Sensory Integration Education

Dr. Georgia DeGangi, an international leading expert in assessment and treatment of children with self-regulation, sensory processing, attention and interactional difficulties discusses poignant moments in her career and shares insights from her practice.

SensorNet: Tell us in a brief about your career to date 

Georgia DeGangi: It was 1973 and I was standing in the bookstore at Boston University collecting my books for my senior year in O.T.  On the shelf were copies of A. Jean Ayres’ recent book entitled “Sensory Integration: Theory and Practice”.  I quickly stacked the book in with my other assigned books even though it wasn’t required for any of my classes. As soon as I got home, I began devouring the book, rereading it several times.  It wasn’t until several weeks later that I learned that one of the graduate students in O.T. didn’t have a copy of the book because they were one book short. Oops!  I never admitted that I was the culprit. Reading that book and later on that year meeting A. Jean Ayres at a conference was life changing. If only I could learn sensory integration and use it as a therapy technique in my future practice!  A few years later, I was working at Georgetown University Child Development Center in Washington, D.C. and got my chance.   There I worked in the premature follow-up clinic, neonatal intensive care nursery, and conducted assessments and treatment on young children on an interdisciplinary team. I then conceptualized my first test on sensory integration for preschool children- The DeGangi-Berk Test of Sensory Integration in 1982.  Interestingly, that test is still in use after all these years.  

While working in these early years of practice, I was struck by how many children with sensory integration problems also experienced problems with mood regulation and emotional development.  This spurred me to get my doctorate in clinical psychology.  I spent those years in private practice, then after completion of my doctorate I became the Director of Research at the Regional S. Lourie Center for Infants and Young Children in Rockville, Maryland. We began studies on fussy babies, developing assessment instruments, looking at what were the most effective treatment approaches, and examining the long-term outcomes of fussy babies as they grew older.   During these years, I had the amazing good fortune to work with Dr. Stanley Greenspan, the child psychiatrist who conceptualized developmentally based interactive therapy, also known as floor time.  Together Dr. Greenspan and I developed the Test of Sensory Functions in Infants, the Infant/Toddler Symptom Checklist, and the Functional Emotional Assessment Scale. Through this work, I was able to see the strong connections between problems in sensory processing, mood regulation, attachment, behavioral control, attention, and learning.  

In the last 20 years of my work as both an occupational therapist and clinical psychologist, I worked in private practice at ITS:PALSS (Integrated Therapy Services: Psychological and Learning Support Services) in Kensington, Maryland.  In my work at ITS:PALSS I worked with many children, adolescents, and adults with a combination of sensory and emotional difficulties. I had the amazing opportunity to work with some of the babies at the fussy baby clinic from our initial studies as they grew older into young adulthood.  Through them, I learned so much about what works and doesn’t work in helping them to lead happy, fulfilling lives.  During these years of work, I published several books on this topic including Pediatric Disorders of Regulation in Affect and Behavior: A therapist’s guide to assessment and treatment (1st and 2nd editions), Effective Parenting Strategies for the Hard-to-Manage Child co-authored with Anne Kendall, and The Dysregulated Adult: Integrated Treatment Approaches.   I also authored Kids’ Club Letters: Narrative Tools for Stimulating Process and Dialogue in Therapy Groups for Children and Adolescents with Dr. Marc Nemiroff, an interesting book on children’s advice to letters from children struggling with a range of problems.  The combination of teaching, research, and clinical practice led to my teaching graduate programs on infant/young child mental health at Johns Hopkins University, training programs at the Washington School of Psychiatry, and traveling throughout the U.S. and the world to share what I had learned.  I am also a fellow of the American Occupational Therapy Association and was the 1992 recipient of the A. Jean Ayres award from the American Occupational Therapy Association and the 2011 recipient of the Reginald S. Lourie award from the Reginald S. Lourie Center for Infants and Children in Rockville, Maryland. 

SN: You were a practicing clinical psychologist but also have experience as an occupational therapist, a very interesting and complementary mix of skills. How did these careers influence each other? 

Georgia DeGangi: How often have you worked with a child with severe tactile defensiveness who reacts by screaming when touched by others and cannot be held by their caregivers to help console them?  Soon the child learns to avoid social contact and they often develop behaviors that create conflicts like hitting or slamming their body against other children, screaming when someone approaches them, or developing a bubble to avoid social contact.  Then there are the children who react aversely to being moved, hating to have their feet leave the ground. A child with gravitational insecurity often becomes clingy with their caregivers and fearful to experiment with movement, especially in group social situations.  These are the kids that sit on the bench and avoid other children on the playground, some become selectively mute, and others have severe anxiety disorder.  I began puzzling about how sensory and emotional problems affected one another which led me to pursue further education in clinical psychology.  When I studied children in our fussy baby clinic, I discovered too that there was a bi-directional effect.  Sometimes babies with attachment disorders looked as if they had severe tactually defensiveness, which I assumed was a big contributor to the problems with bonding.  Helping parents to engage with their babies in a more regulated, modulated pace without overstimulating the baby and learning how to mirror and engage with their baby in a mutually satisfying way created a space for both parent and child.  The tactile defensiveness that we had observed magically improved by working on the relationship between parent and child.  These are some of the things that I observed and that have influenced the way that I work with children and their families.  There is a very strong link between emotion regulation and sensory processing.  

SN: With over 40 year’s experience of working with children, adolescents, adults, and their families – what have been your key take home points from working with these populations? 

Georgia DeGangi: It is very important to keep your eyes wide open, curious, and thoughtful about who this child or person is, what makes them tick, what they like in this world, and how to connect with them so that they can blossom and heal their own problems.  If we can help the child, person, and parent-child dyad to understand themselves in rich and enduring ways, they become their own therapist, able to recognize their own needs and how to address them.  It is very important to work relationally with the client, but also to balance that with strategies that they learn to apply to their own life.  

SN: You have conducted research focused on the early regulatory problems in young children and their impact on the developing child. Can you tell us more about this and what we should be looking out for as clinicians working in early intervention in particular? 

Georgia DeGangi: Problems of self-regulation impact the foundation of self-calming, state regulation, sleep, feeding, sensory processing, attention, and mood stability.  Our research on young children with regulatory disorders speaks to the importance of addressing these foundation skills so that the child can build a secure base of attachment to others, emotion regulation, and developmental competence and learning.  An early intervention program should focus on these foundation skills of self-regulation regardless of the age of the client. We modify the techniques and strategies for the age and level of functioning for the client, but keep our focus on improving self-regulatory capacities. This will provide a strong backbone as we work on higher level skills. 

SN: It is very important for clinicians to recognize the symptoms of young children with regulatory disorders. What determines a comprehensive assessment in this area? 

Georgia DeGangi: A comprehensive assessment should include a combination of observational scales that examine sensory processing, play skills, and attachment behaviors, a comprehensive interview with the caregivers to learn about the child’s behaviors at home, school, and in the community, as well as systematic checklists that examine regulatory capacities, sensory processing, attention, communication, and developmental competence.  In my recent book on Pediatric Disorders of Regulation in Affect and Behavior (Revised edition), I describe a number of scales that can be used for each of these, including interview questions, symptom checklists, and observational scales.  

SN: We know that early problems with self-regulation impact later development of a child – what aspects of early intervention and treatment should be targeted in order to influence this? 

Georgia DeGangi: An integrated treatment program focusing on self-regulatory capacities should address functional behaviors in everyday life (i.e., sleep, feeding, self-calming, etc.), how play interactions, attachment, and social behaviors are impacted by poor self-regulation, and sensory processing skills, attentional focus and behavioral control in a range of activities (i.e., motor, social, cognitive, language, and everyday sequences).  Considering that most of us have limited resources and time to address all of these areas, a combination of parent guidance sessions to help the child in the home environment, direct treatment with the child whether in naturalistic settings that may include the clinic, the classroom, or at home, and consultation with day care providers and teachers can often work as a model of care. 

SN: The criteria for children with moderate to severe regulatory disorders are ones that experience at least three of the following symptoms: poor self-calming with high irritability, sleep problems, feeding problems, inattention, mood regulation problems, and sensory processing problems. What can help to decipher what is sensory or what may be behaviour here or can it be as simple as this?  

Georgia DeGangi: Aha!  The million dollar question!  We often ponder what is sensory and what is behavior, but there seems to be a co-directional influence of one with the other. A population with whom I have worked that have taught me a lot on this topic are the post-institutionalized children adopted from Eastern Bloc countries.  These children suffered from emotional and sensory deprivation in the first few years of life and even after adapting to a loving, enriched adoptive family, they continue to show extraordinary sensory and emotional problems over time.  There are videos that show how these children were required to sit dutifully, waiting for their turn to use a plastic sliding board, a simple toy or piece of equipment that might be available in the impoverished environment of their orphanage.  One girl whom I treated who was adopted from Romania had her hands tied down when she ate or slept in the orphanage, and when adopted would only eat in a dark closet.  A boy with whom I worked with for many years built dark cave forts all over his adopted family’s house and needed to retreat in them constantly.  He did the same thing in my therapy room, then would go into his fort, make terrifying sounds like he was being attacked by a bear, then would come out to tell me never to go in there with him, that it was too dangerous.   He felt that he had to bear his distress alone.  There are many stories of what these children experienced. In the instance of these children, they suffered from both sensory and emotional deprivation.  In other instances, it may appear more straightforward.  A fussy baby may scream and arch when held by his caregiver.  The parents soon find that the best way to calm their screaming child is to put him in an infant swing for long periods of time and avoid touching him.  As he grows up, this child remains severely tactually defensive and learns to navigate his school environment by striking out at any peer who comes within three feet of him.  Soon he is known as the “bad boy” who hits.  Or in the instance of a socially inhibited child with gravitational insecurity.  She is terrified of swings and slides and the fast moving children on the playground.  Soon she learns to avoid all children and playground equipment, becoming a social outcast.  When the child comes from a multi-problem family environment, the sensory disturbances may be secondary to emotional abuse and neglect.  When a child fears that he will be hit or slapped by his caregivers,  he soon learns to withdraw from others or the opposite adaptation—to yell, hit, and boss other children, avoiding any friendly contact with them.  When the teacher places a reassuring hand on his shoulder, he screams and pushes her away.  So what do we do as therapists?  It is helpful to address symptoms by providing the child with good sensory grounding, decreasing aversive sensory experiences in the environment, and finding sensory regulating experiences and emotionally satisfying relationships.  We also need to help the child’s behaviors to become more adaptive, and pro-social while fostering fulfilling attachments.  Approaches should be modified for the family environment, working at a the level that is most helpful to caregivers while taking into account what they are willing and able to do.  It is not a one size fits all model.  In our research, we found that when we provided child-centred therapies that focused on both the child’s sensory and behavioral skills within the context of the parent-child relationship, we found extraordinary progress on many fronts—sensory, developmental, behavioral, and emotional dimensions.  When we focused only on functional skills and more prescriptive activities directed at improving sleep, eating, play, communication, or motor competence, those skills improved but only in the areas directly addressed in treatment.  Ultimately a combination of both structured and child-centred interactive therapy is the way to go to help the child’s behaviors, emotional control, self-regulation, and sensory processing abilities. 

SN: Can you discuss the validity of the different types of regulatory disorders proposed by the Diagnostic Classification: 0-3 system and how this is used in practice? Is there an update on research being conducted with this system?

Georgia DeGangi: When the Zero-to-Three diagnostic classification system developed their proposal of the types of regulatory disorders, they were empirical but had not been validated on clinical populations.  The three types included hypersensitive type: fearful and cautious or negative and defiant; under-reactive type; and motorically disorganized type.  Our sample of children with regulatory disorders seemed to indicate that the hypersensitive type is most common as well as the motorically disorganized.  We observed the under-reactive type more frequently in children who were in the pervasive developmentally delayed or autistic spectrum groups.  As far as I know, there is no other research on these types of regulatory disorders on other clinical samples.  This would be a great study for somebody to conduct!

SN: Hypersensitivity or over reactivity can be easier to identify and can get more traction than children who may be presenting as under-reactive. Do you feel we know enough about the under-reactive individual? 

Georgia DeGangi: The under-reactive individual is common in children who are withdrawn, difficult to engage, or self-absorbed.  Children with this pattern may engage in repetitive sensory behaviors and may be underreactive to sensory stimuli. For instance, one child I worked with could fall down a flight of steps or fall off a high retaining wall and not react with pain.  When other children accidentally ran into him on the playground, he never reacted.  Some children with this pattern of under-reactivity have global developmental delays as was the child I treated.  We might also see this pattern in children who are severely depressed, usually brought on by neglect, trauma, or abuse.  

SN: Anxiety in particular can be linked to sensory processing difficulties – it is often referred to as the chicken and the egg scenario. Does one cause the other? 

Georgia: Yes—one begets the other!  A person is terrified of heights, fearful of falling, and frightened of fast moving physical activities like riding a bicycle down a windy hill.  This creates a high degree of anxiety in the person just thinking about these activities.  They avoid them and restrict their activities with friends as a result of this fear of movement.  Another person has extreme social anxiety, avoids talking to anybody, and withdraws from any group gathering.  As a result, she restricts her life in such ways that she avoids tactile contact and close proximity with peers.  Because her tactile system is never stimulated through typical physical contact in social games, she becomes tactually sensitive.  This is not to say that all people with sensory processing difficulties have anxiety and vice versa, but there is a common overlap.  

SN: Your book “Pediatric Disorders of Regulation in Affect and Behavior: A Therapist's Guide to Assessment and Treatment” is for mental health professionals working with children experiencing disorders of self-regulation. What was your main aim behind writing this practical skills based treatment book? 

Georgia DeGangi: I hoped to help educate mental health professionals in the dynamic interaction between sensory processing, self-regulatory, and social-emotional difficulties. Many emotional problems such as mood disorder often have underlying problems with sensory processing and self-regulation. When we treat only the symptoms of the emotional disorder without understanding some of the core problems, we miss the boat.  I also hoped that this book would be helpful to occupational and physical therapists, early interventionists, and speech and language therapists who work with these children to understand how difficulties in self-regulation interface with emotional difficulties.

SN:  You have written about the “The Sensory Defensive Adult”. Many of our readers are working everyday with this population. Several cases depict integrating sensory integrative treatment strategies with psychotherapy. Tell us more how these can complement one another. Have you any advice for those working in settings where this is not yet a fluid process? 

Georgia DeGangi: Helping the sensory defensive adult understand their own constitutional makeup is life-changing.  If they can learn to approach their work lives, social interactions, and everyday routines with an understanding of what triggers them from a sensory standpoint, they can be more pro-active in living a happier life.  For some individuals, this may mean modifying aversive situations to feel safer, to seek activities that are both organizing and satisfying, and to learn how to signal family members or spouses that they are being triggered by a sensory event or interaction.  In a psychotherapy session, the therapist can help the client observe and understand what these reactions are and the interface between sensory and emotional reactions.  A woman longs for a life partner but is so tactually defensive that she can’t tolerate even a hug from another person.  She goes through her adult years lonely and depressed.  A father is triggered by the loud bustling sounds of his household, and is especially upset with the little crying baby.  He avoids his family, marital problems develop, and he ends up leaving the family.  These are sad scenarios that can be addressed therapeutically.  

SN: Use of environmental modifications to modulate the sensory systems for adolescents and adults is an important consideration. This is where our consultancy and education skills of those around the individual come to life – would you agree? Are environmental modifications a key treatment technique for this population? 

Georgia DeGangi: Yes!  It is very important to help the adolescent and adult to understand how to organize their life and their environment in ways that it is regulating for them.  This can be extended as well to how the entire family functions.  For example, meal preparation and eating together is an ideal time to work on organizing routines, social interactions, and sensory regulation.  Some families may eat at the kitchen counter at haphazard times, never gathering together for a family mealtime, or if they do eat together, they are glued to electronic devices and avoid conversation.  The parents or older children may leave the kitchen in total chaos with dirty dishes stacked and everything out on the countertop, making it extraordinarily chaotic and visually disorganizing.  By helping families develop a method of coming together in an organized way at mealtimes, creating a soothing and sensory appealing dining experience, and facilitating conversations, the entire family benefits.  Helping individuals and their families with these kinds of everyday routines can be very profound in changing the entire family system as well as the individuals within it. 

SN: Regulatory disorders are becoming more recognised within mental health practice – what changes in practice have you seen in recent years to reflect this and what changes do you feel are still necessary? 

Georgia DeGangi: Many child and adolescent psychotherapists are recognizing the interaction of problems of self-regulation and emotional/attachment disorders. Dialectical behavioral therapy is one of the most popular psychotherapy techniques that recognizes how sensory techniques can help alter states of mind and emotional dysregulation. For example, a teenage girl might self-harm  when she is emotionally distraught and having suicidal thoughts. Her therapist teaches her to take an ice cube and hold it on her forearms, to still her mind by deep breathes and listening to soothing music. Once she feels more self-regulated, she writes down in her journal 3 things that she will do to make it a better day.  There are many good books on DBT that describe these techniques.  In my book on The Dysregulated Adult, I blend DBT techniques with sensory integration and other dynamic psychotherapy techniques to address common problems seen in this population.  

SN: How has the field of sensory integration progressed within the area of regulatory disorders? 

Georgia DeGangi: I think that we now have a very good understanding of how problems of self-regulation are mutually related to different types of sensory integration disorders.  Our treatments now are much more integrated – addressing both sensory integration and emotional development in highly dynamic ways.  Not only are we thinking about sensory integration and how it impacts developmental skills such as motor planning, attentional focus, and communication, but we consider how it affects attachment behaviors, relationships with peers and caregivers, responses to stressful situations, and adaptability in a range of life experiences. 

SN: Research into regulatory disorders is complex – how do you see this field evolving and progressing over time. What do feel is needed from a research perspective within this field now? 

Georgia DeGangi: It would be wonderful if we had funding for large-scale studies to study how early symptoms of poor self-regulation impact learning and behaviors in the school-aged years, and diagnostic outcome.  Intervention studies that compare and contrast sensory integration, developmental guidance, psychodynamic therapies and an integrated SI/psychodynamic model would be very useful.  We also need to evaluate the impact of different models of therapy—e.g., consultation to teachers and caregivers versus direct intervention in the home, classroom or clinic.  Unfortunately, these kinds of studies are extremely expensive and labour intensive, but school districts and early intervention programs may be able to institute data collection as part of their usual protocol of care to accomplish such studies. 

SN: Tell us about what you are involved with currently in relation to your teaching, supervising and consultation.  

Georgia DeGangi: Two years ago I retired from my clinical practice at Integrated Therapy Services in Kensington, Maryland. I am involved as the scientific meeting chairperson for the Vermont Association for Psychoanalytic Studies and am currently working on a book of psychotherapy vignettes that focuses on challenging clinical moments and what I as the therapist am thinking, the clinical decisions I make in the moment, and how both my client and I respond.  I am hoping that the book will be finished in another year’s time. I think of my dear friends and colleagues in Ireland and the UK and wish all of you the very best. I have such fond memories of my visits to your countries and the wonderful colleagues that I met in those trips.  

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