The relationship between sensory processing, childhood rituals and obsessive–compulsive symptoms

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Abstract

Background and objectives

Studies of Obsessive–Compulsive Disorder (OCD) and research in occupational therapy suggest a link between sensory hypersensitivity and excessive use of rituals. The present research constitutes an initial attempt to examine this potential link.

Methods

In Study 1, parents of 4–6-year old children (N = 61) completed the Childhood Routine Inventory, the Sensory Profile and the Screen for Child Anxiety Related Emotional Disorders. In Study 2 we administered an adapted version of the sensory profile to an internet sample of adult participants (N = 314) together with the Obsessive–Compulsive Inventory-Revised, the anxiety subscale of the International Personality Item Pool – NEO and items measuring participants’ recollection of their childhood oral and tactile hypersensitivity.

Results

Strong reactions to everyday sensory events were highly correlated with childhood ritualism, even after controlling for anxiety. In the adult sample, current and recollected oral and tactile hypersensitivity were significantly related to OCD symptoms.

Limitations

In Study 1, children’s sensory sensitivity was not tested directly, but rather through parental report. The scale was developed ad hoc based on face validity and relationship with ritualism. The studies were cross-sectional in design. Study 2 partially relied on recollection of childhood behavior.

Conclusions

The results suggest a strong relationship between sensory sensitivity, childhood ritualism and adult OCD symptoms. Oral and tactile hypersensitivity in childhood may be one pathway to adult OCD.

Highlights

► In kindergarten children, dysfunctional sensory processing was highly correlated with childhood ritualism. ► In adults, both current and recollected oral and tactile hypersensitivity were significantly related to OCD symptoms. ► These correlations were not accounted for by anxiety levels.

Introduction

A potential link between sensory hypersensitivity and the use of excessive rituals has been suggested independently in research on Obsessive–Compulsive Disorder (OCD) (Hazen et al., 2008, Shapira et al., 2003, Stein et al., 2001) and in the discipline of occupational therapy (Baranek et al., 1997a, Baranek et al., 1997b). So far, no research has attempted to integrate these findings into a more comprehensive model. The present research constitutes an initial attempt to integrate findings from research on sensory processing and ritualism in childhood and adult OCD.

Sensory processing refers to the way in which the nervous system manages incoming sensory information (Miller & Lane, 2000). The terms sensory integration and sensory processing are sometimes used interchangeably. However, sensory integration is only one component of the wider concept of sensory processing, referring to the capacity of the nervous system to organize sensations from multiple sensory modalities into an integrated understanding of the environment and one’s place in it.

The study of the phenomena of sensory processing and sensory integration has been given much attention in the area of occupational therapy. The starting point of the focus on these issues in occupational therapy was the work of Jane Ayres (2005/1979), who championed the development of Sensory Integration Theory. Sensory Integration Theory is based on the premise that the primary building blocks of the central nervous system are the senses, and that all other skills are complex processes based on a strong foundation of sensory integration. If the sensory input is not processed and organized accurately, the consequences may sometimes be developmental lags as well as behavioral and emotional problems. Ayres’ theory has given rise to a plethora of studies, mainly dealing with the study of dysfunctions in sensory integration in children. The terms used to describe these conditions include Sensory Processing Disorder, Sensory Modulation Disorder, Sensory Integration Disorder and Sensory Defensiveness (Kinnealey and Wilbarger, 1995, Schaaf and Miller, 2005; Wilbarger & Wilbarger, 1991). These terms all refer to a situation in which a child routinely demonstrates exaggerated or inappropriate response to everyday sensory inputs. These responses are expressed either as over- or under-responsiveness. Examples of common presenting symptoms for over-responsiveness include aversive responses of the child to certain types of clothing, refusal to eat certain types of foods and strong reactions when others touch him/her. Examples of common symptoms for under-responsiveness include not noticing being touched and failing to respond to sounds or visual objects that are obvious to others. None of these conditions are currently diagnosable in the DSM-IV or the ICD-10 and there are no universally agreed upon diagnostic criteria. In order to determine whether a child suffers from any type of sensory dysfunction, clinicians rely on inventories that indicate where the child is located on a continuous spectrum.

One of the popular inventories for assessing sensory processing is the Sensory Profile (Dunn, 1997), which is based on Dunn’s (1997) model of sensory processing. According to this model, people are characterized by their positioning on four major types of sensory processing, defined according to two axes: the response threshold of the nervous system (high/low) and the strategy of response (passive/active). High response threshold and passive response strategy constitutes a processing style called “low registration;” high response threshold and an active response strategy is called “sensory seeking;” low threshold and passive response strategy is called “sensory sensitivity;” and a low threshold and an active response strategy is called “sensory avoiding” (see Table 1).

Sensory dysfunction in a child is likely to be experienced as psychologically distressing and upsetting. Consequentially, the child may search for ways to calm herself down and create order and predictability. A central hypothesis of the present study is that in an attempt to achieve this goal, children may develop excessive ritualistic behavior.

There is some evidence that dysfunctional sensory processing, especially in the form of sensory defensiveness, is related to stereotypic, rigid and inflexible behaviors in children (Baranek et al., 1997a, Baranek et al., 1997b). Repetitive, rule-governed and inflexible behaviors in children are often referred to as rituals. Up to a certain degree, childhood ritualism is considered normative in any child’s development (Evans et al., 1997, Gesell, 1928, Gesell et al., 1974, Leonard et al., 1990). In fact, learning to focus one’s attention and engaging in repetitive behaviors helps the child to achieve a sense of control and mastery of her sensory universe (Gesell, 1928, Gesell et al., 1974, Zohar and Felz, 2001). Some children, however, may engage in an exaggerated amount of rituals, upsetting the daily routine and causing problems in their daily functioning. In pre-school age children, a high degree of childhood rituals was shown to be related to increased anxiety and fears (Evans, Gray, & Leckman, 1999).

The link between childhood rituals and anxiety shares intriguing similarities with the phenomenology of obsessive–compulsive disorder (OCD) (Bolton, 1996, Evans et al., 1997, Leonard et al., 1990), a psychiatric condition associated with repetitive behaviors and ritualism. Especially striking is the similarity between childhood rituals involving excessive insistence that things be done “just so,” rigid repetitiveness and sensitivity to minute details (e.g. stains, defects; Evans et al., 1997) and OCD symptoms involving need for symmetry and exactness, repeating rituals and counting compulsions (Leckman, Mataix-Cols, & Conceicao do Rosario-Campos, 2005). In fact, research has shown that high levels of ritualism in young children constitute a risk factor for the development of obsessive compulsive (OC) symptoms (Bolton et al., 2009).

Some previous findings indeed suggest a relationship between OCD and sensory sensitivity. OCD has been shown to relate to excessive disgust (Shapira et al., 2003, Stein et al., 2001), which can be seen as a type of olfactory, gustatory and tactile hypersensitivity. This excessive disgust is believed to lead to rituals, often centered on cleanliness and on avoiding contamination. More specifically, a series of case studies recently focused directly on the linkage between childhood OCD and sensory sensitivity. This case series suggested that children with OCD exhibit intolerance of ordinary sensory stimuli, which leads to significant subjective distress and time-consuming ritualistic behavior. In this series, the sensory sensitivity symptoms were the primary presenting symptoms, rather than the intrusive thoughts, images, or ideas that are usually associated with OCD (Hazen et al., 2008).

Other than these case studies, no research to date has focused explicitly on the relation between sensory processing, childhood ritualism and adult OC symptoms. The present studies aimed to provide initial data on these relationships. Our working hypothesis was that strong reactions to everyday sensory events may be related to excessive childhood rituals and later to OC symptoms. The studies reported here employed a non-clinical sample in order to gather initial data on these relationships. This approach is justified by abundant evidence regarding the similarity in content and type of OC phenomena across clinical and non-clinical populations (e.g., Rachman and de Silva, 1978, Salkovskis and Harrison, 1984). The use of non-clinical or sub-clinical populations in OCD research has led to valuable insights regarding many aspects of this disorder (e.g., Amir et al., 2001, Gibbs, 1996: Hajcak et al., 2004, Nedeljkovic and Kyrios, 2007, Nedeljkovic et al., 2009, Rachman and de Silva, 1978, Salkovskis and Harrison, 1984, Soref et al., 2008), some of which have been successfully replicated with a clinical population (e.g., Reuven-Magril, Dar, & Liberman, 2008).

In our research program, we first examined the link between strong reactions to everyday sensory events and childhood ritualism in a sample of caregivers for pre-school children (Study1). Based on the results, we created a scale measuring oral and tactile hypersensitivity (OTH). This scale was used in an internet study of adult participants (Study 2) to investigate the linkage between OTH and OC symptoms in an adult population.

Section snippets

Study 1 – strong reactions to everyday sensory events and childhood ritualism

Study 1 aimed to investigate the hypothesis that strong reactions to everyday sensory events are related to ritualism in children. In order to rule out the possibility that this effect is entirely due to anxiety, a measure of trait anxiety was also included.

Study 2 – oral and tactile hypersensitivity and OC symptoms in adults

This study was performed in order to investigate whether past and current oral and tactile hypersensitivity is related to obsessive–compulsive symptoms in adults. As in Study 1, we also measured trait anxiety to verify that any association, if found, was not accounted for by anxiety.

Discussion

The two studies reported here examined the hypothesis that childhood oral and tactile hypersensitivity is related to childhood rituals and to OC symptoms in adult age. Study 1 showed that strong reactions to everyday sensory events in general, and oral and tactile hypersensitivity in particular, are related to childhood ritualism. This relationship remained significant after controlling for the effect of anxiety. Study 2 showed that oral and tactile hypersensitivity is associated with OC

Conflict of interest and financial support

The authors declare no actual or potential conflict of interest in relation to this study. The study was not supported by any agency.

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