Sensory Integration Education

Amy Hartman, MS, OTR/L is an American paediatric occupational therapist with over 10 years of experience. She is currently a PhD doctoral candidate at the University of Pittsburgh and is studying sleep health in children with sensory over-responsivity. Roxanna Bendixen, PhD, OTR/L, FAOTA and Stefanie Bodison, OTD, OTR/L are two of the many mentors that have informed her research. Here, they discuss the relationship between sleep and sensory processing. 

 Amy Hartman, MS, OTR/L

Roxanna Bendixen, PhD, OTR/L, FAOTA

Sleep is one of the most critical pillars of health and has a strong influence over general wellbeing. Unfortunately, sleep is also an overlooked area of health in allied healthcare professions (Tester & Foss, 2018). Insufficient sleep is a pervasive health concern in children, impacting 20-30% of children in the general population (Williams Buckley et al., 2020). For children with developmental diagnoses, the prevalence of poor sleep is significantly higher (Reynolds, Lane, & Thacker, 2011; Singh & Zimmerman, 2015; van der Heijden, Stoffelsen, Popma, & Swaab, 2018). After a poor night of sleep, children can demonstrate difficulties paying attention, problem solving, and higher rates of behavioral concerns (Spruyt, 2019). Additionally, chronic insufficient sleep leads to significant delays in cognitive development, emotional regulation, and even physical growth by impacting multiple physiological processes (i.e., stress, body metabolism, physical healing, hormonal balance, and immune system activity (Beebe, 2011; Bonanno et al., 2019; James & Hale, 2017; Raikkonen et al., 2010)). 

Sleep health is largely unstudied in children with sensory processing concerns. However, neuroscience literature and clinical experience tells us there may be a connection between poor sleep and sensory processing concerns. Children with sensory over-responsivity can have sensitivities to everyday sensory stimuli which results in increased activation in the hypothalamic-pituitary-adrenal (HPA) axis leading to high stress levels and behavioral reactions (McIntosh, Miller, Shyu, & Hagerman, 1999; Schoen, Miller, Brett-Green, & Nielsen, 2009). It is also known that in typically developing people, excessive activation in the HPA axis leads to increased wakefulness, thus impacting sleep (Han, Kim, & Shim, 2012). It can be reasonably hypothesized that children with SPD have higher rates of sleep problems than neurotypical peers due to these differences in neurological processes.

What is sleep health?

To address sleep health concerns, one must first understand sleep. Sleep is a complex process that is balanced with arousal through intricate and expansive circuits involving the whole body and nearly all areas of the brain (Eagleman & Downar, 2016; Jones, 2020). There are two processes involved in sleep: Process-S and Process-C. Process-S, or your sleep propensity, is driven simply by the amount of time a person is awake. The longer you are awake, the higher the pressure to sleep. Upon sleep onset, your sleep pressure quickly dissipates. Process-C is powered by your circadian rhythm in which your alertness level oscillates within a near 24-hour cycle. While the circadian rhythm is driven by a small nucleus in the hypothalamus called the suprachiasmatic nucleus, it can be informed and adjusted by external cues (called “zeitgebers”) like light, diet, social interactions, and exercise. 

It is important to note that sleep is not just measured by the duration of your sleeping period. Sleep health is “a multidimensional pattern of sleep-wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being” (Buysse, 2014). The sleep health theoretical framework (Buysse, 2014) has been recently adapted for pediatrics by Dr. Lisa Meltzer and colleagues (2021) to include 6 dimensions that can be used to thoroughly describe sleep health: Behavior at bedtime, Satisfaction with sleep, Daytime Alertness, Sleep Timing, Sleep Efficiency, and Sleep Duration (B-SATED). Good sleep in pediatrics is characterized by healthy sleep behaviors (self- or caregiver-reported), sleep satisfaction (self- or caregiver-reported), appropriate timing of sleep within a 24-hour day, adequate duration which is dependent on age, high sleep efficiency (the amount of time spent asleep divided by the time spent in bed), and sustained alertness during waking hours (Meltzer, Williamson, & Mindell, 2021). 

Asking the right questions about sleep and sensory processing

Caregivers of children with sensory processing concerns may not readily identify sleep as an issue that impacts their child’s life. Further, they may not recognize that sleep health can be addressed in treatment. Therefore, it falls on the health care provider to ask the right questions to understand the child’s sleep health and its potential impact on the other goal areas caregivers present. Questions should cover each dimension of sleep health to paint a thorough picture (Table 1). From these questions, healthcare providers can target specific sleep health dimensions that may need intervention. 

Table 1: Examples of questions to ask related to a child’s sleep health

Measuring sleep health

Measuring sleep in a way that captures the multiple dimensions of sleep health is important because it can give a thorough characterization of the areas that may be impacted, leading to targeted intervention. Polysomnography, also known as a sleep study, is the gold standard of measuring sleep, but requires access to a sleep clinic and many medical professionals. Beyond a clinical interview, healthcare providers can use questionnaires (both child and caregiver reported), daily sleep diaries, or technology like activity monitors or smart-phone applications. 

Questionnaires can cover many, if not all, sleep health dimensions, but are inherently subjective, creating opportunities for bias. There are many, well-validated parent and child reported questionnaires to choose from (e.g. Owen’s Children’s Sleep Habits Questionnaire; Owens, Spirito, & McGuinn, 2000). Daily sleep diaries, or records of sleep onset timing, nocturnal awakenings, and morning wake timing (among other things that may be relevant to track), are commonly used to provide a snapshot of sleep patterns that may be maladaptive. These often are very informative and can help identify areas of sleep routine and timing that may need to be addressed. Finally, technology like wrist-worn activity monitors can use movement (and sometimes heart rate) to estimate sleep periods. Using algorithms that often have been developed in healthy, young adults, activity monitors offer data that can add to the knowledge about sleep timing and daytime activity but should be coupled with other means of measurement. 

Sleep Intervention

Sleep intervention should be driven by the specific areas of sleep health that are noted to be impacted. If a child’s sleep timing is sporadic, then intervention will focus on consistent timing. If a child delays bedtime with stalling techniques, behavioral or cognitive techniques can be applied to support increased success for the parent and child. Generally, the guiding principles for sleep intervention are based in cognitive behavioral therapy (CBT): cognitive restructuring of thoughts surrounding sleep, behavioral interventions helping the body and mind to prepare and engage in sleep, and psychoeducation around good sleep hygiene (Newsom, 2020). For pediatric clients, there is a special focus on bedtime routines, parental interactions surrounding sleep, and environmental supports (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006). 

Healthcare professionals, like occupational therapists, are called to focus on the whole child and consider the sleep health of their clients. Sleep is foundational to health and insufficient sleep can negatively impact typical goal areas like cognitive development, attention processes, and gross motor function. Through understanding the basics of sleep, recognizing the six main sleep health dimensions, asking the right questions, and choosing multifaceted measurement tools, we can incorporate sleep intervention techniques in daily practice. Addressing sleep health will improve the overall health and wellbeing of both the child and the family.

REFERENCES

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