly called Sensory Processing Disorder (SPD). Research into this condition is ongoing, but many pediatric health professionals believe that certain therapies can help children learn to cope with the constant, distracting, sometimes overwhelming sensations their bodies experience daily.

"(SPD) is associated with over- or under-sensitivity to sensory stimuli – visual, auditory, tactile and stimuli related to balance and spatial awareness – that results in some degree of functional impairment,” explains Dr. Andrea Dunk, a pediatrician at Chapel Hill Pediatrics and Adolescents.

Dunk lists the following examples of children suffering from SPD:

"When their reactions create problems in their home or school experiences, I refer their parents to specialists who may be able to help,” Dunk says.

Some children with SPD experience pronounced social, academic and behavioral problems as a result of their condition. According to Barbara Hawk, a psychologist at Chapel Hill Pediatric Psychology, SPD leads many children to engage in coping behaviors that can create problems, especially in a structured environment such as school.

Children who resist physical contact because it is too stimulating might have trouble standing in line because they fear being bumped by other students. Those who are bothered by the sensation of a cold floor or itchy carpet on their legs might refuse to join circle time. Loud noises may send others scurrying for the relative quiet of the coat closet. Children with SPD also can have trouble controlling their emotions, so their outbursts seem disproportionate to the situation at hand.

“To someone unfamiliar with SPD, these behaviors may seem bizarre, and the perception that these children are difficult or troublemakers can lead to ostracism,” Hawk says, adding that because information is processed by the senses, children with SPD face a higher risk of attentional and learning disabilities.

The exact number of children affected by SPD is unknown because the symptoms vary widely among the population and can be transient even in the individual child. In addition, it is likely that many children with these symptoms go undiagnosed. Some estimates suggest that 5 to 10 percent of the pediatric population may be affected, about half of which would meet the clinical guidelines for therapy.

Some pediatric health professionals remain skeptical as to whether SPD is a discrete condition or if its symptoms are part of a pervasive developmental impairment, such as autism. To rule out other possibilities, experts stress that a complete medical evaluation should be part of any effort to evaluate a child for SPD.

But SPD advocates emphasize that parent testimonials and the growing number of clinics offering treatment for sensory-integration problems in otherwise thriving children illustrate a growing awareness that this condition, whatever its cause, is a significant challenge to families.

As a psychologist, Hawk’s role in helping families facing SPD is both diagnostic and therapeutic. Some children may exhibit a wide range of difficulties, including attention, motor and language problems, necessitating a thorough evaluation and a multi-pronged treatment plan. She works with other professionals to address the needs of the child, the parents and, if appropriate, the school.

Most importantly, she works to help parents understand why their children do what they do and how to make the world a less stressful place for them.

“We might develop a ‘sensory diet’ that helps the family create an environment that minimizes the effects of SPD on the child,” she explains. “We also work with the child to help him anticipate situations in which he might be uncomfortable and use strategies to mitigate or avoid an inappropriate response.”

Many treatment plans for SPD also involve physical therapies. Bonnie J. Hacker, a pediatric occupational therapist and founder of Emerge – A Child’s Place in Durham and Chapel Hill, provides a range of interventions for children struggling with SPD. What she does for her clients, she says, “looks a lot like play."

"Our treatment area looks like a gym, with activities and equipment designed to provide controlled sensory input and enhance body awareness and motor skills,” Hacker says.

Children at such a clinic might listen to different sounds through special headphones, engage in balancing or swinging on a suspended apparatus or participate in group play. Because every child is different, therapy plans are individualized and continuously updated to provide what therapists call “the just-right challenge” – exposure to stimulation that encourages the child to stretch his or her boundaries of comfort without becoming overwhelmed or distressed.

Therapy may take only a few sessions for a child with minor degrees of processing difficulty. It may be a much longer process for a child who is more significantly affected. Hacker emphasizes that the benefits of therapy are worth the effort.

“We are sensory beings,” she explains. “We cannot interact or learn without the use of our senses.”

Most therapy plans also involve strategies to use at home. For example, we learned that vigorous regular exercise is one key to managing our daughter’s reactions to tactile sensations. Distraction, such as a hard piece of chewing gum, can be helpful when she balks at certain textures when getting dressed.

And, most crucial to success in the long term, we came to realize that clothes are, well, just clothes. If she dresses appropriately for the occasion and weather, it isn’t important for everything to match or a problem if her outfit looks a lot like what she wore the day before.

She might outgrow or overcome her problem, or she might not. But we knew to do our best to manage her hypersensitivity.

Then she secretly stopped wearing underwear. Having given them up, she was now excessively aware of how they felt when she put them back on.

"Too small,” she complained, although they were actually oversized. “Too tight, too scratchy, too binding” were other responses.

Panicked, I began buying every kind of underwear I could find, making clumsy alterations in a desperate effort to ease her back into wearing them. Why doesn’t anyone make “boy shorts” underwear that is also high-rise? A girl who doesn’t like elastic digging into her legs will not consent to a waistband hitting below her belly button.

In the end, the conflict was successfully resolved. I finally found underwear that works for her – granny-style briefs, hitting at the natural waistline, made of soft cotton, pattern-free, no lace around the edges, tiny seams, one size too large – although she claims that not every pair in every multi-pack feels the same, and she reserves the right to refuse any given pair on any given day.

It’s a fragile peace, and it works for now. But when it comes time for her first bra, I may be going AWOL.