QUESTION: What Can Interoception Dysfunction Cause Toilet Training Issues?

QUESTION:

I am a school-based OT working with a 7-year-old, regular education student. I initially began treating her in kindergarten for fine motor, visual motor, and SI deficits. She has a diagnosis of Autism, but she is very high functioning. She is not toilet trained and must wear pull-ups to school. Her parents have taken her to specialists to rule out medical reasons and have not found any answers. She is unaware of when she goes even with underwear. Very recently, her parents shared that she has trouble with constipation and over-eating as well. Her body temperature regulation also seems off. At their most recent appointment in Boston, their doctor brought up the possibility of interoception dysfunction. As a result, her mother contacted me to see if I’ve had experience working with this and if there was anything I could do to improve the functioning of this sense. I’ve been an OT for about 10 years and have not heard of this. I formally tested her primitive reflexes, and she does have a retained ATNR reflex, so I plan to incorporate more integration exercises into my sessions and train the parents to complete them at home. I’ve read that therapeutic listening, Wilbarger brushing protocol, and a consistent sensory diet might also help but I was wondering if you had any insight to share on this topic. Any feedback would be greatly appreciated. Thanks for your time!

GWEN’S ANSWER:

Interoception is now considered to be the eighth sense. This sensory system tells us if we are hungry or thirsty; if we need to go to the bathroom; and if we are hot, cold, ill, or in pain. It does indeed sound like this child has symptoms of interoceptive dysfunction. Unfortunately, we don’t have easy access to this sensory system. But there does seem to be a link between the vestibular system and the interoceptive system. So if I see interoceptive UNDER-responsiveness, I use alerting vestibular input. If I see interoceptive OVER-responsiveness, I use calming vestibular input. Sounds like you are describing interoceptive UNDER-responsiveness so I would incorporate activities like the following into her sensory diet:

  • spinning
  • multi-directional fast swinging
  • bilibo, balance boards, therapy ball activities

I have also had some success with pressure garments as it seems to increase awareness of what’s happening internally. One boy I treat stopped having accidents after starting to wear the Squease Pressure Vest. This one is from the Netherlands, but the Snug vest from the states is very similar. Both are expensive, but it may be worth it to the family. I do use both the iLS and Therapeutic Listening programs in my practice but haven’t looked into the use of either for these types of issues. It makes sense that certain programs/tracts from both could be helpful. There isn’t much research on this issue yet, so we are still at the trial-and-error phase. I hope this gives you a starting point at least. Please let me know if I can be of further assistance.

Best Wishes,
Gwen