I don't know how to make my baby happy. He cries a lot; and when I try to rock or console him, he cries more. My husband and I limit friends and family members coming over to visit because our baby will cry uncontrollably if things get too loud or people look at him the wrong way. I have even started to think that my son doesn't like me because when I hold him, he wants to be facing away from me except for when I breastfeed him. Although he is now four months old, sleeping is sporadic. some days good and others not.

-A concerned mother

Upon hearing this mother's report, many clinicians would wonder if this baby has sensory processing difficulties. Although we cannot see how this baby's brain detects and responds to the sensory information it receives, we can make educated guesses by observing the baby's behavior.

He seems to overly respond to touch, noise, movement and visual information he receives from other people and things within his environment. But what is the "fit" between the parents and baby in terms of the interaction style and environment¹ as well as the baby's medical history? Sometimes it takes a lot of investigating to figure out why a baby acts the way he does.

Even though babies are born with all of their sensory systems present, their ability to process sensations is not fully developed.²Transition from the womb to the outside world is a big change in sensory experiences. It takes time over the first year of life for babies to learn to process all of these sensations.

Early on, the baby can be observed trying to calm himself, regulate his sleep/wake cycles, feed efficiently and interact with other people. Later in the year, you will see improvements with sensory processing abilities as he manipulates toys, babbles and moves in and out of various postures. If a medical problem, poor environment or developmental delay interrupts the progression of sensory and brain development over the first year of life, the baby's ability to process sensations could be impaired. This can also happen if there is a genetic predisposition for a sensory processing disorder.³

Everyone has different patterns of sensory processing. One may be sensory sensitive, avoidant, seeking or have low registration, among other tendencies.⁴The determining factor for a sensory processing disorder is whether the individual's difficulties disrupt his everyday life.³It is important to diagnose a sensory processing disorder as early as possible because the immature brains of younger children are more easily changed, which makes intervention more effective for them.³

The evaluating clinician must be trained in sensory processing disorders as well as infant development and basic care issues. Generally, these clinicians are occupational therapists. Evaluations usually include a review of the infant's medical history, parent interview, standardized and non-standardized testing, and clinical observations. The evaluation results and parents' priorities will then guide the plan of care and intervention process.

Medical History

The first step of conducting the evaluation will be to look at the baby's medical history by asking:

V What is the baby's (and mother's) medical history prenatally? At delivery? Since birth? If the baby was born prior to 37 weeks gestation, he is already at risk for sensory processing problems. Full-term babies typically develop the various sensations at different times in utero without competing stimulation. A preemie may be exposed to multiple sensations simultaneously.⁵Also, if a full-term baby incurred complications during delivery³ has spent much time in a hospital or was otherwise sick, this could hinder his sensory development as well.

V Does this baby have any unresolved medical problems or undiagnosed developmental disabilities? Seizures, digestive problems, allergies, ear infections, genetic syndromes and impairments in visual or auditory skills are just some of the possibilities that could be interfering with sensory processing abilities.

V What medication, if any, is the baby taking? Some medications have side effects that may interfere with how the baby responds to sensory input or alter the sleep-wake cycle.

Interviewing the Caregiver

During the interview, pay special attention to what the caregiver says in terms of how the baby responds to touch, vision, hearing, proprioception, vestibular stimulation, taste and smell. Ask the parent to describe the events of a typical day with special attention to how things occur. What position is the child in during an activity? How long does it take to finish the event? Does the child become upset if things do not go a certain way?

If possible, have the parent demonstrate feeding and diaper changing. When observing these routines, take into account that the parents may be nervous or intimidated about someone watching them interact with their baby. Also, remember that evaluations taking place in a clinical setting may reveal different information than evaluations occurring in the natural environment such as the home.

The following questions (below, left) can serve as a guide during the interview. Answers given by the parents can provide information about how the baby processes sensations he receives from himself, the environment and during interactions with other people.

References available at www.advanceweb.com/OT or upon request.

Teresa de la Isla, MS, OTR, has more than 14 years of experience in pediatrics and currently works for an early childhood intervention program in Texas. She has a Web site, www.sense-ablebaby.com and can be reached at http://ot4specialtots.blogspot.com.

At Mealtime

Bottle Feeding

V How long does it take the baby to finish a bottle and how many ounces of fluid are in it? How many bottles does he consume a day?

V Does he have a good latch-on and pattern of suck-swallow-breathe? Is he taking in excess air? What is the flow rate of the nipple?

V Where is he fed and how is he held by the adult? Can he hold the bottle with both hands?

V Does he burp well? Does he spit up or vomit after a bottle?

Breast Feeding (Ask the bottle-feeding questions in addition to these)

V Is the baby fed on a schedule or on demand? How long does it take him to nurse? Does he switch sides or just nurse off of one breast during a feeding?

V Will he let you hold him facing toward you only when he is nursing or at other times too?

V When the mom expresses breast milk, how much milk is she making in the morning? In the evening? (The amount of milk made in the morning is typically higher than in the evening.)

Foods

V Does he like pureed baby food? How does he react to textured or lumpy foods? Does he like certain categories of taste (sweet, tart, bland, salty, spicy)? Is he a picky eater?

V Does he like his food at particular temperatures? How does he respond to odors?

V Does he like various textures of snacks: soft, crunchy, resistant? Can he munch and chew or does he suck the food until it is mushy or dissolved? Can he finger feed himself snacks?

V Does he gag or choke often? Does he pocket food in his cheeks or the roof of his mouth?

V Where is he located while eating baby food and/or snacks: walking around, high chair, booster seat, swing, adult's lap? Does he graze, have scheduled feeding and snack times, or eat only when acting hungry?

V If he is an older baby, can he drink from an open cup, sippy cup or cup with a straw?

V Do certain foods tend to cause diarrhea or constipation?

Changes and Dressing

V Where does a typical diaper change occur: changing table, bed, floor or other place?

V Does he mind if the wipes/cloth are cold or do they need to be warmed? Does he get rashes?

V When clothing is pulled over his head, how does he respond?

V If upset with diaper changes and dressing, how long does it take him to calm down?

V Does he fuss less if not lying down when getting dressed? Does he fuss when wearing clothing of certain textures or fabrics such as lace or polyester?

Bath

V Does he enjoy taking a bath? Does the bath seem to relax him? Is he more or less interactive during a bath such as babbling, moving around or reaching for items?

V Does he bathe in a baby tub/seat, sink or large tub?

V How does he respond to water over his head or on his face? Does he like splashing or playing with toys during the bath? Is he particular about the temperature of water?

V Does the sound of water running seem to bother him?

V Does he get upset when being dried off with a towel? Does he like lotion being rubbed onto his skin?

Play

V What type of toys does he enjoy: musical, light-up, mechanical?

V Does he play with a variety of toys in a variety of ways? Does he give up easily if he cannot figure out how a toy operates?

V Will he play in a variety of positions (lying, sitting or standing? Are his balance and posture skills age-appropriate? How is his muscle tone (low, typical or high)?

V How long does he stay in positioning devices: bouncy seat, bouncer, car seat?

V Can he obtain toys by rolling, crawling, scooting or while sitting, cruising or walking? Is he fearful of movement such as in a swing or slide?

V Does he use both hands equally or have a preference?

V Does he bring toys to his mouth or like to rub teethers onto his gums?

V How long can he attend/focus on playing with a toy or person? Does he coo, babble or talk while playing?

V How much television is he exposed to? What is he doing while the caregivers or family members are watching television?

V Does the child get to play outside or mainly just indoors? Does he play with the pets or siblings?

Car Rides

V Does he enjoy car rides? Does he tolerate getting in and out of the car seat?

V Will he hold toys in his hand during the car ride? Does he reach for dangling toys attached to his car seat?

Away from Home

V What places other than the home does the baby commonly go?

V Does he like being in a stroller?

V How does he respond to crowds or loud environments? How does he respond to strangers?

V How does he do with schedule changes? How does he do with transitions from one activity or place to another?

V Can he eat, drink and sleep in places other than his home?

Socializing

V How long can he participate in reciprocal interaction with another person (e.g. babbling or smiling as a parent talks to him)?

V Does he become upset if a person gets too close to him or talks too loudly?

V Does he have to be held a certain way or can it vary?

V Does he separate well from parents and other caregivers?

Soothing

V Do you consider him a fussy, typical or easy baby? How many hours a day does he typically cry?

V Are you able to discern what his cries mean or do they all sound similar?

V How long does it take for him to recover when getting upset? Can he calm himself by sucking his thumb, fingers or pacifier? By holding a comfort toy? If he requires you to console him, what techniques work best?

V Does he get overwhelmed by activities with limited sensory stimulation or those with multiple sensations?

Sleep

V How many hours does he sleep at night? Once asleep, does he wake easily or stay asleep? Is his night waking on a regular basis or only when he suffers from colic, teething, an ear infection or other illnesses?

V How long does it take him to fall asleep? Does he have to take a bottle or nurse in order to fall asleep?

V How many naps does he take during the day and for how long?

V Where does he sleep: crib, play yard, car seat, swing, floor or co-sleep in adult's bed? In which room does he sleep: own, parents, with sibling? Does he sleep in a different place for a nap than at night? Is he easily disturbed by noises while trying to sleep?

V How does he let you know he is awake: cry, babble, play?

V What type of fabric is his bedding and sleepwear?

V How is the room decorated: pastel or bright colors, minimal or many wall decorations, minimal or many toys sitting out?