Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

An Overlooked Population: Adults with Sensory Modulation Disorder

Jessma Barrani

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

Abstract: This paper brings to light the physical, emotional, and social difficulties
experienced by children and adults with Sensory Modulation Disorder (SMD). SMD is a subtype
of Sensory Processing Disorder (SPD). SPD is a condition in which a persons perception and their
responses of sensory stimulation are atypical to the stimulus (Miller & Benjamin, 2013). Sensory
modulation disorder is defined as difficulty modulating and regulating the degree, intensity, and
nature of responses to sensory input. Their uncharacteristic response prevents them from adapting
to the demand of everyday life (Kinnealey, Koenig, & Smith, 2011, p. 320).
Most people have occasional problems processing sensory information. For children and
adults with SMD, problems with sensory processing are chronic and disruptive to everyday life.
Extensive research has been done on children with SMD. Very little research has been conducted
on Adults with SMD. As SMD is a life long disorder without a cure, it is puzzling that there is such
a lack of research on adults with Sensory Modulation Disorder. There needs to be more research
focused on adults with SMD.
Introduction
A teacher is frustrated at a student who jumps up and down in their seat, does not
participate or interact with other students, is slow to respond to their name, and doesnt recognize
social cues. For some students that fit this profile, the issue is purely behavioral, but for other
students, the root of the problem is the way they process their senses. Sensory Processing is a term
used to describe the way the nervous system receives messages from the senses, decides what the
messages are, and then responds. Receiving, integrating, and responding are qualities that children
and adults with Sensory Modulation Disorder (SMD) struggle with. People with SMD are often
misunderstood, misdiagnosed and mislabeled by doctors, professionals, and even their own family
members.
SMD is a subtype of larger processing disorder known as Sensory Processing Disorder
(SPD). This is a condition in which a persons perception and response to sensory stimulation are
uncharacteristic and different from most peoples response. An example is walking on grass
barefoot, an experience that is painless and tolerable to most people. To a person with SPD, it
might feel like stepping on needles or it may even feel unbearable slimy.

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

Neurologically, its like a traffic jam that inhibits certain parts of the brain from receiving
the information needed to then appropriately integrating sensory information (Miller & Benjamin,
2013). People with SPD encounter difficulties in everyday life experiences from brushing their
teeth to embracing a hug. SPD is observable by motor clumsiness, behavioral problems, anxiety,
depression, academic difficulties, and problems coping during social situations.
SMD displays similar traits, but as Miller and Benjamin (2013) further explained, people
who suffer from SMD experience difficulties "modulating and regulating the degree, intensity, and
nature of responses to sensory input in a way that is consistent to the situational demand. Sensory
processing disorders are as common as attention deficit hyperactivity disorder (ADHD) , yet
receive far less attention because it is not recognized as a distinct disease (Bumin, 2013). As a
conservative estimate, 5% of school age children, one in every twenty, have a form of SMD,
(Kinnealey, Koenig, Smith, 2011, p.321). Kinnealey (2011) estimates the percentage is similar in
adults. Individuals with SMD experience everyday life very differently than others.
One of the best ways to demonstrate the differences in reactions from children with SMD
to a child without SMD is to compare how two react to the same situation. Kranowitz (2005) in her
book The Out of Sync Child," conducted such an experiment with two seven year old girls
playing the same game of jacks outside. She records how the two girls react to the situation. Her
illustration is very useful because she pinpoints typical red flags of SMD.
Susie, a child without SMD, is at recess on a cold day playing jacks. The cement she is
sitting on is cold, but she ignores it because she is interested in the game. She is not playing as
well as usual because her hands are so cold. The first time her hand fails to scoop up the jacks, she
is disappointed but continues playing. The second time, she is more frustrated. The third time, she
decides to jump rope instead to warm up her body (Kranowitz, 2005, p.58).

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

Placed into the same situation, Mary, a child with SMD cant concentrate because the cold
cement is too distracting. On her first two turns, Mary struggles to scoop the jacks. On her third
try, Marys hands are too stiff. Suddenly Mary explodes, kicking the jacks, and screaming, I hate
jacks! She begins to cry uncontrollably and stays upset for the rest of the morning. Mary is so
distressed all morning she cannot focus on her school work (Kranowitz, 2005, p.58).
The first red flag is the extreme difficulty Mary had mentally blocking out the cold cement.
Second was in her fine motor movement, from the very beginning Mary had trouble coordinating
the movement. The third major red flag is how Mary could not socially regulate her emotional
frustration instead she exploded. The fourth major red flag is how her emotional stress lasted for
hours, instead of minutes. Most adults with SMD have encountered similar situations and have
learned to develop coping mechanisms such avoidance, mental preparation, talk through, and
confrontation to deal with such situations (Kinnealey, Oliver, Wilbarger, 1995).
As illustrated in the experiment above, people with SMD have very hard time adjusting to
their environment. It manifests itself emotionally, and socially, and physically. Extensive
research has been done on the neurological underpinning and the effectiveness in therapeutic
techniques used in treatment in children with SMD. Very little research has been done with adults
with SMD. As SMD is a disorder that has no cure and is pervasive, it is disconcerting the lack of
research that has been done in adults. More research needs with adults with SMD, an overlooked
population.
Understanding SMD
First its important to understand that our senses give us essential information about the
surrounding environment. People with SMD do not receive accurate information from their
senses. The human body has seven senses including sight, smell, sound, taste, tactile, vestibular,

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

and proprioception (Bod, Gough, Home, 2013). The last three mentioned are often over looked
and need further explanation.
Tactile senses give information from the skin about temperature, pressure, texture, touch,
pain, and movement. Vestibular senses give information about where our body is in relationship to
gravity. It contributes to posture, balance, and eye movement. The bodys proprioceptive senses
are similar to a mental body map of the positioning and movement of muscles and joints. All
sensory receptors and processors are housed within the nervous system (Bod, et al., 2013)
Individuals with SMD perceive and respond to sensations differently because of the way
their nervous system modulates sensory information. Sensory modulation refers to the brains
ability to respond appropriately to the sensory environment and to remain at the appropriate level
of arousal or alertness (Wild, 2013). A simple example of sensory modulation is the ability to
tune out the noise of a crowd and listen to a friend. The brain acknowledges the presence of the
crowd and the sound, but adapts by redirecting the focus to the conversation with a friend. A
person with SMD may not be able to do this. Instead he/she may become overwhelmed by the
noise and become frustrated, angry, and want to leave. Modulation helps us self regulate and be
selective of what we cognitively sense.
There are three subtypes within SMD: over-responsive, under-responsive, and sensory
seeking. Over-responsive is an exaggerated response to sensory input. These individuals are
receiving too much sensory input. They may be overwhelmed by busy environments, have
problems with tags and seams in their clothes, and have a low frustration tolerance.
Under-responsive refers to a lacking of response to sensory input. They do not get enough
information about their environment and may seem tuned out. Sensory seeking individuals need
extreme input for the sensation to register properly. These people have a very difficult time

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

staying still and may seem to want to touch everything. Sensory seeking children will often crash
into walls on purpose to get that extra input (Wild, 2013). Its important to remember most people
experience symptoms similar to the symptoms described above with in their life. Yet these
symptoms for a person with SMD are chronic and life disruptive to everyday life.
Emotional and Social Experiences
The emotions of people with SMD are not only caused by the discomfort of the sensory
stimuli, but also social situations surrounding them. Children and Adults with SMD are often
unable to meet social expectations, and in turn experience high feelings of inadequacy and low self
esteem. These feelings translate into coping patterns of conflict and/or isolation at home, work, or
school. Anxiety and depression are strongly linked to SMD (Kinnealey & Pfeiffer, 2003;
Kinnealey, Koeing, & Smith, 2011; Kinnealey, Oliver, & Wilbarger, 1995; Dunn, 2011). In both
children and adults, social relationships and activities are greatly compromised due to their
difficulty regulating their response to sensory stimuli.
Children
Emotional deregulation and outbursts are the most challenging aspect of SMD for both the
child and the parent. (Kranowitz, 2005, p.261) The degree and frequency of emotional outbursts
directly affects their participation in social life. To look deeper into the social participation patterns
of children who suffer from sensory processing difficulties, researcher Cosbey, Johnston, and
Dunn (2010) compared social participation patterns of children with SPD and without SPD ages
6-9 years old. In areas of enjoyment both groups scored very similar. However in categories
involving diverse social networks children with SPD scored significantly lower than their peer
without SPD. Cosbey (2010) reported, most of their social activities took place with immediate
family [members] or alone (p.470). The findings suggest, children with SPD do not get the same

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

opportunities to develop social skills necessary in building and maintaining social relationships.
Social skills learned in childhood include the following, but are not limited to the abilit[y] to
comfort, share, help, and cooperate [and] learn conflict resolution (Cosbey, 2010, p. 462).
Cosbeys (2010) conclusion of isolation and limited social networks can be applied to children
with SMD because of the overlapping symptoms seen in both SPD and SMD. Isolation and
limited friendship is a disadvantage that affects adulthood. As childhood, is the time we learn
social skills fundamental to healthy meaningful adult relationships.
Adults
Emotional and social patterns of children with SMD found by Cosbey (2010) are similar to
those of adult. Researchers Kinnealey, Koenig, and Smith (2011) described adults with SMD as
having perceived a daily experience as [being] irritating, overwhelming, disorganizing, and
distracting (p. 320). Even though the emotional collision adults experience is rooted in the way
in which he/she perceives stimuli, adults with SMD are more often referred to a mental health
professional (Dunn, 2011).
Adults with SMD have a significantly high correlation with mental health issues such as
anxiety, depression, social-emotional issues, autonomic nervous system reactivity, and coping
strategies [that are not socially expected] (Kinnealey et al., 2011, p.320). Kinnealey (2011)
conducted a study to further investigate the mental health of adults with SMD ages 18 to 46. The
researcher found that anxiety and was inversely correlated with social supports (Kinnealey et al.,
2011, p.324). Meaning individuals with higher symptoms of anxiety perceive themselves to have
less social support. Social support is powerful factor in coping with stress and developing
emotional resiliency (Kinnealey et al., 2011, p.320). The authors supported the claims of previous
studies done by Dun (2011) and Kinnealey, Koeing, & Oliver, & Wilbarger, (1995) and found that

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

those with more social support were better able to regulate their emotional responses and better
adjust to demands of life.
Often adults will exert an excessive amount of time coping with their sensory
defensiveness, Kinnealey (2011) writes a situation that leaves them feeling exhausted and
frequently isolated (p.320; Kinnealey et al,, 1995). To reduce the occurrence and/or the overall
impact of environmental stimuli, adults develop coping mechanism; a topic which has been
observed and reported by numerous occupational therapists and mental health professionals.
Kinnealey, Oliver, & Wilbarger (1995) further explored the subjective experiences of
coping mechanisms in adults with SMD. The study identified six coping mechanisms used which
included avoidance, predictability, mental preparation, talk through, counteraction, and
confrontation (Kinnealey et al., 1995, p.444). The coping mechanisms observed and indentified
are both emotional and socially taxing. Kinnealey (1995) concluded that coping mechanisms
drastically influenced their choices of activities and opportunities for social interaction (p.451).
Social relationships and leisure activities have been identified as central components to an
individuals quality of life by the World Health Organization (Cosbey et al., 2010, p. 320). People
with SMD may experience a significantly lower quality of life because of the sensory confines of
his/her disability.
Limited research has been done on the long term effects of living with such coping
mechanism, nor its effect on occupation or intimate relationships. High feeling of anxiety,
depression, and social isolation have been studied and agreed upon by numerous occupational
therapist and health professionals (Kinnealey et al., 2003; Kinnealey et al., 2011; Kinnealey et al.,
1995; Dunn, 2011). The underlying pitfall toward making real improvements in treating Adults
with SMD the need to validating the disease by using technology to prove physiological and

Running Head: AN OVERLOOKED POPULAITON: ADULTS WITH SMD

neurological biomarkers of SMD in adults.

Physical
Children with a SMD diagnosis look from the outside as being normal and so do adults.
SMD is considered to be an invisible disability, meaning it is not apparent by appearance or they
way in which someone walks or speaks. For this reason, technological biomarkers are very
important to prove the legitimacy of SMD to the medical community. There have been several
important studies using technology to establish physiological and neurological biomarkers in
children diagnosed with SMD and SPD.

Children
The most recent and promising research was conducted by child neurologist Marco, MD
and Owen, PhD (2013), a postdoctoral scholar in radiology and biomedical imaging. Using an
advanced form of an MIR, researchers discovered abnormal white matter tracts in areas involving
tactile, visual, and auditory sensory processing. The abnormal white matter found in children with
SPD correlates directly with the atypical sensory behavior that is pervasive and chronic in both
SPD and SMD (Owen, Marco, Desai, Fourie, Harris, Hills, Arnett & Mukherjee, 2013).
White matter insulates neural tissue to make neural processing faster and more efficient.
The white matter tracts responsible for processing the seven senses are one of the fastest signals
conducted within the brain (Ingebretsen, 2013, p. 47). Children with SPD and SMD either have too
much or too little insulation in different sensory processing areas. This gives scientific reasoning to
why the population has spectrum characteristic, on one end extreme sensitivity and the other what
appears to be numbness to sensation. Owen and Marco (2013) finished their research by clearly
stating, from a clinical perspective, these findings suggest that children with SPD have a specific

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imaging biomarker for their clinical disorder and the pattern of their shared structural difference
(Owen et al., 2013). This study established biomarkers SMD and SPD and as a result validates the
disease itself.
Another bench mark study implemented by Schaaf and Benevides (2010) evaluated
activity patterns within the autonomic nervous system of children diagnosed with SMD. To
understand the study, first its important to understand the basic parts of the nervous system. The
autonomic nervous system is the control center for all the unconscious functions in the body,
meaning function controlling all organs, movement, emotions, and thought patterns. The
autonomic nervous system is then split into distinct branches, the sympathetic and
parasympathetic. The branches are connected in a tetter tooter fashion, when one branches activity
goes up the other goes down. Schaaf and Benevides (2010) study focuses on the activity of these
branches. The role of sympathetic branch is to defend the body by causing emotional and
biological defense responses such as fear, anxiety, and increased heart rate. The job of the
parasympathetic branch is to seek and maintain a stable state, in which the body adapts to the
external environment (Ingebretsen, 2013, p. 43). Now that the basics are covered we can evaluate
the study.
Researchers found, children with the most severe SMD demonstrate significantly lower
baseline parasympathetic functions and as a result high sympathetic functions (Schaaf,
Benevides, Blanche, Brett-Green, Burke, Cohn, Koomar, Lane, Lane, Miller, May-Benson,
Parham, Reynolds, & Schoen, 2010). This means their body biologically does not adapt and self
regulate their response to the environment, such as a busy crowd. Most people can ignore the busy
crowd and adjust to the environment. Those with an impaired parasympathetic function cannot
grade or regulate their response to the crowd, and become overwhelmed. They also experience

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anxiety, fear and exhibit defense responses of the sympathetic branch. The authors added that the
parasympathetic nervous system also plays an important role in the recovery from a
stressor[s]/challenge[s] (Schaaf et al., 2010). This too biologically supports why stress lasts
hours instead of minutes for children with SMD.
Adults
Owen and Marcos (2013) validate the structural differences within the brain of children
with SMD, while Schaaf (2010) proves the neurological impairment of adaptating to their
environment. These too studies medially validate the significance of the disorder in children, but
completely neglect the adult population with SMD. Structurally, both a childs brain and an adults
brain have designated areas for sensory processing. But clinicians cannot assume this study
validates an adults diagnosis with SPD or SMD. These two study methods must be conducted on
adults with SMD; not only validate the disease but to have biological biomarkers to diagnose and
measure the biological impact of the disease.
Interventions:
Occupational therapists have developed a treatment method known as sensory integration
to treat both children and adults with sensory processing disorders. Sensory Integration (SI) is
based around two capabilities of the brain modulation and neuroplasticity. As discussed earlier
modulation is the brains ability to selectively filter stimuli, a functional impairment in SMD.
Neuroplasticity refers to the brains lifelong ability brain to reorganize itself by creating new
neural connections (Ingebretsen, 2013, p. 46).
Occupational therapists combine sensory experiences that are familiar, relaxing, and
challenging for a persons individual sensory needs into one treatment session. This combination
of is called a prescribed sensory diet. It literally feeds the senses in area that are both deficient and

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healthy by experiencing senses. The sensory diet uses the brains neuroplasticity, to mend sensory
processing areas found by Marco and Owen (2013) to be structurally abnormal in the brains of
children with SPD. By building new neural connections in sensory processing areas, the brains
ability to modulate stimuli and is directly affected. Its very important for the occupational
therapist to find specific sensations like rocking in a rocking chair, to relax the nervous system and
counteract the anxiety from aversive stimuli. As found by Schaaf (2010) the anxiety children with
SMD feel is a result of the increased sympathetic activity in the nervous system. Sensory
Integration has been used on with children for over forty years, far before any studies proved the
scientific basis for sensory processing disorders.
Children
Occupational Therapists use play and stories to integrated familiar, relaxing, and
challenging sensory stimuli. The interventions appear less threatening and formalized, yet the
prescribed diet is integrated to the session. Miller, Coll, and Schoen (2007) carried out a
randomized control trail on twenty four children with SMD. Interventions were twice a week and
lasted ten weeks. Children in the sensory integration group showed a considerable decrease in
sensory defensiveness after the ten weeks. Researcher claimed, this findings suggest that
[Occupational Therapy-Sensory Integration] may be effective in ameliorating difficulties of
children with SMD (Miller, Coll & Schoen, 2007 p. 232). Much of the research is in small
sample sizes making its effectiveness questionable to many physicians. Pediatricians Zimmer and
Desh (2012) expressed the need for parents to be aware of the lack of research in sensory
integration and the controversy of it efficacy.

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Adults
As is in children, research on the effectiveness of sensory integration in adults is very more
limited. Given that studies have shown the correlation between SMD and anxiety, researchers
Kinnealey and Pfeiffer (2003) conducted a study to explore the effects sensory integration on both
anxiety and sensory defensiveness.
Fifteen adults diagnosed with SMD and high levels of anxiety participated. Occupational
Therapists prescribed individualized daily sensory diets to each participant. They then compared
levels of sensory defensiveness and anxiety before and after the one month of treatment. Results
indicated that both levels of anxiety and sensory defensiveness levels decrease in one month of
sensory integration treatment. The results supported Kinnealy and Pfeiffers( 2003) hypothesis of
the significant relationship between defensiveness and anxiety(p. 183; Kinnealey, Koeing, &
Smith, 2011; Kinnealey, Oliver, & Wilbarger, 1995; Dunn, 2011). Kinnealey and Pfeiffers
(2003) study and other case studies, show there is promise in treating adults with a prescribed
sensory integration diet. Nevertheless before sensory integration is viewed a s justifiable form of
treatment more research must conducted on its efficacy.
Integrating Research
Within the last ten years research studies conducted by neurologists have supported many
studies that have been conducted and clinically observed by occupational therapists and healthcare
professionals. Owen and Marcos (2013) breakthrough study detecting abnormal white matter
provides tangible scientific reasoning to why children and adults with SMD exhibit a spectrum of
sensory difficulties. Schaafs (2010) findings of increased sympathetic function in children with
SMD support Kinnealey and Pfeiffer (2003) and Kinnealeys (2011) research by neurologically
proving why SMD and anxiety have a significant correlation. Anxiety is a byproduct of

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heightened sympathetic function. Schaafs (2010) detection of decreased parasympathetic

function with SMD supports the reason children with SMD have such a hard time self regulating
their response to environmental stimuli. It also gives reasoning to why this populations emotional
stress lasts hours instead of minutes. The studys support each other and also revile why SMD is a
chronic and debilitating disease.
Given that the brain is structurally impaired, circuits are causing the defensive reactions.
When a defense reaction take place sympathetic activity increases, parasympathetic activity
decreases and emotional processing areas are affected, like the feeling of anxiety (Kinnealey &
Pfeiffer, 2003, p. 183). Once sympathetic activity is high, sensations like sound and touch are
much more profound and feelings of anxiety increase. Since parasympathetic activity is low, the
ability to tune a sound out is impaired and it more difficult to ignore. The anxiety and persistent
strong stimulus causes their stress to last a long time and its difficult to relax. This series of daily
events is debilitating and circular momentum. It not only effects one persons quality of life, but
its biologically dangerous of long periods of time.
Prolonged periods of stress are strongly associated with developing secondary conditions
and lifelong diseases. Studies have shown that people with increased sympathetic functions are at
a higher risk of developing autoimmune disease, fibromyalgia, chronic headaches, migraines, and
other genetic diseases (Ingebretsen, 2013, p. 56). These are conditions and diseases are not only
challenging to treat, but often have no cure. Its baffling that researchers neglected adults with
SMD, a population that experiences extreme stress daily.
Its crucial that technological imaging and parasympathetic/sympathetic analysis be done
on adults with SMD. More research needs to be conducted on the efficacy of sensory integration
with adults. This populations quality of life is already compromised and with the additional

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likelihood of developing another chronic condition, its puzzling more research has not been done
on adults. Adults with SMD are a population that can no longer be overlooked.

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