Sensory needs and sleep

What most sleep coaches get wrong about neurodivergent children and sensory needs.

What do sensory needs have to do with sleep? Why do we devote an entire module to the sensory needs of babies and children on the Holistic Sleep Coaching Program? How do sensory needs manifest themselves in infancy? And what can we do to support babies, children and parents with these needs in order to improve quality of life, behaviour and sleep?

What are sensory needs

During everyday life, one of the many jobs the brain has is to integrate and organize sensory input from many different sources, and interpret them correctly. Our sensory systems are constantly providing information about the world around us – sights, smells, light, pressure and touch, temperature and taste. The brain has to receive this information via many different neural pathways and different parts of the body – for example our tongue, mouth, fingers, feet, skin receptors, eyes, ears and many other sources.

How do sensory needs affect us?

To some extent, modern life is making our sensory processing harder. We are often overwhelmed with sensation, such as light, noise and crowded spaces. Increasingly, we have more sedentary lives – urban life makes this even more likely, as opportunities to explore and exercise in nature are limited, and this changes the types of sensory input we receive. In addition, we are exposed to numerous artificial adaptations, such as chemical processes, foods, and synthetic substances, as well as artificially manipulating our very environment. We make it colder when it’s too hot, we make it wetter when it’s too dry, and we make it lighter when it’s dark outside. In short, some of the demands of modern life is forcing our bodies to adapt in ways that are not always biologically rhythmical.

When we think about babies and children, some of the activities that may be making childhood harder are the very devices that parents seek to make life easier. We choose activity centres, baby gyms, jumping toys and screens. We ferry the kids to school in cars, and we take them to structured activities after school as well.

From a young age, babies develop to a large extent in response to the care, interactions and opportunities presented to them. If they are responded to promptly, kept calm, and held a lot then they receive appropriate levels of touch, co-regulation and communication exposure. When children can walk, they should be encouraged to have as much exercise as possible to build strong bones, develop lean muscle mass and core strength, and expend their energy. Sadly, sedentary lives, lack of physical exertion and an over-reliance on mental stimulation rather than physical play can lead to obesity, over-stimulation and in some children already pre-disposed – sensory difficulties.

The seven senses, and the two most people miss

Most people can name five senses: sight, smell, touch, hearing and taste. Two more matter enormously when we think about sleep, and they are the two most often overlooked.

It helps to think of the senses as the foundation of a pyramid. When we assess children, we tend to notice the obvious signs first: behaviour, speech, balance and communication. What is easy to miss is that these are ‘higher order’ abilities, and they rely on a fully functioning and regulated brain and emotional state. We react to a child’s outward behaviour without realising that behaviour depends entirely on their sensory systems being appropriately contained.

Unless a child’s sensory needs are met, it is unlikely that much improvement will be made in those higher order areas, because the central nervous system depends on sensory feedback, integration and interpretation. Put simply: a child who is stressed and dysregulated will not learn, behave and function until their sensory needs are balanced. Any strategy that tackles the top level — behaviour — without addressing the underlying sensory needs is quite literally only touching the tip of the iceberg.

The vestibular sense

This is the sensory system that provides balance and spatial orientation — knowing you are standing upright rather than upside down. It helps with acceleration, gravity, balance, movement, rotation and posture. It is made up of structures in the inner ear: the cochlea and semicircular canals, which also send messages to the eye and to the postural muscles that keep us upright.

If a child has an under-developed vestibular system, they are not getting the right messages from their eyes, ears, gravity and movement. This is incredibly disorientating and stressful, and children generally respond by being hyper-vigilant, alert and negatively aroused. That state of stress activates their fight-or-flight response — and you can see immediately that sleep will not come easily until it is dealt with.

Disorders of the inner ear can also cause problems with balance, hearing and dizziness, including glue ear and chronic ear infections. That makes a lot of sense when you think about it.

The proprioceptive sense

Proprioception tells the brain where all our body parts are in relation to each other, using feedback from the deep muscles about movement, pressure and position. A correctly functioning proprioceptive system is what lets us:

• Pick up an egg in one hand and a brick in the other, and know how much pressure to exert on each so we neither crush the egg nor drop the brick.
• Know how hard to squeeze someone when giving a hug, or how much pressure to use with a handshake.
• Apply the right pressure when writing, so the pen does not tear the paper.
• Know roughly where something is without looking, because we know how long our arm is.
• Climb up and down stairs, run, jump, use a climbing frame or hit a ball with a racquet.

An under- or over-developed sense of proprioception can cause havoc with the activities of daily living. Imagine how hard that must be for a child who cannot articulate it.

Sensory seeking or sensory avoiding?

There is a measurable physiological difference between the two. Sensory seekers show a reduction in heart rate when exposed to a new stimulus, which is why those activities and sensations calm them down. Sensory-avoidant people show a faster heart rate on exposure — a fear response, which leads to avoidance of that stimulus (Dunn, 2001).

Avoid rigid thinking about sensory needs, because they evolve over time. Most infants love to be picked up and held, but the same infant may find gentle baby massage irritating. As that infant grows, they may avoid hugs altogether. As with so many other areas of parenting, the ability to be adaptive and responsive, and to react according to the child’s emotional state, is vital.

In practice, many children do not fit neatly into either category. It is common to see what is often called a ‘spiky profile’ — areas of under-responsiveness alongside areas of over-responsiveness in the same child.

Everyone has sensory needs. The only question is whether those needs affect or inhibit the activities of daily living. It is really important to avoid pathologising sensory seeking and avoiding behaviours. Many responses are entirely normal and indicate no particular pathology in and of themselves (Ahn et al, 2004). On its own, a single sensory behaviour does not equal a problem. Even multiple behaviours do not equal a problem — it could simply be a child’s natural tendency towards preferring quiet, a higher level of emotional reactivity, or a greater need to move around.

Sensory processing differences require investigation and therapy, usually by a qualified occupational therapist, only when they are part of a wider diagnosis that undermines normal function, deny the individual the opportunity to make and sustain relationships, or prevent them experiencing important activities (Dunn, 2001).

Once a parent understands that their child is not being ‘difficult’, ‘fussy’ or ‘pathological’, they can begin to make adjustments (Gere et al, 2009) — avoiding places that genuinely cause distress, changing behaviours, or learning to recognise the signs of dysregulation.

Oversensitive?

For most people, the nervous system responds appropriately to ordinary sensation and stress. For example, if you walk into the street and a car unexpectedly drives past, it is normal and appropriate for your fight-flight mechanism to kick in. This comes from your sympathetic nervous system, and an instant stress response is mounted that enables you to quickly deal with the dangerous or stressful event that has presented itself. This is our primitive survival instinct. Once you have acted on the fight-flight response by moving out of harm’s way, your parasympathetic nervous system helps you to breathe normally, get your heart-rate don, and stop your palms from sweating!

However, for a person with faulty wiring, this normal process is exaggerated and often inappropriate. For example, it is not normal to mount a stress response when we receive a hug, or put on socks, or take a shower. These are normal activities, that should not alert our parasympathetic nervous system to the possibility of threat or danger.

For a person with sensory processing problems or oversensitivity, a vast array of different events, experiences, sensations and environments can provoke a profound stress response, so that a person can feel like they are lurching from one physiological crisis to another, never safe, never calm, and frequently on ‘high alert’.

The overall result is that a sensitive person will remain in fight-flight mode all the time, living in a state of vigilance and arousal, physiologically ready for the next ‘threat’. When an actual stressor comes along, this can tip them over the edge.

How does this present in babies?

Everyone has different sensory needs, so it is often more appropriate to give an explanation of what to look for, rather than suggest what might be causing babies or children to become dysregulated and distressed. However, there is sometimes value in giving some examples.

Perhaps you have met a baby who seemed to be on high alert all the time, never calm, found sleep impossible, and seemed to become distressed at seemingly random events or experiences?

Have you met a child who breastfed continuously all night. They rejected any other forms of comfort, even a pacifier or bottle as a substitute. Only the breast would do.

What about the baby who screams as if in pain during changing, dressing, nail clipping or bathing?

It would be unwise to ‘diagnose’ any baby or child with any of the above symptoms, until more possibilities have been ruled out, but equally, there are some simple suggestions that you can make to parents to calm and regulate their child.

How do sensory needs affect sleep?

Normally, people cycle through different states of sleep quite easily. People who are stuck in ‘fight-flight’ mode can find it harder to get into and stay in deep sleep. These may be the infants who wake at the slightest noise, or are sensitive to minor fluctuations in temperature, pressure or movement.

In addition to this sensitivity to changes, it is also much harder to calm infants or children who are in high alert, as their cortisol and adrenaline levels are high, making it hard to calm them and get them settled for sleep.

While harsh sleep training may teach a child to expect a ‘non-response’ – i.e. no matter how long they cry, nobody will come and stay/hold their hand/nurse/rock or whatever it is that the child usually expects, this approach is wholly inappropriate as it fails to address the child’s underlying dysregulation. Not only this, but allowing a child to remain in constant fight-flight mode can permanently change their behavioural response to stressors, and tech them to exist in a state of high arousal even in non-threatening situations. They become the children and teens who never seem to relax, and the adults who are quick to lose control, panic, or over-react.

The correlation is well documented. Sensory processing problems are closely correlated with sleep problems (Koenig and Rudney, 2010). Around 25% of children who have sensitivities to touch have sleep problems, and sensory seeking children seem to have a particularly hard time — around 42% of them struggle with sleep (Shocat et al, 2009; Vasak et al, 2015).

Night-time and sleep are usually devoid of multiple sensations, so it makes sense that sensory seeking children would find sleep harder than sensory avoidant children. When lying down and trying to sleep, a sensory seeker is denied movement, taste, sound and smell all at once.

Many children have specific preferences about touch and pressure. If the touch is the wrong sort — pyjamas that are too tight, or a blanket that is not heavy enough — the child is more likely to become hyper-aroused, and sleep becomes more difficult.

Sensory avoiding children may find the following difficult:

• A noisy home
• Sibling or neighbour disturbance
• Baby or toddler sleeping bags
• Swaddles
• Nightlights
• Mobiles and lullabies

For a child who finds certain types of touch, noise or pressure challenging, some of the very strategies commonly assumed to improve sleep may actually be irritating.

Babies who are sensory seeking may also be inaccurately diagnosed as having colic (De Santis et al, 2004), which may explain why some babies settle with bouncing, rocking, swaying, dim lights and white noise. Helping parents tune in to their baby’s senses helps them care for their infant more sensitively and responsively.

Meltdowns are not tantrums

Many people use ‘meltdown’ to describe a tantrum. Meltdowns are more than a tantrum: they are a total loss of emotional control, like a car whose brakes have completely failed. The two can look similar, and many parents and professionals assume a child’s meltdowns are down to being over-indulged or naughty. They are not the same thing.

Some parents find it useful to keep a diary of meltdowns to identify possible triggers: noise, transition times, sensations, eating, or coming out of preschool or nursery. Once a parent can see the pattern, they can build a picture of what their child finds difficult and either avoid those situations or have a back-up plan ready.

Warning signs

Some children seem to go from nought to sixty in a second. They switch, lose control, and it can feel impossible to predict. With practice and close observation, though, most people notice warning signs:

• The child may ask to leave a place.
• A child may begin to rock.
• You may notice fidgeting, moving around more, or becoming more hyperactive.
• The child may run away.

If a parent is still struggling to identify the warning signs, the best approach is to try to remember what happened just before the meltdown. Hindsight is a wonderful thing, but sometimes it is the only way to build the picture.

When a child is in meltdown, the only thing you can do is support them and wait for them to calm. The skill is noticing the warning signs and intercepting at that point.

Sensory strategies for sleep, sense by sense

Your approach needs to stay flexible, adaptive and responsive to each child. That said, some broad generalisations apply. Continuous background pink or white noise is usually less disruptive than intermittent breakthrough noise — door slams, toilet flushes, cars accelerating outside the window. And firm, still pressure is usually more regulating than light stroking touch, which can be irritating in the same way tickling is.

It is really important to view each child as an individual and not have too fixed an idea of what will help. Children with sensory needs are vulnerable to being stereotyped and handed the same strategies as everyone else. Each child presents differently, and we need to let the child’s behaviour and the parent’s story guide the approach.

A sensory diet: activities that support regulation

Children who struggle with sensory processing may find it useful to have activities built into their usual routine which, over time, desensitise them to the sensations of everyday life and help them cope better.

These activities are play-based and meant to be fun. If a child clearly does not like a particular activity, do not persist — try another, or try again another time. It is also important not to overload a child with sensation. You can have too much of a good thing.

Proprioceptive activities help to regulate and calm children who are highly sensitive. Being under-responsive (usually the sensory seekers) or over-responsive (usually the sensory avoiders) to this sense can feel disorientating, and both groups benefit from proprioceptive activities (Kranowitz, 2005). These usually involve heavy work and deep pressure.

For babies

• Sitting on a yoga ball and doing slow, deep bounces
• Tummy time
• Firm, deep pressure massage
• Wearing in a sling
• Rolling baby up in a soft blanket like a sushi roll, head sticking out, then rolling them on the floor while playing peekaboo
• Swimming
• Crawling

For toddlers

• Push-ups against a wall
• Trampolining
• Soft play
• Carrying a backpack with a bottle of water in it
• Play wrestling
• Ball games
• Gymnastics
• Jumping

For older children

• Carrying groceries
• Climbing on play equipment
• Skipping rope
• Hammering nails into wood
• Hiding a toy in a piece of Plasticine and having to find it
• Carrying heavy books
• Using a resistance band
• Handstands
• Movement breaks at school
• Fidget toys and chewellery, for children who otherwise chew their hair or clothing

A child’s autonomic nervous system fluctuates throughout the day. The goal is to help parents notice when their child is heading into the yellow zone, and give them strategies to get regulated again. Parents will need to try different ideas and notice what works and what does not.

How do we support parents of sensitive children?

As sleep coaches, we may encounter children who are constantly alert, stressed or dysregulated. We are also going to meet their parents, who are frequently confused, frustrated, exhausted and stressed. Finding ways to support them is crucial to the sleep plan success.

• Recognise the challenge: Parents who are caring for a sensitive child often have to deploy far more tactics than other parents, and yet get less positive feedback for all their effort. They may have resigned themselves to the need to rock, bounce, or dramatically alter their child’s daily routines or environment in order to keep the peace. This is exhausting, draining, often misunderstood and socially isolating. I have often found that these parents go ‘underground’, having encountered one too many incredulous looks at the levels they have to go to keep their child calm. Perhaps they have been accused of ‘pandering’ to their child, or making a ‘rod for their own back’. Faced with this lack of comprehension from others these parents sometimes retreat within their own carefully controlled evironments to avoid the stares, meltdowns and embarrassment. This can lead to social isolation and subsequent mental health problems that this can cause. The truth is, these parents aren’t ‘pandering’ or doing something that was ill-advised: They were just attempting to meet their child’s needs, and this is an area that is not widely understood or recognised. Far from chastisement, these parents deserve our unswerving admiration and support for the challenges they face.
• Provide reassurance and education: Often parents first need to have their concerns validated and understood. It is often enlightening and empowering to have someone recognise that their struggle is real, they are not alone and that solutions exist to reduce the struggle.
• Teach them skills to support their children to become calm: Parents are often surprised at how much of an impact their own emotional state can have on their child. An experienced, calm, responsive and well-adjusted parent is able to accurately interpret infant dysregulation and moderate their response to support the infant to become calm. This may include noticing subtle changes in the child’s physiological state and behaviour that give clues as to whether the current intervention – whether that is rocking, shushing or swaying are helping or hindering the calming process. A parent who is stressed, exhausted, depressed or frustrated will themselves become dysregulated and stressed by their stressed child. This negative cycle of parent and child dysregulating each other can be difficult to break. In my experience, this is often when parents reach breaking point and ask for help with sleep. But sleep is just one small aspect of this situation. The bigger picture is to be able to educate parents about sensitivities and support them to be the calming influence their child needs.
• How to calm a stressed parent: This sounds all very well, but what about the highly stressed, anxious and exhausted parent who is at the end of their rope? First of all, parents may need more support than a sleep coach is able to provide. Importantly, sleep coaches must always refer to more appropriately trained professionals. Secondly, we must be able to talk about stress in a way that doesn’t make parents feel stressed about being stressed. Normalising stress, and providing practical solutions is a good way to achieve this balance. Try suggesting thought journaling, guided mediation, mindfulness, or alternate nostril breathing. Cover one nostril and breathe in through the other. Hold the breath, then uncover the first nostril and cover the other side. Repeat. This is deeply relaxing and a good alternative for parents who do not find it natural to practice yoga breathing!
• Help them to develop strategies to prevent hyper-arousal, and intervene when necessary: Teaching parents how to spot the signs of dysregulation is a very empowering and transformative skill. Even experienced and responsive parents sometimes need help with learning about infant cues. Keeping a diary of behaviours can be an effective way to spot any potential patterns. Suggest noting down how the child reacts at certain times of the day, to particular environments, activities and routines. Do they have meltdowns over the same things every day? Do they always find bath-time stressful? Then also have parents note down what activities help, and at what time. Does rocking help, or make it worse? Does calm music help, or does the crying escalate? Can they only tolerate the bath when they are neither hungry nor overtired?

How do we help children who are sensitive?

As well as supporting parents, we will also need to be able to suggest strategies to calm children. With the best will in the world, we cannot always prevent all problems, nor can we always predict them and stop them in their tracks. But we should be able to equip parents with tools and solutions for their children.

• Zones of regulation: An emerging area of practical help is learning to recognise when a child is calm, and when they are becoming dysregulated, and when this escalates into a full-blown meltdown. ‘Scaling’ the level of distress in this way helps parents to moderate their response to meet the child’s needs. For example, rocking may only be needed during certain times. During a meltdown, deep pressure may be more helpful than rocking or bouncing or shushing. Only by keeping a diary can you work this out. The goals are to spot patterns of behaviour, enable the parent to be more attuned to the needs of their child in particular states, and reduce the number of meltdowns to keep a child calmer and spend less time in fight-flight mode. This will help with settling and sleep, as well as general behaviour, attachment and bonding, and parental confidence.
• Sensory activities: Most parents have already tried a variety of tactics to try to calm their hyped-up child. Others have found one method that seems to work at certain times – such as sleep, and that method has become unsustainable. If the child was calmer throughout the day, it is likely that the child would naturally need a lower level of support in order to be calm enough to go to sleep. Helping parents to stay on top of their child’s stress levels throughout the day is therefore intrinsic to the success of the sleep plan. In addition, they may need some alternative strategies up their sleeve to soothe their child. Children’s sensory needs tend to evolve over time, so what works in early infancy may not work in later infancy. They therefore need a large bank of solutions ready to experiment with to find the right combination and balance of strategies.
• Modify the environment: Often, parents do this instinctively, but again, once a child is calmer in general, they may find that their world, which may have started to close in on them due to self-imposed restrictions and limits they place on where they can go and whom they can meet, may open up again. The child may begin to tolerate going to the supermarket, or crowded spaces, or toddler groups. This may only be possible by making adaptations at other times – for example providing background noise for sleep, or giving a toddler heavy work to do during the day to keep them feeling grounded.
• Provide gentle, evidence-based and holistic sleep solutions: The Holistic Sleep Coaching Program is committed to gentle and respectful care of children of all ages. Children with sensory needs re no different, but they sometimes need a more creative approach. It is certainly not appropriate to leave these children to cry for any length of time, as this will just serve to further dysregulate them.

Understanding sensory needs is more than just a broad awareness of sensory strategies such as white noise and deep pressure! It is about a holistic awareness of the multiple factors that take place for a child who is sensitive. The Holistic Sleep Coaching Program is passionate about empowering parents and professionals with accurate and evidence-based information about the myriad aspects of sleep, parenting and family life. This is very true when it comes to sensory needs, as the needs of the whole family, environment and other variables such as diet and exercise all have a part to play. Sleep coaches can be surprisingly transformational with these families who have been battling with a dysregulated child for months or even years. While other professionals may be required to support families, a well-informed holistic sleep coach can provide an empathic and compassionate ear, as well as a variety of targeted solutions to support families.

When to refer

Sensory processing disorder is a condition in which the brain has difficulty receiving and reacting to sensory information — smells, tastes, sounds and sensations. Like a lot of other conditions, it exists on a spectrum. It often co-exists with other conditions and is not currently recognised as a condition in its own right, which means children who are autistic or have ADHD tend to get support for their sensory needs, while children who only have SPD may struggle to get the diagnosis, support and treatment they need. Where it is diagnosed, it is usually alongside autism, ADHD or extreme intellectual ability.

As a sleep coach you cannot assess, diagnose or treat a sensory condition. What you can do is help parents recognise whether their child finds certain sounds, sensations and experiences stressful or calming. Being able to interpret a child’s emotional state, and match the level of intervention to their level of distress, is at the heart of responding to a child’s cues and needs.

The best person to involve with a child who is sensory seeking or avoiding is a paediatric occupational therapist. For children who have both sleep problems and significant sensory problems, referral to a paediatrician and an occupational therapist is essential — particularly where there are parental concerns about an underlying developmental disorder. If in doubt, suggest the parent seeks advice from a specialist.