Interoception

When I went on Sensory Integration training (admittedly about ten years ago) we were taught that there are seven senses: all the ones you usually think of (taste, touch, sight, smell, hearing) plus proprioception and the vestibular system.

Proprioception is the sense of knowing where your body is in space and is stimulated by things like deep pressure, heavy work and vibration.

The vestibular system is in your inner ear and is the sense that helps you battle gravity. It is stimulated by movement, especially spinning or being upside down, and is the sense that causes travel sickness. If anybody has experienced Labyrinthitis they will have experienced their vestibular system on overdrive! Grizzly had it so badly that he literally didn’t know whether he was the right way up or not and couldn’t get out bed for several weeks or even move his head.

I think about Sensory Integration (SI) quite a lot when it comes to Little Bear and I’ve previously written about it a little in Too fast, too hard, too loud. The basic premise of SI is that everybody has a sensory system and we are integrating sensory stimulation all of the time. Everybody’s system is different and what we can cope with/ what we need in terms of sensory stimulation in order to be comfortable in our bodies will differ too. Little Bear certainly seeks proprioceptive and vestibular input which has led to us having a free standing pull up bar in the playroom so he can climb and hang as he needs, instead of seeking similar input in a more dangerous fashion (like clipping his belt loop to the bed and hanging from there. Full marks for ingenuity but a little too dangerous for my liking).

However, a couple of articles have caught my eye recently which have suggested my SI knowledge is a bit out of date. Current thinking is that there are in fact 8 senses: all the ones I mentioned plus something called Interoception. I have done some digging to figure out what it is and why it might be important for our children and thought it may be useful to share.

Interoception is a bit like proprioception but from the inside. It is the sense of knowing how things are within our bodies. It includes things like being aware of our heart beat and whether it has sped up or slowed down; being aware of our digestive system – are we hungry/are we full/do we feel sick; is our temperature ok – are we too cold or too hot; awareness of blood sugar – are we getting shaky and a bit low on fuel; awareness of our bowel and bladder – are they full/ do they need emptying; do we have pain anywhere.

I’m imagining it like there is a telephone system between our internal organs and our brain. The lines of communication need to be kept open so that if our heart is beating faster, it can “ring” the brain which can then take measures either to ignore that or suggest for you to sit down and rest for a bit. Or you might have a full bladder. The bladder would call and tell the brain to make you aware you needed a wee and you would go to the toilet. It’s all good and very effective when working properly but there are lots of things that can get in the way.

Studies of infants have suggested that interoception develops very early, perhaps in the first few months of life and might be stimulated by things such as their parent stroking their cheek or rubbing their back – which are pleasant sensations that might ease internal states. One study showed that being stroked on the face led to a decrease in heart rate in 9 month olds. I read something else which stated that infants “associate interoceptive signals of warmth and satiety with their caregiver’s face, which in turn drives attachment behaviour”.

From the limited evidence, you can see that a child who has been neglected (hasn’t received physical comfort) or who has had multiple caregivers (seen many carers faces), might not develop typical interoceptive skills. There is already evidence to say that children who have suffered physical abuse grow up to have altered pain sensations. One article I read suggested that investigating the impact of adverse childhood experiences on interoception is a big area which requires loads more research.

Even if we don’t fully understand all the reasons why a child may end up with a faulty interoception system, we do know that they can and that they may be under-responsive, over-responsive or seeking of interoceptive input. Being over-reactive to bodily signals such as heart rate, butterflies and muscle tension has been associated with anxiety and depression. I suppose that is the equivalent in my analogy of the brain being phoned constantly for every internal twinge or tickle instead of just for the big ones.

Being seeking or under-responsive to feelings of a full tummy has been linked to eating disorders. In this example the brain isn’t getting the call when the tummy is full or the brain starts to panic when there aren’t calls so stimulates the body to continue eating. Something about the feeling of fullness is desirable. I think the converse could also happen – being empty being the more desirable feeling.

If children struggle with interoception, they can find it difficult to know whether it is something inside or outside of them that is causing discomfort, leading to dysregulation or an unusual response. I think hunger is a really good example as Little Bear definitely struggles to identify when he’s hungry (hangry!) and will tend to get irritable and aggressive with anything and everything rather than identifying his tummy is empty and that he needs to eat.

Some researchers think that interoception could underpin many psychopathologies and could be a lot more crucial than we yet realise. One thing they do agree on is that being able to recognise and respond to your internal states (interoceptive feedback) is a crucial skill for recognising your own emotions, learning and good decision-making. Poor interoception tends to be linked to risk-taking behaviours such as drug-taking, promiscuity and alcohol abuse in later life. Could this be because these things tend to heighten sensation, giving the brain the feedback it needs but doesn’t usually get?

As emotions such as anger, nervousness, and excitement have a physical impact on the body, as well a neurological one, we can see how interoception also has an involvement with our emotional development. In fact interoception is crucial in helping us to identify which emotions we are feeling from the signals our bodies are giving us.

It turns out that interoception is a much more complex and wide-ranging sense than you would initially think.

So what about Little Bear? What I have learned that is of use to him?

Well, according to SPD Star “it’s only when all of the other senses are regulated and in check that our body is quiet enough to listen to what those internal signals are telling our brain”. In other words, most children who experience SI challenges are likely to experience some interoceptive differences and they won’t be resolved until their other sensory needs are being met. Let’s hope that hanging bar is doing its job then.

I have identified that when it comes to the interoceptive sense, Little Bear is under-reactive. I have already mentioned that he would neglect to eat without adult support but perhaps the biggest thing I’ve learned is that he is probably under-reactive in the bowel/bladder department too. I have talked about his Continence Issues previously but this information shines a new light on them. It seems very likely that the phone line between Little Bear’s bowel/ bladder and brain is a bit faulty. When the bowel/bladder start to fill up, the message does not immediately get passed to his brain. It is only when they are full to capacity and the red warning light should be going off that Little Bear’s brain gets the signal to tell him to go to the loo. By that stage he often needs to run and sometimes he inevitably doesn’t make it. The theory certainly fits with the behaviour we observe.

I like this as a way of explaining why he’s not consistently dry, it makes sense. As with most aspects of SI it also means there is hope and that with the right approach he should be able to make progress.

I have found it more difficult to find specific advice about how exactly to work on interoception, other than to speak to an OT or get a sensory diet written. However, what I have gleaned is that you basically want to get the brain more tuned into the signals from the organs/ muscles and Mindfulness is mentioned quite a bit in the literature. I guess that makes sense – quietening everything down so that you can hear the internal whispers that you would otherwise miss. Once you are more tuned into those signals, your brain should get better at listening out for them.

Some of the things we already do at home seem to be appropriate for improving this sense. Things like when Little Bear is hungry, I will draw his attention to the rumbling sounds from his tummy and explain what they mean. Sometimes he will say he has tummy ache and I’ll know from the coincident hyperactivity that he needs the toilet. Since reading about interoception I am getting more conscious of not just herding him to the loo but trying to encourage him to feel that tummy ache and identifying it as the feeling of needing the toilet and explaining that when you feel that sensation, you know you need the loo. This sort of cause and effect doesn’t always come naturally to our children anyway and sometimes they do need us to state things that seem obvious to us (it isn’t obvious to them otherwise they would be able to act on the sensations).

Apparently regularly prompting a child to go to the loo helps them to get used to the sensation of an empty bladder and to experience the contrast with a full bladder which should help to develop their interoception over time. Using technology such as vibrating watches is a helpful way of keeping on top of their interoceptive challenges a bit more independently, as well as teaching them strategies such as going to the toilet during every break whether they think they need it or not.

As with most things adoption related, this isn’t a quick fix. It takes time and getting other sensory needs under control first.

I can see improvements in Little Bear’s interoception system though. He was certainly under-responsive to pain when we first met him and though he still has a high pain threshold (a few more than average phone calls from the injured area to the brain before a response happens) he does now respond to knocks and bumps in a much more typical way. He will cry and come for a rub where previously he could have banged his head on a solid object and not even broken step or let out a yelp. The toileting and hunger issues have improved too, but in a stepwise fashion, where we still have some steps to go.

Interestingly, while being hyper-aware of your own heart rate can go hand in hand with anxiety, some children enjoy the sensation of a heavily beating heart and actively seek this – driving them to exercise – and consequently they become very fit. I’m not sure if this applies to Little Bear but I’m not sure that it doesn’t either as he certainly likes running about/ bouncing/ hanging etc. and is developing into an impressive sportsman.

As with most differences, a differently developed interoception system brings its challenges but also its unexpected silver linings.

 

 

*If you want to know more about interoception, this is a particularly comprehensive article:

https://www.sciencedirect.com/science/article/pii/S187892931630127X

 

**This blog is based on my own reading. If you think I’ve missed something or not quite explained something properly please let me know.

 

 

 

 

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Our Just-Right Challenge

The term ‘just-right challenge’ was first coined by well-known Occupational Therapist (OT) Jean Ayres. She was referring to finding activities for children that are neither too easy nor too hard. The secret, she said, was pitching a task just above their current level of functioning – so that it was definitely attainable but not so difficult that they would experience frustration and not so easy that they wouldn’t develop any new skills. I think it’s a concept well-known and used within the field of OT.

The just-right challenge is like the sweet spot of learning, when you pitch something just perfectly and you can see your child grasping a concept right before your eyes. The just-right challenge is essential for developing confidence and turning the I’m Stupid feelings on their head. It’s a crucial, yet largely underrated skill in any parent, teacher or therapist.

The idea first came to my attention when I attended a Sensory Integration training course, an approach also derived by Ayres, several years ago. Despite practising it all the time without actively labelling what I’m doing, the term just popped into my head the other day, probably because we have been having some issues with finding the just-right challenge for Little Bear.

Little Bear attends swimming lessons every Saturday and has been doing very well, so well in fact that his teacher said he was ready to move up to the next group. Little Bear seemed pleased with himself and I took him along the following week. I popped back to the pool a few minutes before the end to wait for Little Bear with his towel. When I got there I was shocked to see he was crying. “What’s the matter?” I asked the instructor who was closer to me than he was. “He’s just cold” she said.

Well that didn’t stack up because Little Bear is one of the toughest children I’ve ever met, he’s practically a Marine, he doesn’t cry because he’s cold.

Little Bear’s lesson is now at the deep end of the pool and he, along with the other children, was standing along the furthest edge, preparing to jump in. I noticed that Little Bear was about a foot smaller than the other children who appeared about 8 or 9 years old. Little Bear looked extremely uncertain but did jump in. He swam straight to the edge, got out, came to me and dissolved into a crying wreck. It just wasn’t like him. What on earth was wrong?

After a lot of cuddling and drying Little Bear managed to tell me that it was too deep and he was scared. I said I would speak to his instructor as I could already foresee a problem with next week’s session. I went back into her, wondering if he’d accidentally gone into the wrong group. No, she said, he was absolutely fine, he could keep up with the lesson. He was fine; he’d be fine next week. She said ‘fine’ a lot. I don’t find ‘fine’ particularly reassuring.

The following day Grizzly took both Bears for a fun swim, thinking it would boost Little Bear’s confidence. They had fun, they dived in, and it was all good. It was fine.

When the next swimming lesson rolled around I was careful to keep an upbeat approach. It was working until we got to the front door of the pool building when Little Bear began crying and wouldn’t go in. He didn’t have to do the jumping in bit if he didn’t want to I reassured, I would come back early for him. Anyway, the long and short of it was that when we entered the pool area Little Bear was crying and gripping on to me for dear life. This is not like him: he usually skips in on his own. The new instructor, who I was quickly growing annoyed with, told him to get in, he’d be fine: cue more crying and clinging to me. The instructor continued to teach the other children and made no move to come to Little Bear, reassure him or anything else remotely useful.

Thankfully, Little Bear’s previous instructor, who was teaching a class in the middle section of the pool, noticed what was happening and asked if he would like to re-join her group. “Sometimes the jump to the next group is too much,” she said, “don’t worry about it, he can come with me”. I thought Little Bear would have been relieved (I certainly was) and would have hopped straight back in. He didn’t though, continuing to cry and hold onto to me. He managed to tell me that although he did want to go back to his old tutor he now didn’t know any of the children in her group because the time of his lesson had also changed. Evidently this was unsettling him.

The old instructor listened, took him quickly into the pool, introduced the other children and had him swimming a width before he had time to protest further. She was like a swimming fairy and I couldn’t have been more grateful. The would-be new instructor was unfortunately more like a wet lettuce.

I watched the rest of the session from the side, in the bit where parents are forbidden to be, as I had promised Little Bear I would and he kept checking I was still there. As I stood, I reflected. The thing is that we want our children to do well and we want to be able to celebrate their achievements with them. When children work hard and succeed they are generally rewarded by being able to move up a group or go onto a harder task or level. That is the usual way of things in school and sporting situations. However, what is often not considered (and I failed to consider on this occasion) is that moving up means leaving behind everything familiar to you. In this case it meant leaving the instructor Little Bear knew and was comfortable with. It meant leaving the children he knew and was familiar with. Although he would still be going to the same place, it also meant he would be in a different part of the pool: a deeper, more challenging part. As a transition I had underestimated it.

Yes Little Bear was doing really well at swimming but moving him up a group was not the just-right challenge for him. It was a too-far-out-of-the-comfort-zone challenge.

That is the tricky thing for children who have experienced developmental trauma or who struggle with attachment: finding the just-right challenge for them (obviously it’s very different child to child). You cannot simply base the level of challenge on their skill level. Clearly in terms of Little Bear’s swimming ability, he was capable of being in the harder lesson. However, that didn’t take into account his emotional or attachment needs which, at the moment, mean that taking the leap away from everything familiar leads to him feeling unsafe. He would probably have coped better (it’s all good in retrospect) had the whole group and the tutor moved to the deep end; or had they stayed where they were and just done harder swimming.

I suspect also, that Little Bear has had a bad experience in water in the past as he was terrified of it when he first arrived and clung onto me the first time we went into a pool – arms tight around my neck, feet wedged between my thighs, clutching on limpet-like. It was ironic really as I dislike water and can barely swim but it was undoubtedly good for bonding as I kept him safe, successfully hid my fear and he slowly found his confidence. Grizzly takes the boys swimming a lot now and Little Bear had seemingly fully conquered any fears he used to have. That’s the thing about trauma though, it pops up when you least expect it and perhaps something about standing at that deep end, already out of his comfort zone, staring into the aqua depths triggered something? A memory? A fear?

We couldn’t really have anticipated the possible trigger but with hindsight I think we should have been able to see that moving up a group was a challenge too far. For now, doing very well in the group he is in is the just-right swimming challenge for Little Bear.

When it comes to education, finding the just-right challenge for him has been even trickier. Not only do we have to consider his skills, his attachments and familiarity but we also have to consider his self-esteem and sensory needs (he is pretty confident physically and sports meet his sensory needs well). In addition, as with many children, what Little Bear is capable of on any given day can fluctuate. If he’s particularly anxious or hungry or unwell or excited he is unlikely to manage as much as if he is calm and relaxed. The just-right challenge can vary minute to minute and task to task and requires an adult to really know him to be able to differentiate demands accordingly. My post Jigsaws is a good example of me getting the just-right challenge bob-on and the positive outcome that resulted from it.

Too often we don’t hit the right challenge level, usually making the challenge too hard, resulting in upset, frustration and even aggression. As a rule we have now learned that Little Bear’s just-right challenge tends to be a little below his full ability when all the stars are in alignment. Pushing him too hard causes a panic, even if we know he is able to achieve whatever it is.

In a recent meeting with school, his teacher told us that he is doing well in his Maths group and they are considering moving him up. Whilst it is fabulous that our little dude who couldn’t count for toffee on school entry has overtaken some of his peers and has taken to extending his own learning (why do tens and units when you could do twenties or thirties and units?!), knowing him as we do, the just-right challenge for him is being the best in the group he’s in, not struggling to keep up in the next group. Yes, he would probably be able to do some of the work but he would find it hard and his confidence would suffer. I think he would enter scared-mode. Where he is, he can succeed nearly all of the time which is just-right for now.

 

 

*It’s difficult in a situation like swimming where the teachers don’t know anything about Little Bear or his background so aren’t aware of the need to make reasonable adjustments. I never know whether I should try to tell them or not but, practically, it would be difficult as they are in the pool and I would need to shout!

**Whilst I have spent the whole post pointing out the problems, I shouldn’t omit to point out that Little Bear did fabulously being able to let his emotions out and putting his fears into words and telling them to me. It’s not so long ago that he would have had a meltdown or punched somebody instead. Progress comes in many forms.