SENSORY REGULATIONSENSORY REGULATION DIFFICULTIES WITHIN A MOTHER- INFANT DYAD

FIRST YEAR AND BEYONDFIRST YEAR AND BEYOND

Dr Pratibha N ReebyeDr Pratibha N Reebye Clinical Professor

U i it f B iti h C l biUniversity of British Columbia

AcknowledgmentsAcknowledgments

• Thanks to all participating and consentingThanks to all participating and consenting families teaching us respect for infants and children under our care

• All students and research coordinators who helped with self-regulation studyp g y

• Thanks to organizers of meeting such as WAIMH Quebec, that provides a platform p pto discuss clinical and research complexities

Learning ObjectivesLearning Objectives

• Participants will be able to appreciate theParticipants will be able to appreciate the development of sensory brain

• Participants will describe clinicalParticipants will describe clinical presentations of Regulation Disorders with Sensory perception(RDSP) through the y p p ( ) guse of clinical vignettes/video clips

• Participants will be able to list appropriate p pp pinterventions that can be used with children diagnosed as having RDSP

Learning Objective #1Learning Objective #1

P ti i t ill b bl t i t th• Participants will be able to appreciate the development of sensory brain

• Key words: Sensory Development, Physiological capacities, Maternal role

What is the purpose of having a b i ?brain?

• In all species brain task is to put sensoryIn all species, brain task is to put sensory information into motor behaviour and motor behaviour into sensory informationmotor behaviour into sensory information

• Species specific variations are to enable an organism to survive (e g dogs andan organism to survive (e.g. dogs and sense of smell)

What is the purpose of having a b i ?brain?

• The overall function of the brain is to beThe overall function of the brain is to be well informed about what goes on in the rest of the body the body proper; aboutrest of the body, the body proper; about what goes on in itself; and about the environment surrounding the organism soenvironment surrounding the organism, so that suitable survivable accommodations can be achieved between the organismcan be achieved between the organism and the environment (Schore)

Another thought:Another thought: • Brain discharges the need of the internal milieu g

according to the opportunities and restrictions presented by the environmentS l i l di ib d k• Selectively distributed networks

• Regions dealing with the body random distribution more diffusedistribution , more diffuse

• Regions dealing with the world, complex and narrow response properties(more specialized)a o espo se p ope t es( o e spec a ed)

Mesulam

New way to look at brain functionsNew way to look at brain functions

Executive

Relevance

Sensory Present at birth

RegulationHighly dominant at birth

Lillas and Turnbull,2008

Developing Human BrainDeveloping Human Brain

• Relational brainsRelational brains • Sensory motor plasticity

• Interplay Brain Body Environment • Capacity for Anticipation

Theoretical conceptsTheoretical concepts

• Sensory ProcessingSensory Processing

S M d l ti• Sensory Modulation

• Sensory Integration

Sensory Brain(1)Sensory Brain(1)

• Energy converted into sensory informationEnergy converted into sensory information• Sensory info translated first primary, then

secondary and last through associationsecondary and last through association areas Fi ll d liti i t t d• Finally, sensory modalities are integratedtransmodal

Sensory Brain(2)Sensory Brain(2)

Olfactory, gustatory, and vestibular :Olfactory, gustatory, and vestibular :• Multisensory neurons • Represent more of the sensory events associated with p y

the bodyAuditory, visual :• More differentiated neurons : are oriented toward the

events in the external worldSomatic sensesSomatic senses • Receive both types of neurons (High differentiated and

less differentiated)less differentiated)

Sensory Brain(3)Sensory Brain(3)• Auditory: Responds poorly to sounds, covers ears ,avoids noisy

places• Visual: Glazed eyes, continual gaze aversion, poor tracking of

objects• Tactile: resists hugs, even by touch from attachment figures, avoids

certain textures, distressed with light touch• Taste: strong aversion to tastes , or licks toys constantlyg , y y• Smell : aversive response to parent's body scent• Proprioception: Cannot locate parts of own body, clumsy, trips

consistentlyconsistently• Vestibular: motion sickness suscptibility,distressed on swings • Pain: Under or over responsive ( Pain is not a sensory modality)• Adapted from Lillas and TurnbullAdapted from Lillas and Turnbull

Regulatory System and Ph i l i l A lPhysiological Arousal

• Regulatory system controls arousalRegulatory system controls arousal• Arousal is required for high cognitive and

emotional functioningemotional functioning• Arousal: 1)sensory alertness 2) motor

ti it 3) ti l ti itactivity 3) emotional reactivity• Low to high energy continuum:

sleep,drowsiness,hypoalert, alert, hyperalert,flooded ( loaded)

Interactive(Mutual) regulationInteractive(Mutual) regulation

• Role of the caregiverRole of the caregiver • Mother as an external regulator setting

brain to brain developmentbrain to brain development• Provides dynamic container for mutual

i t tiinteractions• Right hemisphere :gaze, non-verbal

communication, emotional processing, and somatic aspects of communication

Mutual Regulation Model and l i i hi d dregulation within a dyad

• Regulated dyads • Dysregulated dyadsg yInteractive errors made but mother repairs errorsD di i f

y g y• Interactive errors are not

repaired on consistent basis• Self and interactive regulation• Dyadic expansion of

states of consciousness expand and become

Self and interactive regulation systems are functioning outside open systems

• Dyad disallows complexitycomplex

• Yet, coherence of interactive milieu is

Dyad disallows complexity required for expansion of states of consciousness

interactive milieu is maintained.

Right Brain(Baby) to Right B i (M h ) d B kBrain(Mother)and Back

Right Orbitofrontal CortexRight Orbitofrontal Cortex

Learning Objective #2Learning Objective #2

Participants will describe clinicalParticipants will describe clinical presentations of Regulation Disorders with Sensory perception (RDSP) through theSensory perception (RDSP) through the use of clinical vignettes/video clips

Key Words: • Diagnosis of RDSP, regulation/

dysregulation

How to understand the Regulation S ?System?

• HomeostasisHomeostasis

• Allodynamic Regulation( Flexibility and• Allodynamic Regulation( Flexibility and Stability)

• Allodynamic coordination

• Arousal

Optimal regulationOptimal regulation• Alert Processing would be the

predominant state ( Baby # 6 )predominant state ( Baby # 6 )• Smooth transiting from one state to

another (Baby # 1)another (Baby # 1)• If challenged , appropriate state change

but good recovery to baseline( Vignettebut good recovery to baseline( Vignette follows)

• Able to balance/modulate variety of within• Able to balance/modulate variety of within state changes

Regulation Disorders of Sensory P iPerception

3 Concepts important in assessments:R t C lt l f il d• Respect Cultural family codes

• Learn theoretical concepts of Sensory perception , arousal regulation & stress recovery

• Have your DC 0-3 -R ready

Ponder overPonder over …• Why is the child brought to you?y g y

• What capacities are perceived to be disturbed?

• Can parent be involved in constructing their child’s symptom profile?symptom profile?

• Based on the information who is/are the bestBased on the information, who is/are the best professionals to be involved?

AssessmentsAssessmentsGeneral Principles(1)

• Evaluation of the child and caregiverEvaluation of the child and caregiver • Developmentally appropriate measures

Li t i t t i t t• Listening to parents important• Multidisciplinary team is a must• Occupational therapist+ Psychiatrist

essential members

Assessments(2)Assessments(2)• Assess for Risk Factors and load

conditions• Office tasks for self-regulationg• Take Johnny to the apple tree

(Reebye,96)(Reebye,96)• What is missing on the face?(Reebye,96)

Walking on the line( Kochanska)• Walking on the line( Kochanska)• Drawing circles ( Kochanska)

DC:0-3R Diagnostic ClassificationRDSPRDSP

Constitutionally based responses toConstitutionally based responses to sensory stimuli across settings and multiple relationshipsmultiple relationships

R iRequires • Sensory Processing Difficulties• Motor Difficulties • A specific behavioural patternA specific behavioural pattern

Regulation Disorders :gCreate a Pie Chart for each

dysregulated capacitydysregulated capacity

Behaviour Physiology

motor

sensoryEmotion

DC:0-3R Diagnostic ClassificationRDSPRDSP

• HypersensitiveHypersensitive ( Fearful/Cautious, Negative/Defiant)

H iti /U d i• Hyposensitive/Underresponsive • Sensory Stimulation Seeking

RDSP and InfancyRDSP and Infancy

• Biobehavioual shifts ( 2-3 9-12 15-18Biobehavioual shifts ( 2 3,9 12,15 18 months) Ref: Stern

• Fussy Babies• Fussy Babies• Sleep arousal difficulties• Feeding /sensory aversion Caregiver has a major input in providing g j p p g

assistance

RDSP and ToddlersRDSP and Toddlers

• Tasks of regulating their sensory, motor,Tasks of regulating their sensory, motor, physiological, and behavioural responses are all important p

• Aggressive or impulsive behaviours may increase

• Disorganized behaviours in highly stimulating situationsg

• Fine balance between toddler autonomy and parental assistancep

RDSP and PreschoolersRDSP and Preschoolers

• A preschooler is expected to mange hisA preschooler is expected to mange his emotions, behaviour, motor activity, and react appropriately in novel and social pp p ysituations. In addition, their sensory processing and organizational ability gets

hi ti t d ith th d t f t isophisticated with the advent of maturing prefrontal cortexSt t i f tt ti d ff t• Strategies: focus on attention, and affect organization

RDSP and Middle ChildhoodRDSP and Middle Childhood

• Diagnostic confusion and need for labelsDiagnostic confusion and need for labels• Educating educators

Ed ti th hild• Educating the child• Enhance school readiness• Safety net for the child with RDSP• Self regulation strategiesSelf regulation strategies • Attachment needs and caregiver role shifts

RDSP and AdolescenceRDSP and Adolescence

• Clinical Experience onlyClinical Experience only • Community data unknown

N i i l t di f• No empirical studies so far• Tendency toward Mood Disorders , ADHD

diagnosis, or sometimes PDD-NOS• Do early sensation seekers become risk y

takers in adolescence with impulse control problems?p

RDSP and AdulthoodRDSP and Adulthood

• Does RDSP exist in adulthood?Does RDSP exist in adulthood?• Difficult to study, too many confounders

I l t l di d ti di d• Impulse control disorders, eating disorders

Video clipsVideo clips

• Self regulation tasks are assessed in theSelf regulation tasks are assessed in the clinical setting

Dyadic Assessments and RDSPDyadic Assessments and RDSP

• Parent –Child teaching Scales NCASTParent Child teaching Scales NCAST • Parent-Child Feeding Scales NCAST

F ti l E ti l A t• Functional Emotional Assessment Scale(Greenspan)

Video clipsVideo clips

Free play between a mother and her childFree play between a mother and her child to determine dyadic and child’s regulation capacitiescapacities.

Learning Objective #3Learning Objective #3

Participants will be able to list appropriate interventions that can be used withinterventions that can be used with children diagnosed as having RDSP

K d I t tiKey words: Interventions, RDSP,Developmental paths

Answer to three questionsAnswer to three questions

1. There is only one time that is important--1. There is only one time that is importantNow! It is the most important time because it is the only time when we have any power.

2. The most necessary man is he with whom you are, for no man knows whether he will ever have dealings with any one else: and

3. the most important affair is, to do him good,b f h lbecause for that purpose alone was man sent into this life!

Answers to three questionsAnswers to three questions

• The interaction starts right nowThe interaction starts right now• Baby is the most important person

(Child i t d h i )• (Child oriented approach is necessary)• To practice good sound parenting that is

adaptable to the baby in question

InterventionsInterventions

• Child/baby specificChild/baby specific

D di ifi ( hild/b b i l d d)• Dyadic specific( child/baby included)

• Ecology and Context specific(Child/baby to be kept in mind at all times)p )

Child Oriented(1)Child Oriented(1)• Infants: Allow self soothing : soothers, playing g p y g

with a textured blanket, listening to favourite music, favourite teddy bear with special clothing

• swaddling rocking positioning massageswaddling, rocking, positioning, massage • Toddlers: deep touch, comforting music,

movement therapy, dance therapy, swim /float th H2O( ti i i i t ion the H2O( sometimes immersing in water is

worse),games that support swinging, individual pace( hide and seek) as versus playing Tag(

l i )motor planning)• Preschoolers: readiness for group learning,

physical activity schedule that is OT approvedphysical activity schedule that is OT approved

Child Oriented (2)Child Oriented (2)• Smooth brushing/ Wilbarger Protocol after consulting OTg g g• Teach quiet time starting from1 minute then increasing• Teach respect for body and emotional boundaries• Strategies for shampooing, nail cutting, hair

cutting,outdoor indoor apparel, shoe shoppingPlay dates with children carefully matched• Play dates with children carefully matched

• Group participation planned from minute to minute such as at birthday partiesy p

Dyadic specificDyadic specific

• Unique Parenting strategiesUnique Parenting strategies • Nurturing Parenting Ego • Reading child’ cues effectivelyReading child cues effectively• Relation specific therapies• Role modelling by the parents as a therapeutic• Role modelling by the parents as a therapeutic

intervention• Involvement in social play ( Biking together)• Involvement in social play ( Biking together)

Ecology SpecificEcology Specific

• Provide adaptive environment: quiet roomProvide adaptive environment: quiet room, darker room

• Special scents or music• Special scents or music • Swings, trampolines in the garden• Mixture of sensory and non-sensory toys

but kept separately• Reduce visual, auditory clutter• Provide white sound if neededProvide white sound if needed

Training Parents Vid li f G S iVideo clip of Group Session

• This group has mother baby dyads andThis group has mother baby dyads and they are learning socialization in a group setting with the therapist present andsetting with the therapist present and directing each move

Training the Dyad Vid li f h iVideo clip of the session

• Dysregulated child and her motherDysregulated child and her mother learning mutual negotiation skills

Training Other CaregiversVid liVideo clip

• Grandparents taught to play with a childGrandparents taught to play with a child who is under responsive and self absorbedabsorbed

Assisting babies Vid liVideo clip

• Massaging babiesMassaging babies • A grandmother is massaging the baby

Knowledge TransferKnowledge Transfer

• Educating Ourselves• Educating Ourselves• Nurturing OurselvesNurturing Ourselves• Parental empowerment

C i t• Caregiver empowerment• Educating policy makers

Thanks

I will be happy to share Self- regulation assessment procedures. For further information please contact Preebye@cw.bc.ca