Sensory Over-Responsivity, Psychopathology, and Family Impairment in School-Aged Children

Abstract

To establish the diagnostic validity of sensory overresponsivity (SOR), there is a need to document rates of SOR and the co-occurrence of SOR with other psychiatric disorders. Although this was not a diagnostic study of SOR, this study was designed to investigate rates of elevated SOR symptoms and associations between elevated SOR symptoms, psychiatric disorder status, and family impairment.
From a larger birth cohort followed from infancy to school age, 338 children aged 7 to 10 years (51% boys, 49% girls) and their parents participated in an intensive assessment. Parents were interviewed with the Diagnostic Interview Schedule for Children (DISC) and completed the SensOR inventory and the Family Life Impairment Scale.
Approximately one-fifth (21.2%) of children had elevated SOR symptoms. One-fourth (24.3%) of those with an elevated SOR score met criteria for a DSM-IV diagnosis, and 25.4% of children with a DSM-IV diagnosis had an elevated SOR score. Parents of children with elevated SOR alone reported a similar number of restrictions in family life as parents of those with an internalizing and/or externalizing diagnosis. SOR predicted concurrent family impairment above and beyond DSM diagnostic status and socio-demographic risk.
Elevated SOR occurs in the absence of other psychiatric conditions and is associated with impairment in family life. Services for children with comorbid elevated SOR and an externalizing disorder are needed to address the extremely high level of family impairment reported.

Full text

Sensory Over-responsivity, Psychopathology, and Family
Impairment in School-Aged Children
Dr. Alice S. Carter, Ph.D.,
University of Massachusetts Boston
Dr. Ayelet Ben-Sasson, Sc.D., and
Center for the Study of Child Development, University of Haifa
Dr. Margaret J. Briggs-Gowan, Ph.D.
University of Connecticut Health Center
Abstract
Objective—To establish the diagnostic validity of Sensory over-responsivity (SOR) there is a
need to document rates of SOR and the co-occurrence of SOR with other psychiatric disorders.
Although not a diagnostic study of SOR, this study was designed to investigate rates of elevated
SOR symptoms and associations between elevated SOR symptoms, psychiatric disorder status,
and family impairment.
Method—From a larger birth cohort followed from infancy to school-age, 338 children ages 7–10
years (51% boys) and their parents participated in an intensive assessment. Parents were
interviewed with the DISC and completed the SensOR inventory and the Family Life Impairment
Scale.
Results—Approximately one fifth (21.2%) of children evidenced elevated SOR symptoms. One-
fourth (24.3%) of those with an elevated SOR score met criteria for a DSM-IV diagnosis and
25.4% of children with a DSM-IV diagnosis had an elevated SOR score. Parents of children with
SOR alone reported a similar number of restrictions in family life as parents of those with an
internalizing and/or externalizing diagnosis and SOR. SOR predicted concurrent family
impairment above and beyond DSM diagnostic status and socio-demographic risk.
Conclusions—Elevated SOR occurs in the absence of other psychiatric conditions and is
associated with impairment in family life. Services for children with co-morbid elevated SOR and
an externalizing disorder are needed to address the extremely high level of family impairment
reported.
Correspondence to: Alice S. Carter, Ph.D., Department of Psychology, The University of Massachusetts Boston, 100 Morrissey
Boulevard, Boston, MA 02125, Phone: 617-287-6375; FAX: 617-287-6336, alice.carter@umb.edu.
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Disclosure: Drs. Carter, Ben-Sasson, and Briggs-Gowan report no biomedical financial interests or potential conflicts of interest.
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Published in final edited form as:
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. 2011 December ; 50(12): 1210–1219. doi:10.1016/j.jaac.
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Keywords
Sensory Over-responsivity; Psychopathology; Internalizing; Externalizing; Family impairment
Accurate diagnosis of childhood conditions has implications for service eligibility and for
planning interventions that meet child and family needs. Sensory over-responsivity (SOR), is
a condition in which exaggerated or prolonged responses to sensory stimuli interfere with
participation in daily life1, 2. However, criteria for diagnosis and differential diagnosis are
not adequately specified and the validity of the disorder continues to be questioned3. Due to
limited research, SOR has not been considered as a formal diagnosis within the Diagnostic
and Statistical Manual of Mental Disorders4 or International and Statistical Classification of
Diseases and Related Health Problems5 nosological systems. One criterion for determining
that SOR warrants consideration for inclusion as a significant form of psychopathology is
independence from other forms of psychopathology. A second criterion is that the presence
of elevated SOR symptom presentation is impairing to children and families, independent of
other diagnosable disorders. Thus, the goal of this report was to determine whether elevated
SOR would be observed independent of other psychiatric conditions and whether SOR
contributes uniquely to family impairment, independent of the presence of other psychiatric
disorders.
As described by Miller and colleagues1, SOR is characterized by behavioral responses
towards sensory experiences that are exaggerated in intensity, frequency, and/or temporal
features, such as rapid, intense onset and long duration of response. Children with SOR
often show high distress levels and may be easily irritated and distracted by various sensory
stimuli from one or more sensory modality. High SOR scores are stable across early
childhood6. Although evidencing one or two symptoms of SOR (e.g., being bothered by tags
in shirts or having finger or toe nails cut) may be normative in school-aged children, those
with four or more symptoms of SOR appear to be at increased risk for social and emotional
problems7. SOR is conceptualized under the broader category of Sensory Processing
Disorders (SPD) and is considered to reflect an imbalance between sensitivity (i.e.,
identification of novel or changing stimuli) and habituation (i.e., adjusting to familiar or
ongoing stimuli). Supporting the validity of SOR, children with SPD evidence differential
physiological responses than children without SPD8–11 and there is evidence of genetic
heritability of SOR symptoms12, 13.
Clinical models classify SOR into subtypes which capture two different associated
behavioral and coping profiles. Dunn2 classified SOR into two subtypes: (1) an
avoider
subtype
, characterized by responding to overwhelming sensations with withdrawal, defiance,
resistance and taking control over input, and (2)
a sensitive
subtype, characterized by
distress, fear, and distractibility. These sensory subtypes seem to include symptoms from and
are somewhat comparable to distinctions between internalizing and externalizing problems.
Similarly, the Interdisciplinary Council of Developmental and Learning disorders14
described two subtypes of sensory over-responsive children under the age of three years; an
over-responsive fearful and anxious subtype versus an over-responsive, negative and
stubborn subtype. Both clinical classifications define SOR with an associated affective
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profile to account for the different emotional patterns and coping strategies displayed by
those with SOR. There is some preliminary evidence to support these subclassifications15.
Given the linkage to anxious and disruptive behaviors, it is not surprising that there would be
some confusion as to the independence of SOR in relation to other psychopathological
conditions.
Few studies have documented rates of co-occurrence between SOR and other DSM
diagnoses. Gouze and colleagues16 reported that 33–63% (depending on criteria applied) of
4-year-old children who met criteria for a SPD (including but not limited to SOR) also met
criteria for a DSM diagnosis according to parent reports. However, the sample was not
representative and a broader set of sensory problems included. Using continuous measures
of SOR, researchers have reported moderate correlations between SOR symptoms and
scores on internalizing scales (e.g., anxiety) in children with developmental disabilities such
as autism spectrum disorders (ASD)17, 18 and Attention-Deficit Hyperactivity Disorder
(ADHD).19 There also appear to be elevated anxiety symptoms in adults with sensory
defensiveness.20 Moreover, there is evidence for an association between internalizing
symptoms and SOR13 or dysregulation in general21 among non-referred children. In a study
of a representative sample, 28% of children with elevated SOR also showed elevated
internalizing scores which is significantly higher than the expected 10% rate based on the
Infant-Toddler Social and Emotional Assessment (ITSEA) norms13. Further, multiple studies
indicate that infants who are highly reactive to sensations show higher levels of fear and
inhibition at school age22, 23. Thus, SOR appears to be associated with both internalizing
symptoms and psychiatric disorders.
Empirical evidence of an association also exists in the externalizing domain but to a modest
degree. In a study of preschool Latino children there were low-moderate correlations
between parent-based sensory scores and parent reports of externalizing problems, ODD,
and ADHD24. Consistent with this, SOR scores showed modest correlations with
externalizing scores in two population-based samples of children up to 3 years of age13, 21.
In a representative community sample of one and two-year olds, 20.6% of children with
elevated SOR also had elevated externalizing scores on the ITSEA; however this rate did not
differ significantly from the expected ITSEA normative rate of 10% with elevated scores13.
Yet, clinical characterizations suggest that SOR may result in externalizing behaviors, such
as impulsivity and aggression in response to unexpected and overwhelming input1.
Researchers have generally studied associations between SOR and child rather than family
impairment. Children with SOR demonstrate impairments across a variety of daily activities
including self-care and social participation2. Understanding children's impairment through
restrictions in family life activities provides an additional measure of the severity of SOR
impairment. It is also important to recognize that the impact of SOR upon the child and
family is not solely a reflection of the child's symptom severity and coping strategies but
also reflects family resources and the ways in which family members respond to, adapt, and
cope with the child's over-response.
In the current analyses, our measure of family impairment is based on parents attributing
difficulty completing tasks of daily family life to their children’s “
behavior, personality or
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special needs
” (e.g., not being able to take a long car ride or visit with relatives). Previous
research describing an earlier time point for the full sample showed strong relations between
elevated early social-emotional problems and greater family life impairment25 as well as
evidence that family life impairment was a significant predictor of persistent social-
emotional problems26 and help-seeking for social-emotional problems27. Studies of children
with developmental disabilities such as ASD describe SOR as a factor that limits family
participation and contributes to rigidity of routines and to parental stress28, 29. Whether or
not a developmental disability is present, parents of a child with SOR may restrict family
activities (e.g., outings, shopping) to minimize the child's exposure to bothersome,
unpredictable, and overwhelming sensations (e.g., loud sirens, being bumped into gently by
a stranger in a public place, trying on new clothing), and consequently avoid tantrums and
outbursts associated with their child’s negative responses to sensory experiences. Thus we
hypothesized that elevated SOR symptoms would contribute uniquely to family impairment,
even after controlling for symptoms of other psychopathological conditions.
In conclusion, the study goals were to conduct a preliminary investigation of the construct of
SOR by: (1) determining whether children with no other psychopathologies evidence
elevated SOR, and (2) quantifying its unique contribution to family impairment in both
children with and without other significant psychopathology.
Research questions were:
1. What is the rate of co-occurrence between elevated SOR
symptoms and DSM-IV disorder status?
2. Does having elevated SOR symptoms contribute to family
impairment uniquely, above and beyond other DSM-IV
disorders?
3. Do parents of children with elevated SOR (with or without
co-occurring DSM-IV disorders) report greater family
impairment than those with only a DSM-IV diagnosis or
those with neither elevated SOR nor a DSM-IV diagnosis?
Method
Participants
This study is comprised of a subsample of children whose parents provided data on sensory
over-responsivity and DSM-IV disorders when children were in second or third grade.
Children and parents had all participated in a larger longitudinal sample. Details about
sampling and longitudinal response rate and retention are provided in30. As shown in Figure
1, children were initially selected from birth records (N=8,404) provided by the State of
Connecticut Department of Public Health from July 1995 to September 1997. A random
sample of birth records was stratified to have equal representation of girls and boys within 3-
month age groupings between 11 to 35 months of age. Eligible children were born healthy at
Yale New Haven Hospital and lived in the Greater New Haven Standard Metropolitan
Statistical Area of the 1990 Census. Children who were likely to have developmental delays
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due to low birthweight (<2200 grams), prematurity (<36 weeks), low APGAR scores
(defined as both 1 and 5 minute scores below 5), or birth complications (e.g., need for
resuscitation, anoxia, long hospital stay) were excluded and only one child per family was
sampled. A random sample of 1,788 was selected from the 7,433 births meeting these
criteria. Children were excluded after the initial sampling if no parent was able to participate
in English; no biological parent had custody of the child; the family had moved out of state
at the time of the first survey (1998–1999), or eligibility could not be verified. After
exclusions, 1,491 subjects were eligible, of whom, 1,329 participated in one or more of three
early childhood surveys (89.1% response rate).
All participants in the early childhood surveys were followed to school-age. The focus of
this report is on data collected when children were in second or third grade. By the time of
this final wave of data collection, 24 children had been excluded on the basis of significant
genetic disorders, developmental delays, and/or ASD (including autism, Pervasive
Developmental Disorder – Not Otherwise Specified, and Asperger Syndrome), resulting in
an eligible sample of 1,306.
Of the full eligible sample, an intensive assessment subsample, which was enriched for
psychopathology (
n
= 567 following removal of one child lost to custody), was selected for
more in-depth diagnostic interview and direct child assessment [For details please see Carter
et al., 201030]. All children who met the following criteria were eligible (
n
= 434): (1)
Persistent Social-Emotional/Behavioral Problems in Early Childhood
– parent-reported
social-emotional problems on measures completed at both 2 and 3 years-of age; (2)
Social-
Emotional/Behavioral Problems in Early Elementary School
– parent- or teacher-reported
social-emotional/behavioral problems on a standardized checklist or indicated need for
social-emotional/behavior problems services at school age; and (3)
Risk for Language/
Learning Difficulties –
parent reported low language at 3 years of age or in Early
Elementary School or teacher-reported low language on a checklist or significant concern
about the child’s language abilities in Early Elementary School. Language difficulties were
included in these criteria because these have been linked to problem behaviors31. An
additional 134 children who were negative on all of these criteria were also selected.
In this paper we focus on 338 (82% of 413) children whose parents completed the intensive
assessment and completed a school-age SensOR inventory32, a measure added to the school-
age survey after data collection began. This subsample was similar to the full school-age
intensive subsample with respect to poverty status, single parent household, child sex,
maternal education, minority ethnicity and the percentage selected based on meeting
enrichment criteria (Chi-squares ranged from 0.04 to 3.17, p>.05; See Table 1). In this
subsample, children were between 6.9 and 9.6 years of age (
mean
=8.0,
SD
=0.4), 50.6%
were boys, and 64.5% were Caucasian. Informants were between 23.0 to 56.5 years of age
(
mean
=38.7,
SD
=6.5), and 94.0% were biological mothers. Most informants had a partner,
were working, and had an education level greater than high school.
Sampling Weights—Weights were applied in all analyses to adjust for unequal
probabilities of initial selection and retention across the longitudinal study. Information from
birth records concerning sociodemographic background (e.g., parental age and race) and
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birth status (e.g., birth weight and gestational age) were used to calculate sampling weights.
As sociodemographic changes in the retained sample based on loss-to-follow-up are
associated with small effect sizes30 and we are not inflating to the full sample, sampling
weights are associated with small changes in sample sizes.
Measures
Sensory Over-Responsivity inventory (SensOR32)—includes 76 items that describe
sensations that may bother a child. In the present study, 41 items from the auditory and
tactile modalities were included as sensitivities in these modalities are the most frequently
reported3. Parents are asked to check all items that apply to their child. Items are divided
into five lists that assess tactile over-responsivity (garments, activities, experiences, surfaces,
and materials) and three lists that assess auditory over-responsivity (specific sounds,
background noises, and loud places). A total over-responsivity score as well as modality
scores are computed.
This inventory was validated through factor and reliability analyses as well as discriminant
analysis. The sensitivity and specificity of the SensOR inventory in differentiating children
with SOR (
n
=101) from typically developing children (
n
=120) was highest
(sensitivity=69.09, specificity=84.16) when at least four tactile
or
auditory items were
present32. Previously, we reported that the internal consistency for the 41 SensOR items was
good in the full school-age sample (
Cronbach's alpha
=0.74)7. In this report we categorize
children into two groups: those with SensSOR total scores of four tactile
or
auditory
symptoms and those below this threshold.
The Diagnostic Interview Schedule for Children, Version IV33—is a structured
interview that determines DSM-IV child psychiatric disorders. The following disorders were
assessed: Specific Phobia, Social Phobia, Separation Anxiety, Generalized Anxiety,
Agoraphobia with and without Panic, Depression, Dysthymia, Tic Disorders, ADHD,
Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD). The DISC has
acceptable test-retest reliability. Diagnostic status is determined by a set of computerized
symptom algorithms. Impairment is defined as present if interference in functioning
occurred “some of the time” or “a lot of the time” or caused “bad” or “very bad” problems
or feelings in at least one context, including home, school or other context. In this study a
conservative approach was applied by focusing on DISC diagnoses based on moderate level
of impairment in all analyses.
The Family Life Impairment Scale (FLIS34)—assesses the extent to which parents
report that child behavior limits participation in activities typical of families with young
children (e.g., family outings, leaving child with babysitter). Items are rated on a 3-point
scale from
Not true
to
Very true
and begin with “
Because of my child’s behavior, personality
or special needs, we rarely…”.
The FLIS has good internal consistency (
Cronbach’s alpha
=
0.81) with item loadings ranging from 0.33–0.62. Test-retest reliability was 0.70. Support for
the validity of the FLIS comes from evidence that it is associated with persistence of mental
health problems26 and with service-seeking among families of children with behavior
problems27.
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Socioeconomic (SES) Risk Measure—was based on six parent reported demographic
variables: parent education, minority ethnicity, poverty and parent employment status,
single, and teen parenting. The distribution of SES risk scores supported the categorization
of SES risk into: '0' showing no more than 3 risk factors (93.9% of the sample) and '1'
showing above 3 risk factors. We decided to adopt a conservative approach and include SES
as a covariate as it was associated with SOR in the full school-age sample7 and with social-
emotional problems at earlier time points25.
Procedure
The current study describes the fifth assessment time point, with separate parent consent
obtained at each time point. Data collection for this survey, which included the SensSOR,
FLIS, sociodemographic and new diagnostic and services information began in the
2002/2003 academic year and continued through the 2005/2006 academic year with families
first contacted to identify whether or not their children had entered second grade. DISC-IV
interviews were conducted during the intensive subsample visits, which occurred in project
offices or at the family home, depending upon family preference. Parents received $30 for
completing this survey and $100 for participating in the intensive visit.
Results
Research Question 1: Rates of SOR and DSM-IV Diagnosis Co-occurrence
Approximately one fifth of parents (21.2%, n=71) reported that their child was bothered by
at least 4 auditory sensations and/or 4 tactile sensations (the recommended cut-off for the
SensOR). These children with elevated SOR symptoms represented 25.4% of children with
any DSM-IV diagnosis. Similarly, children with DSM-IV diagnoses represented 25.4% of
children with elevated SOR. Examined by diagnostic domain, of children with elevated
SOR, seven met criteria for an Internalizing disorder (10.0%), 13 met criteria for an
externalizing disorder (18.5%) and two children (2.9%) met criteria for all three
classifications (elevated SOR, internalizing and externalizing disorder) (see Table 2).
Research Question 2: SOR Unique Contribution to Family Impairment
A linear regression model showed that having an SOR score above the cutoff contributed
unique variance to family life impairment after controlling for variance associated with
concurrent DISC internalizing and/or externalizing diagnoses, and SES risk (
F
(4, 322)=9.27,
p
<.001) (See Table 3). The full model
R2
(0.11) was translated into a Cohen's d of 0.7; SOR
explained 4% of this variance (Cohen’s d = .4). Meeting criteria for an externalizing
diagnosis significantly (
p
<.001) predicted family life impairment upon entry and in the final
model.
Research Question 3: Family impairment of children with SOR and DSM-IV diagnosis
To further understand the clinical significance of these relations, a follow-up ANCOVA,
controlling for SES risk, was run. Significant differences in mean FLIS scores were
observed across four groups of children: (1) neither elevated SOR nor DSM-IV diagnosis
(
n
=192); (2) elevated SOR only (
n
=47); (3) DSM-IV diagnosis only (
n
=44), and (4) both
elevated SOR and at least one DSM-IV diagnosis (
n
=14) (
F
(4, 296)=6.44,
p
<0.001,
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R2
=0.08) (See Figure 2). Consistent with the results of the regression analysis, SOR
conferred unique risk for family impairment, as Least Significant Difference post-hoc two-
tailed tests revealed that that children with only a DSM-IV diagnosis (
mean
=1.58,
SD
=2.24)
had significantly lower family impairment than those with elevated SOR and a DSM-IV
diagnosis (
mean
=3.09,
SD
=3.18) and that parents of children with SOR only (
mean
=1.85,
SD
=3.76) rated higher family impairment than those with neither condition (
mean
=0.70,
SD
=1.64), who were also lower than the two groups with DSM-IV diagnoses.
Discussion
This study addressed the co-occurrence of elevated SOR symptoms and psychopathology in
school-aged children as well as the unique contribution of elevated SOR symptoms (over
and above DSM disorder status) to family impairment. In our sample there was relatively
limited co-occurrence of elevated SOR and psychiatric disorder status. Specifically,
approximately one fourth of children with elevated SOR also met criteria for a DSM-IV
diagnosis; similarly, approximately one fourth of children meeting criteria for a psychiatric
diagnosis were rated as having elevated SOR. Further, SOR accounted for unique variance in
concurrent family impairment above and beyond that associated with internalizing and
externalizing diagnostic status and SES risk. Examining differences in family impairment
across families with a child with neither elevated SOR nor a DSM-IV diagnosis, elevated
SOR only, a DSM-IV diagnosis only, or both conditions highlights that the presence of
elevated SOR constrains families’ ability to engage in routine daily activities. Parents of
children with elevated SOR without a DSM-IV diagnosis reported higher levels of family
impairment than parents of children with neither of these conditions and these rates were
comparable to those of families with a child with a DSM-IV diagnosis only. Moreover,
parents of children with both elevated SOR and a DSM-IV diagnosis reported greater family
impairment than those with a child with only a DSM-IV diagnosis.
The relatively low co-occurrence (25.4%) of SOR and psychopathology lends support to the
notion that SOR is a distinct entity. This rate is somewhat lower than the co-occurrence of
SPD and DSM-IV disorder status reported in a 4-year-old sample of referred children (33%–
63% depending on impairment criteria)16, but Gouze and colleagues did not focus
exclusively on SOR, including a broader range of sensory problems and disorders and
different ascertainment may have also influenced observed rates. Given that SOR is the most
prevalent sensory disorder3, it would be expected to account for most of the co-occurrence.
A significant limitation of the present estimate of co-occurrence is that the SOR criteria
employed were based on a checklist assessment rather than on a clinical diagnosis that
included direct observation. In addition, although the most prevalent3 it is also possible that
limiting inquiry to tactile and auditory sensitivities reduced SOR rates in this study. In
contrast, DSM-IV diagnoses were assigned following a structured diagnostic interview that
required a moderate to severe level of child impairment. There is a need to replicate and
corroborate these findings using a clinical assessment of SOR and multi-informant ratings of
symptoms and impairment. Moreover, the development of clear criteria, (that specify a
clinical threshold), for assigning a diagnosis of SOR will greatly facilitate research in this
area as currently there is no gold standard method for determining a diagnosis of SOR15.
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The majority of children with SOR did not meet criteria for any DSM-IV diagnosis (74.6%).
Of those with both elevated SOR and a DSM-IV disorder, the majority appeared to adopt
either an internalizing (39% met criteria for an internalizing disorder) or externalizing (72%
met criteria for an externalizing disorder) behavioral style; the mixed style was rare (11% of
those with both elevated SOR and a disorder were comorbid across internalizing and
externalizing, which represents 2.9% of those with SOR). Independent of SOR, the
prevalence of having both internalizing and externalizing disorders has been observed to be
low in this community sample (3.5 %)30. It is possible that some children who did not meet
criteria for a disorder evidence sub-threshold internalizing or externalizing symptoms and
are at higher risk for later diagnosis. It is also possible that our requirement of impairment
for DSM-IV disorders and studying a representative community sample reduced
comorbidities. To date, most of the evidence of an association between SOR and
psychopathological disorders has been derived from correlations between continuous
measures of these constructs in the general population13, 21 or studies of individuals with
developmental disabilities18. Given the higher likelihood of a dual diagnosis for children
with developmental disabilities and the exclusion of children with developmental disabilities
including ASD from this sample, rates reported likely represent an underestimate of the co-
occurrence of these conditions.
To our knowledge, this is the first attempt to examine categorical co-occurrence in a
nonreferred sample at risk for psychopathology. Children with SOR may develop
maladaptive emotional and behavioral patterns as a result of their ongoing alertness towards
and avoidance of sensation. Alternatively, the presence of psychopathology may heighten
risk for SOR among children with baseline vulnerability for SOR35. Longitudinal research is
needed to determine whether specific trajectories of SOR in early childhood are associated
with increased rates of psychopathology and/or whether co-occurrence of elevated SOR and
psychopathology in school-age predicts persistence of psychopathology to adolescence as
shown in younger ages26.
This study also demonstrates that SOR confers unique risk for family impairment over and
above that associated with internalizing and externalizing psychopathology and
sociodemographic factors. Families raising children with elevated SOR symptoms reported
greater restrictions in their social (e.g., rarely take the child to visit friends or family, we
rarely leave the child with relatives) and personal (e.g., I am usually exhausted all day, we
rarely make changes in daily schedule) lives. These restrictions may reflect efforts to
minimize the child's distress, fear, and withdrawal, and/or to increase the child’s need for
control in presence of bothering sensations that parents reported as distressing for their
children36. Consistent with prior work37, the presence of an externalizing disorder was
associated with interference in family life activities. Moreover, findings indicated that
behavior problems such as aggression, non-compliance, and high activity level pose
restrictions to family activities that are independent of those posed by SOR.
Primary findings provide support for consideration of SOR as an independent clinical entity:
(1) elevated SOR appears to be a distinct condition with relatively low co-occurrence with
DSM-IV conditions; and (2) SOR was associated with increased family burden, independent
of DSM-IV disorder status, an index of the impairing nature of this condition. There is a
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need to replicate and extend this work using direct clinical assessments of SOR as well as
multi-informant reporting of symptoms of DSM-IV psychopathology, SOR and family
impairment. Moreover, future studies should include neuro-cognitive and neuro-anatomical
assessments, as it has been recently argued that processes such as selective attention,
inhibition, and sensory gating may be implicated in SOR38.
This study underscores the need for being cognizant of the heightened family impairment
associated with raising children with elevated SOR as a child's aversive reaction to daily
activities and need to control incoming inputs may lead parents to restrict their family
routines in a manner that over time may diminish the quality of family life36. Although only
25% of children with internalizing and/or externalizing disorders evidenced elevated SOR,
assessment of SOR in this clinically significant subgroup could lead to more tailored and
effective intervention efforts. Historically, occupational therapists have identified, diagnosed
and treated individuals with SOR1. As the identification of SOR as a clinical entity may be
new to many mental health clinicians, establishing inter-disciplinary teams with
occupational therapy expertise may aid in differential diagnosis. Reciprocally, occupational
therapists need to be aware of the potential for co-occurring psychopathology among
children with SOR. Evidence of increased family burden supports the need for greater
understanding of the role of SOR in maintaining and exacerbating child psychopathology.
Acknowledgments
Support for this research came from grants to the first author from the National Institute of Mental Health
(R01MH55278) and the Wallace Foundation.
We also wish to thank all of the children and families who participated in the Connecticut Early Development
Project.
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Figure 1.
Flowchart of Intensive Sample and
Sensory Over-Responsivity Inventory
(SOR)
Recruitment and Retention.
Note: SG = Second-Third Grade.
aIncludes all early childhood participants, including those lost to follow-up by school-age;
bThis represented 20% of 670 negatives who participated in the school surveys.
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Figure 2.
Mean Family Life Impairment Scale (FLIS) Scores across Sensory Over-responsivity (SOR)
and DSM-IV Diagnosis Status
Note: Weighted subgroup sizes are presented along with weighted raw means.
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Table 1
Sociodemographic Characteristics
School-age Sample (N=413) Intensive Subsample (N=338)
Sociodemographics Unweighted Weighted Unweighted Weighted
N % % N % %
Boys 208 50.4 48.7 171 50.6 49.7
Girls 205 49.6 51.3 167 49.4 50.3
Marital Status
Single parent household 100 24.4 22.5 76 22.6 20.3
Poverty Status
Non-poor 265 66.6 70.2 217 66.8 71.8
Borderline poverty 60 15.1 12.5 50 15.4 11.5
Poverty 73 18.3 17.3 58 17.9 16.7
Parental Education
Maternal education <=HS 98 24.6 23.9 76 23.3 22.2
Paternal education <=HS 87 30.0 27.5 69 27.7 25.7
Race/ethnicity
Non-minority 260 63.0 67.0 218 64.5 67.6
Minority 153 37.0 33.1 120 35.5 32.4
Note: Sample of children who participated in the home visit was comparable to the subsample that had Sensory Over-responsivity Inventory scores. HS = High school or General Education Development
completion.
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Table 2
Rates of Diagnostic Interview Schedule for Children, Version IV (DISC) diagnoses by Sensory Over-
responsivity (SOR) status
Weighted
% (N) Non-Weighted
% (N)
SOR (n=71) aNo SOR
(n=262) SOR (n=75) No SOR
(n=263)
Any DISC diagnosis:
Yes 25.4% (18) 74.6% (53) 36.0% (27) 26.6% (70)
No 20.2% (53) 79.8% (209) 64.0% (48) 73.4% (193)
DISC Internalizing
diagnosis:
Yes 10.0% (7
b
)90% (63) 16.2% (12) 11.8% (31)
No 9.2% (24) 90.8% (238) 83.8% (62) 88.2% (232)
DISC Externalizing
diagnosis:
Yes 18.6% (13
b
)81.4% (57) 25.7% (19) 19.4% (51)
No 13.7% (36) 86.3% (226) 74.3% (55) 80.6% (212)
Note: SOR grouping was based on Miller's cutoff of at least four bothering auditory or tactile sensations. DISC diagnoses are defined by moderate
impairment criteria.
a
There is one missing child in the Internalizing and Externalizing diagnosis comparison.
b
Two of these children also qualified for an Internalizing diagnosis.
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Table 3
Linear Regression Model Predicting the Family Life Impairment Scale (FLIS) from Sensory Over-responsivity
(SOR) status, controlling for DSM Disorders and Socioeconomic Status (SES).
Steps
β
upon entry
(SE)
β
in final model ΔR2Cohen's d
1. DSM Disorders 0.05 0.5
Internalizing −0.07 −0.04
Externalizing 1.53
**
1.46
**
2. SES −0.19 −0.14 0.01 0.2
3. SOR 1.23
**
1.23
**
0.04 0.4
Total R20.11 0.7
Model F-Value 9.53
**
Note:
** p
<.001.
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