J Child Fam Stud (2013) 22:912921

DOI 10.1007/s10826-012-9650-9

ORIGINAL PAPER

Sensory Processing Difficulties, Behavioral Problems,

and Parental Stress in a Clinical Population of Young Children
Lauren Gourley Carina Wind
Erin M. Henninger Susan Chinitz

Published online: 14 August 2012

Springer Science+Business Media, LLC 2012

Abstract This study examined the relationship between

sensory processing difficulties, parental stress, and behavioral problems in a clinical sample of young children with
developmental and behavioral difficulties. We hypothesized that a high rate of sensory processing difficulties
would be found, that there would be a high rate of
comorbidity between sensory processing difficulties and
behavioral problems, and that childrens sensory processing difficulties and parental stress would be highly correlated. Parents of 59 children ages two to five who attended
an out-patient clinic in a low income, urban community
completed the Child Behavior Checklist, Parental Stress
Inventory-Short Form and the Short Sensory Profile.
Children in this clinical population showed a high prevalence (55.9 %) of sensory processing difficulties, a significantly higher rate than previously reported. Sensory
processing deficits were correlated with behavioral difficulties and parental stress levels-suggesting that as sensory
processing difficulties increase, so do behavioral difficulties and parental stress. Parents of children with sensory
processing deficits had significantly higher levels of
parental stress than parents of children without sensory
deficits. Parenting stress levels were also clinically elevated
for the cohort of children in which sensory processing
difficulties and behavioral concerns co-existed. These
findings suggest that treatment outcomes might improve
and parental stress could be reduced if mental health
L. Gourley (&)
C. Wind
E. M. Henninger
S. Chinitz
Department of Pediatrics, Albert Einstein College of Medicine,
Bronx, NY 10461, USA
e-mail: lauren.gourley@einstein.yu.edu
L. Gourley
C. Wind
E. M. Henninger
S. Chinitz
Early Childhood Center, 1731 Seminole Avenue, Bronx,
NY 10461, USA

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clinicians were trained to identify and address sensory

problems. This could result in more children being
screened and treated for sensory processing difficulties and
an eventual reduction in the rates of parental stress.
Keywords Sensory processing disorder

Short sensory profile
Parental stress

Behavioral difficulties
Preschool aged children

Introduction
Childrens ability to regulate sensationthe process of
noticing, organizing, and integrating information from the
environment and their body and then processing and
responding appropriatelygreatly contributes to self-regulation (Greenspan and Wieder 1997). Difficulty regulating
sensory information such as touch, smell, taste, sound,
body movement, or body position can lead to patterns of
hyper-sensitivity to sensory stimuli or sensory-avoidance
(shying away or intensively reacting to loud noises, bright
lights, being held, etc.), hypo-sensitivity to sensory stimuli
(needing high levels of sensory input such as firm touch or
a loud noise in order to register the sensation), sensoryseeking behaviors (seeking constant and intense sensory
input such as repeatedly crashing into walls or banging
toys), or a mixed pattern of under-responsivity, sensory
seeking and/or sensory avoidance (Dunn 2007).
Over the past several years, a wide range of estimates of
the prevalence of sensory processing disorders has emerged
in the literature. The 38-item Short Sensory Profile (SSP;
McIntosh et al. 1999a), derived from the longer Sensory
Profile (Dunn 1997), is a commonly used parent-report tool
(Gunn et al. 2009; Gouze et al. 2009). The SSP has been
shown to differentiate between children with average

J Child Fam Stud (2013) 22:912921

sensory functioning and those with poor sensory regulation

(Ermer and Dunn 1998). Children with total scores falling
within one standard deviation of the mean are rated as
falling into the typical performance group, a probable
difference rating is given to children with total scores
falling between one and two standard deviations of the
mean, and a definite difference rating is given to children scoring more than two standard deviations from the
mean. In the original sample (comprised of a community
sample of children of whom 91 % were Caucasian) 14 %
of the children showed a probable difference and 2 % of
the children showed a definite difference (McIntosh
et al. 1999a). In other studies utilizing the SSP, significantly higher prevalence rates have been reported. For
example, in Gunn et al.s (2009) sample of urban, low
income, mainly Latino preschoolers, 22 % of the children
showed a probable difference and 28.6 % exhibited a
definite difference.
Two studies (Ahn et al. 2004; Gouze et al. 2009) suggest
that, particularly among minority children, the original SSP
cut-off scores may over-report sensory processing difficulties and should be recalculated. Ahn et al. (2004) based
their SSP cut-off scores on findings from previous psychophysiologic studies of sensory processing difficulties,
which showed correlations between parents report of their
childs sensory processing difficulties and results of physiological tests on childrens sensory functioning (Mangeot
et al. 2001; McIntosh et al. 1999b; Miller et al. 1999). Ahn
et al. (2004) hypothesized that children that scored positive for their more stringent SSP criteria of three standard
deviations below the mean in the total score, 2.5 standard
deviations below the mean in two or more of the seven
subscales, or four standard deviations below the mean in
one subscale, would demonstrate sensory processing difficulties consistent with criteria used to identify children
with sensory processing disorders in ongoing psychophysiologic studies (p. 290). Using these criteria, 5.3 % of
children in their sample demonstrated sensory processing
difficulties. Concerns regarding differences in scores
between children with differing racial groups and socioeconomic status (SES) using the original SSP and Ahn
et al. (2004) criteria, prompted Gouze et al. (2009) to
question the community sample that was used to create the
original SSP cut-off scores. Using a diverse community
sample more representative of the general population,
scores of 796 four-year-olds were utilized to calculate new
cut-off scores based on the sample mean and standard
deviation, (the same methodology that is used for the SSP
and is documented in McIntosh et al. 1999a). This resulted
in only 3.4 % of children showing a definite difference
in sensory processing abilities (Gouze et al. 2009). The
authors found that using their diverse community sample to
generate their proposed cut-off score resulted in no

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differences in rates of sensory processing difficulties

between racial groups. However, SES differences in rates
of children with sensory processing difficulties remained
when applying all three cut-off scores to their community
sample. Although researchers are getting closer to agreeing
on cut-off scores and prevalence rates within the community at large, more attention is needed in the area of
understanding prevalence rates in the clinical populationchildren who have already been identified as having mental health and/or developmental difficulties (Gunn
et al. 2009).
Children with poor sensory regulation demonstrate a
wide variety of difficulties across many domains including
externalizing behavior problems (Mangeot et al. 2001),
internalizing behavior problems (Hopkins et al. 2008),
difficulties in emotional and attention regulation (Miller
et al. 2004), and difficulties in many daily activities (Dunn
1997). Poor sensory regulation has been shown to impact
temperament and the formation of personality (Fox and
Polak 2004). Sensory over responsivity has been shown to
be highly associated with early internalizing and externalizing behavior problems and poorly developed adaptive
social behaviors (Ben-Sasson et al. 2009a). In a sample of
796 four-year-old children it was shown that, depending on
the SSP cut-off criteria used, 3363 % of the children who
were rated to have poor sensory regulation using the SSP
also met criteria for one or more psychiatric disorders of
childhood (Gouze et al. 2009). However, the same study,
along with Van Hulle et al.s (2012) work showed that
sensory processing disorders can and do exist independently of psychiatric disorders of childhood. Poor sensory
regulation is a hallmark of autism spectrum disorders, often
found in other neurodevelopmental disorders such as
fragile X syndrome, and cystic fibrosis (Baranek et al.
2008; Ben-Sasson et al. 2007, 2009b; Cascio 2010). Neurological studies have identified differences in frontal lobe
functioning (Yeo et al. 2003), parasympathetic nervous
system functioning (Schaaf et al. 2010), and electroencephalography (EEG) data (Davies and Gavin 2007; Gavin
et al. 2011) in children with poor sensory processing when
compared with the brain functioning of children without
reported sensory difficulties. The reportedly large comorbidity between sensory processing difficulties and other
problems of childhood is notable and serves as an impetus
to better understand the prevalence and connections
between sensory and behavioral difficulties in clinical
populations of young children.
Our study also seeks to explore the possible impact of
sensory processing difficulties on parenting stress. Compared to groups of parents with typically developing children, higher levels of parenting stress are found in parents
of children with medical and psychological diagnoses
(Epstein et al. 2008), anxiety and depression (Rodriguez

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2010), and ADHD and aggressive behavior (Anastopoulos

et al. 1992). Donenberg and Baker (1993) examined the
parental stress of non-autistic children with clinically significant levels of externalizing behaviors, children with no
significant behavior problems, and children with autism.
Compared with parents of normally developing children,
parents of non-autistic children with externalizing behaviors revealed higher child-related stress and greater negative impact on their social life and feelings towards
parenting. In addition, these parents reported stress scores
nearly identical to parents of children diagnosed with autism. Donenberg and Baker speculate that the high levels of
parenting stress could partly result from the ambiguity
associated with the cause of externalizing behaviors. Parents with children who have been diagnosed with autism
and other disorders are better able to understand the
neurobiological origins of such difficult behavior and have
an easier time getting connected to treatment, supportive
services, and resources specific to the disorder (Donenberg
and Baker 1993). Unlike children diagnosed with autism,
children with externalizing symptoms are not always given
a clear diagnosis, and their behavior may more easily be
attributed to simply being a bad child or as a result of
bad parenting.
Sensory processing difficulties in children can have a
significant impact on the family and parentchild relationship patterns (Dunn 1997). A child with sensory processing difficulties may react to the caregiver or his/her
environment in ways that are unpredictable or seemingly
without reason. For example, a child that has a low
threshold for sensory stimuli may react adversely to a
vocalization or touch from a parent or from a tag in their
clothing that a typically developing child would not react
to or even notice. The caregiver, in turn, may be confused
by their childs reactions and experience a decreasing sense
of competence in their parenting abilities. Demanding child
characteristics have been shown to increase parental stress
and suboptimal parenting practices (Abidin 1995). Thus,
knowledge about a childs sensory patterns and triggers
may help the caregiver understand and explain their childs
behaviors and develop an action plan to make interactions
more enjoyable and satisfying to both partners (Dunn
2001). Consistent with Donenberg and Bakers (1993)
suggestion that the vague etiology of externalizing behavior problems in young children may greatly contribute to
reportedly high levels of parental stress, a better understanding of their childs sensory difficulties may increase a
parents sense of competence, decrease negative parental
attributions, and lead to a reduction in parental stress.
Our study seeks to better understand the prevalence of
sensory processing difficulties in a clinical population of
preschool-aged children referred for developmental and
behavioral problems. We will explore the relationship

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J Child Fam Stud (2013) 22:912921

between reports of parental stress, sensory processing

difficulties, and externalizing and internalizing behaviors
in a clinical population. Based on previous research
(Ben-Sasson et al. 2009b; Gouze et al. 2009; Gunn et al.
2009), we hypothesize that a significant overlap will be noted
between children with behavioral difficulties and sensory
processing difficulties. Additionally, we will explore the
impact of behavior problems and sensory processing difficulties on parental stress. Finding a relationship between
reports of externalizing and internalizing behaviors and
sensory deficits may provide parents with a potential neurological explanation for their childrens problem behavior
and help illuminate additional pathways for treatment.

Methods
Participants
Participants included 59 children and their parents, currently attending an inner-city outpatient clinic, which
addresses social-emotional, behavioral, and developmental
problems of young children through psychosocial therapeutic and comprehensive wraparound services. Inclusion
criteria included children who were actively attending
weekly outpatient clinical services and living with a biological or adoptive parent. Children in foster care were
excluded due to issues in obtaining informed consent.
Table 1 depicts descriptive statistics for participants.
Children ranged between the ages of 3 and 5 years old
(l = 4.1 years) to meet the validated age ranges of the
assessment tools. Ethnic backgrounds of children included:
64.4 % Hispanic/Latino, 16.9 % African-American,
11.9 % mixed race/bi-racial, 5.1 % unknown and 1.7 %
Caucasian. All children resided in a low income, urban
community in New York. A large percentage of our sample
resided in bilingual Spanish and English households
(57.6 %) with an additional 8.5 % monolingual for Spanish
and the remaining 33.9 % monolingual for English. Most
children (89.9 %) were Medicaid recipients and 10.2 %
were covered by private insurance. Childrens diagnoses,
gathered through chart review, included diagnoses from the
Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition, Text Revision (DSM IV TR) and, when appropriate diagnostic classification was not available in the
DSM IV TR, from the International Classification of Diseases Volume 9. Diagnoses included a wide range of
developmental and behavioral diagnoses. In our sample,
54.2 % of children were diagnosed with both behavioral
and developmental disorders, 37.3 % were diagnosed with
only one or more behavioral disorder(s), and 8.5 % were
diagnosed with only one or more developmental disorder(s). Developmental diagnoses included speech and

J Child Fam Stud (2013) 22:912921

language disorders (52.5 %), global developmental delays

(10.2 %), autism (6.8 %), and developmental coordination
disorder (6.8 %). Behavioral diagnoses included parent
child relational problem (PCRP), (38.9 %) attention deficit
hyperactivity disorder (23.7 %), disruptive behavior disorder (23.7 %), post traumatic stress disorder (10.2 %),
adjustment disorder (8.5 %), oppositional defiant disorder
(6.8 %), mood disorder not otherwise specified (5.1 %),
selective mutism (5.1 %), disorder of childhood, not
otherwise specified (3.4 %), and anxiety disorder (1.7 %).
It is notable that only four children (6.8 %) were diagnosed
with only PCRPa v-code diagnosis indicating clinically significant behavioral and/or emotional symptoms in
the child in which the target of therapeutic action is the
relationship between parent and child), and the remaining
19 children (32.1 %) diagnosed with PCRP had multiple
behavioral diagnoses.
Measures
Child Behavior Checklist: Ages 15 (CBCL)

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Table 1 Descriptive statistics for child participants
Characteristic

Age

Total
n (%)

SSP scores
Typical
n (%)

v2

1.10

0.578

1.01

0.316

4.54

0.103

1.38

0.239

1.38

0.441

3.27

0.195

Definite
n (%)

l = 4.1 years

Age 3

18 (30.5)

8 (44.4)

10 (55.6)

Age 4

19 (32.2)

10 (52.6)

9 (47.4)

Age 5

22 (37.3)

8 (36.4)

14 (63.6)

Male

36 (61.0)

14 (38.9)

22 (61.1)

Female

23 (39.0)

12 (52.2)

11 (47.8)

Hispanic/
Latino

38 (64.4)

14 (36.8)

24 (63.2)

AfricanAmerican

10 (16.9)

4 (40.0)

6 (60.0)

Other*

11 (18.7)

8 (72.7)

3 (27.3)

Medicaid

53 (89.8)

22 (41.5)

31 (58.5)

Private
insurance

6 (10.2)

4 (66.7)

2 (33.3)

Gender

Ethnicity

Insurance type

Caregiver
language
English

40 (67.8)

19 (47.5)

21 (52.5)

Spanish

19 (32.2)

7 (36.9)

12 (63.1)

22 (37.3)

13 (59.1)

9 (40.9)

The CBCL (Achenbach and Edelbrock 1983) is a parentcompleted inventory that assesses childrens behavioral,
emotional, and developmental symptoms and is one of the
most widely-used of its kind due to its strong construct,
content, and criterion validity (Gunn et al. 2009). In
addition to providing a total score and clinical cut-offs
derived from a large representative sample, the CBCL
provides many sub-scales which assess facets of internalizing and externalizing behavior problems. Based on a
three point scale of never (0), sometimes (1), or always (2),
parents are asked to respond to 100 questions regarding
their childrens behavior. T-scores of 65 or greater suggest
that there is reason for clinical concern and the child is at
risk. The scale demonstrates good psychometric properties
with testretest reliability correlations consistently between
0.80 and 0.90 and minimal effects of age, gender and SES
on the validity of the scale (Rescorla 2005).

a both multiple choice questions and a 5-point Likert scale

ranging from (1) strongly agree to (5) strongly disagree, the
PSI-SF asks parents to respond to 36 statements such as
my child rarely does things that makes me feel good.
The PSI-SF has been shown to be a reliable and valid
measure of parental stress (Abidin 1995).

Parenting Stress Index Short Form (PSI-SF)

Short Sensory Profile (SSP)

The PSI-SF is a parent-completed assessment of parenting

stress which examines how child characteristics, parent
characteristics and situational variables relate to total
parental stress (Abidin 1995). The measure delineates three
types of parental stress; Parental Distressan impaired
sense of competence in the parenting role, lack of social
support, role-restriction, depression, and conflict with ones
spouse; ParentChild Dysfunctional Interactionchild fails
to meet parents expectations and interactions with the
child are not pleasurable; and Difficult Childcharacteristics of the child that make them difficult to manage. Using

The SSP (McIntosh et al. 1999a) is a 38-item parentcompleted measure created to determine functional
behaviors related to sensory processing difficulties in
children age 310 in seven domains: tactile sensitivity,
taste/smell sensitivity, movement sensitivity, underresponsive/sensation seeking, auditory filtering, low
energy/weak, and visual/auditory sensitivity (Dunn
1999). The Short Sensory Profile is a short form of the
Sensory Profile, and has been normed in English and
Spanish. The SSP asks parents to reply to behavioral
descriptions of various sensory-laden events (avoids

Diagnosis
Behavioral
Developmental

5 (8.5)

Both dev. &

beh.

32 (54.2)

2 (40.0)

3 (60.0)

11 (34.4)

21 (65.6)

SSP scores using original cut-off criteria, Typical typical and probable performance on SSP, Definite definite difference on SSP; N = 59, * other
category was created so that data could be analyzed and consists of 7 (11.9 %)
mixed raced/bi-racial, 3 (5.1 %) unknown, and 1 (1.7 %) Caucasian children)

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going barefoot especially in sand or grass) using a

5-point Likert scale (always, frequently, occasionally,
seldom, or never). Higher scores reflect more adaptive
functioning and more normal performance. The SSP has
been found to be a reliable tool with excellent validity
(Ahn et al. 2004; Rodriguez 2010). Construct validity
was established by showing that children with significant
scores on the SSP has abnormal physiological responses
as measured by electrodermal responses (EDR) during a
standardized battery of sensory stimulating activities
(Miller et al. 1999).
Protocol
Parents of children that met the inclusion criteria were
invited to participate in the study by the childs treating
clinician prior to the weekly therapy session. A bilingual
researcher subsequently obtained informed consent and
administered the SSP to parents in their preferred language
of English or Spanish. While most parents completed the
SSP in written form, parents who indicated reading difficulties were offered the option of having the questionnaire
read to them. Medical chart review documented demographic variables as well as results of the CBCL and PSISF questionnaires which were administered in English or
Spanish based on the caregivers primary language. As
with the SSP, parents were read the CBCL and PSI-SF
questionnaires if they were unable to complete them in
written form. The study was carried out with the approval
of the Institutional Review Board at Albert Einstein College of Medicine.
Data Analysis
Descriptive statistics and frequencies were compiled.
Pearsons r correlations were performed between the subscale and total raw scores of the SSP, CBCL, and PSI-SF.
Independent t tests and Chi-square analysis were performed
to assess the group differences in sensory processing difficulties. One-way between subjects ANOVAs were used to
further examine possible differences between SSP and PSISF scores based on each childs diagnosis. Based on the
preponderance of use of McIntoshs original SSP criteria in
the literature, children who scored in the definite difference category are used throughout the remainder of the
analysis when discussing significant results. The total
problem behavioral score, and internalizing and externalizing subscales of the CBCL qualified as statistically significant when a subject received a T-score of 65 or greater,
indicating the 90th percentile. Total and subscale scores of
the PSI-SF reached clinical significance when reaching the
85th percentile.

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Results
Prevalence
In our clinical sample and using the original cut-off scores
on the SSP, 55.9 % of children were rated in the definite
difference category indicating likely sensory processing
difficulties, 11.9 % had scores which fell into the probable difference category and 32.7 % scores in the typical
performance category (l = 134.57, SD = 29.65). Chi
square analysis showed there were no significant differences in demographic variables and diagnoses for children
scoring above or below the cut-off scores (Table 1).
Table 2 reports differences in prevalence rates using the
criteria proposed by McIntosh et al. (1999a), Ahn et al.
(2004), and Gouze et al. (2009) compared with the rates of
sensory processing difficulties established in their original
community samples. All three cut-off criteria resulted in
significantly higher prevalence rates compared to previously reported estimates of prevalence based on community samples (p \ 0.001). On the CBCL, 44.1 % of
children had clinically-elevated total behavior concerns,
52.6 % of children showed clinically elevated externalizing
problems and 30.5 % showed clinically elevated internalizing scores. Results from the PSI-SF revealed that 42.4 %
of parents reported clinically-elevated levels of total
parental stress.
Correlations
Pearsons r correlations revealed that there was a significant
relationship between poor sensory processing functioning
and total problematic behaviors (r = -0.523, p \ 0.001),
total internalizing behaviors (r = -0.515, p \ 0.001),
total externalizing behaviors (r = -0.459, p \ 0.001),
and parental stress (r = -0.384, p = 0.003) (Table 3).
Although causality cannot be inferred, these results suggest
that as sensory processing functioning worsens, the severity
of behavioral problems and parental stress increases. The
relationship between parental stress and externalizing
behaviors (r = 0.253, p = 0.059), total problematic
behaviors (r = 0.249, p = 0.057) and internalizing behaviors (r = 0.153, p = 0.248) did not reach significance.
Sensory Processing and Behavior Problems
Independent t-test revealed that children who scored in the
definite difference category on the SSP had significantly
higher means of CBCL scores for problematic externalizing
behaviors (l = 68.49), internalizing behaviors (l = 62.88)
and total behavioral problems (l = 67.79) than those with
typical processing (l = 57.26, t(50) = -3.67; l = 54.26,
t(50) = -3.49; l = 56.05, t(50) = -4.29; p \ 0.001).

J Child Fam Stud (2013) 22:912921

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Table 2 Prevalence of sensory processing difficulties with proposed cut-off criteria compared to previous community sample prevalence rates
Cut off criteria

Current study prevalence rates

Previous community sample rates

n (%)

n (%)
Typical
performance

Probable
difference

Definite
difference

v2

Typical
performance

Probable
difference

Definite
difference

McIntosh et al. (1999a)/SSP

19 (32.2)

7 (11.9)

33 (55.9)

871 (83.99)

145 (13.98)

21 (2.03)

347.87

0.0001*

Gouze et al. (2009)

33 (55.9)

26 (44.1)

759 (96.6)

37 (3.4)

125.05

0.0001*

Ahn et al. (2004)

11 (35.6)

38 (64.4)

1700 (94.7)

96 (5.3)

369.22

0.0001*

Current study N = 59, McIntosh et al. (1999a) N = 1,037, Gouze et al. (2009) N = 796, Ahn et al. (2004) N = 1,796; Chi squares are
comparing difference in rates of definite sensory processing difficulties in our studys clinical population versus previous community samples
prevalence rates; * p \ 0.001

Thirty-nine percent of children were co-morbid for both

clinically significant total behavior problems on the CBCL
as well as definite sensory processing issues on the SSP;
16.9 % had only definite difference sensory concerns,
5.1 % only clinical levels of total behavior problems, while
39 % had no clinically significant concerns on either
measure.
Sensory Processing and Diagnosis Category
A one-way between subjects ANOVA was conducted and
showed that mean SSP scores were not significantly different between children with only behavioral diagnoses
(l = 144.77), only developmental diagnoses (l = 130.00),
or who had both developmental and behavioral diagnoses(l = 128.28, F(2, 56) = 2.17, p = 0.124). This means
that in our sample, presence of, or comorbidity with a
developmental diagnosis did not significantly impact SSP
scores.

Table 3 Pearsons r correlations between raw total scores on the

SSP, CBCL and PSI-SF and subscales
Scale

SSP total
score

PSI-SF total
score

CBCL
Total

-0.523**

0.249

Internalizing behavior
Externalizing behavior

-0.515**
-0.459**

0.153
0.253

PSI-SF
Total

-0.384**

Parental distress

-0.273*

ParentChild dysfunctional interaction

-0.266*

Difficult child

-0.496**

SSP short sensory profile, CBCL child behavior checklist, PSI-SF

parenting stress index short form; N = 59; * p \ 0.05; ** p \ 0.001

Parental Stress
Parents of children with definite difference sensory processing scores reported higher levels of total parenting stress
(l = 96.76) than parents of children with typical processing
(l = 80.92, t(57) = 2.45, p = 0.017). Interestingly, when
exploring the subscales of the PSI-SF it was found that parents
who reported that their children had definite difference
sensory processing difficulties also reported significantly
higher levels on the difficult child subscale (l = 38.82)
than parents of children who did not score in the definite
difference range on the SSP (l = 29.88, t(57) = 3.81,
p \ 0.001). Significant differences on the two other subscales
of the PSI-SF, parental distress and parent child dysfunctional
interaction, were not found. Parents who reported that
their child had significant total behavioral problems did not
report significantly higher levels of total parenting stress
(l = 97.54) than those with subclinical behavioral concerns
(l = 84.46, t(57) = 1.79, p = 0.054). However, significantly higher rates of parental stress was found when comparing children who scored in the clinically significant range
on the externalizing problems subscale of the CBCL
(l = 97.79) compared to those who did not (l = 82.03,
t(57) = 2.45, p = 0.043). Significantly higher rates of total
parental stress were found when children scored in both the
definite difference range of the SSP and the clinical range of
total behavior problems on the CBCL (l = 98.62) compared
to those who did not (l = 84.89, t(57) = 2.01, p = 0.049).
Finally, a one-way between subjects ANOVA showed no
statistically significant difference between total parental stress
levels in parents of children with only behavioral diagnoses
(l = 81.14), only developmental diagnoses (l = 93.20), and
children with both developmental and behavioral diagnoses
(l = 95.19, F(2, 56) = 2.07, p = 0.136).
Discussion
Children who presented in our clinic due to developmental
and/or behavioral concerns had a high prevalence of

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sensory processing difficulties identified by the proposed

cut-off criteria of the SSP: 55.9 % by the original McIntosh
et al. (1999a) criteria, 64.4 % by the Ahn et al. (2004)
criteria and 44.1 % by the criteria suggested by Gouze
et al. (2009). Like children with autism who have reported
rates of sensory processing difficulties as high as 4088 %,
the children in our study presented with similarly high rates
of sensory processing difficulties (Kientz and Dunn 1997;
Talay-Ongan and Wood 2000). Children diagnosed with
one or more behavioral disorder(s) in our study did not
have statistically different SSP scores when compared with
children with only developmental diagnoses or children
who were comorbid for both developmental and behavioral
diagnoses. When examining the highest prevalence rate
that resulted from the cut-off criteria proposed by Ahn
et al. (2001) we noted that many of the children in our
study (57.6 %) met their criteria for sensory processing
difficulties due to having more than one SSP subscale with
scores more than four standard deviations away from the
subscales normed mean. The severity of sensory processing difficulties demonstrated by scoring this far from
the normative samples mean is notable and indicates that
not only do many children who present in clinical settings
show signs of sensory processing difficultiesbut their
symptoms and difficulties are severe in nature.
In our preschool-aged clinical population we found high
levels of comorbidity of reported sensory processing difficulties and internalizing and externalizing behavioral
problems. As previously noted (Gunn et al. 2009; Hopkins
et al. 2008; Mangeot et al. 2001), it is important to continue
to highlight this trend due to the likely connection between
sensory difficulties and internalizing and externalizing
behavioral problems. Our study shows that when children
are rated by their parents as having sensory processing
difficulties, they also have significantly higher means of
problematic externalizing behaviors, internalizing behaviors, and total behavioral problem scores than those with
typical sensory processing. Although one possible explanation for this high correlation could be that the SSP produces false positives for children with behavioral
problems and/or psychopathology, previous work has
shown that even when a modified version of the SSP is
used with questions related to temperament or behavioral
difficulties removed there is a high correlation between
sensory processing difficulties and psychopathology
(Gouze et al. 2009). These results highlight the notion that
addressing behavioral problems without understanding and
addressing accompanying sensory difficulties may hinder
progress in treatment as targeted behavioral difficulties
may mask underlying sensory processing difficulties.
Although at the outset we wondered if children with
developmental diagnoses would be more likely to present
with significant sensory difficulties, in our clinical

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population the presence of, or comorbidity with, a developmental diagnosis did not significantly impact SSP scores.
The connection between developmental difficulties and
behavioral problems has been well documented; parents of
young children with developmental delays and disorders
rate their children with more behavioral problems than
non-delayed children (Baker et al. 2002, 2003). Our finding
that there was no statistically significant difference in
sensory processing scores between groups of children with
only behavioral diagnoses, only developmental diagnoses,
or comorbid developmental and behavioral diagnoses
underlines the importance of screening all children who
present in behavioral health settings for sensory processing
difficulties. Addressing behavioral or developmental
problems without understanding and addressing accompanying sensory difficulties may hinder progress in treatment
as the targeted behavioral difficulties may be masking
underlying sensory processing difficulties. Sensory needs
must be considered regardless if they are occurring with
accompanying behavioral, emotional, and/or developmental disorders, or if they are occurring on their own.
Finally, we found that parents of children with definite
difference sensory processing difficulties reported higher
levels of total parenting stress than parents of children with
sensory processing abilities in the typical range. As sensory
processing problems increase in severity, so did levels of
parental stress. Parents of children who were rated as having
definite difference SSP scores reported significantly
higher levels of stress in the difficult child subscale of the
PSI-SF, while showing no difference in stress levels on the
two other subscales which are connected to the parents own
feelings and relationship with his or her child. While causality is not clear, this finding could suggest that the stress
that parents experience could be related to the manifestation
of their childs sensory processing difficulties. Interestingly,
while t-tests showed that parents of children with clinically
significant externalizing behavior scores were more stressed
than parents of children with subclinical externalizing
behavior scores, Pearsons r correlations revealed that
parental stress did not similarly increase as total, externalizing, or internalizing behavioral problems worsened. This
finding could be due to our small sample size and should be
further explored as other studies have established the strong
relationship between behavior problems and parenting stress
(Donenberg and Baker 1993; Walker and Cheng 2006).
Parents of children with both definite difference scores for
sensory processing and clinically significant total behavior
problems had significantly higher levels of stress compared
to children who had only severe behavioral problems or
definite difference levels of sensory processing difficulties. The reportedly high stress levels of parents is cause for
concern and highlights the importance of better detection and
treatment of childrens sensory processing difficulties.

J Child Fam Stud (2013) 22:912921

Previous research has illustrated the reciprocal and

mutually amplifying nature of childrens behavior problems and parental stress (Donenberg and Baker 1993;
Baker et al. 2003). If a child does indeed present with
sensory processing difficulties, identifying the specific
problems and helping parents understand and address their
childs sensory difficulties will likely lead to more efficient
reduction in negative symptomatology and a reduction in
parental stress. Additionally, given that parental stress
often accompanies poorly diagnosed behavioral difficulties
(Donenberg and Baker 1993), identification of sensory
deficits may provide parents with a potential constitutional
explanation for their childrens behavioral problem.
Increasing parents understanding of the possibly neurological basis of the behavior may provide an understandable explanation of the problem behavior, may help
illuminate additional pathways for treatment, and could
increase parental understanding and empathy of their
childs experience and difficulties.
Early identification of sensory processing difficulties and
an increase in referrals for occupational therapy will hopefully
lead to a reduction in childhood difficulties and parental stress.
In addition, we are hopeful that new pathways for multi-disciplinary evaluation and treatment will emerge as the mental
health field becomes more aware of the signs and symptoms of
sensory processing difficulties in young children. One such
documented intervention focuses on enhancing the quality of
mothers interactions with their toddlers diagnosed with sensory processing difficulties (Jaegermann and Klein 2010). The
brief intervention included showing mothers videos of their
toddler in action paired with video feedback regarding their
toddlers sensory profile and fundamentals of quality parent
child interactions. The protocol was successful in increasing
parental empathy, increasing parents use of appropriate
teaching behaviors, and in improving the parents support of
their childs communication behaviors. The authors showed
that a dyadic intervention was more effective in increasing the
quality of motherchild interaction with children with sensory
processing difficulties compared with children who were
provided with individual occupational therapy focused on
sensory processing.
There are several limitations to our study. This study
relies on parents report of stress and their childs difficult
behaviors. While the CBCL, PSI-SF and SSP have been
established as having excellent validity (Abidin 1995;
McIntosh et al. 1999a; Rescorla 2005; Roberts 2011) and
the SSP has been shown to identify sensory processing
difficulties which can also be captured using expert ratings
and physiological tests (McIntosh et al. 1999a; Miller et al.
2012), it is important that future work continues to establish the validity of parent-report measures. Recent work has
highlighted possible overlap between ADHD symptoms
and the auditory filtering and underresponsive/seeks

919

sensation subscales of the SSP leading some researchers to

utilize a modified SSP when screening children with
diagnosed cases of ADHD for sensory processing difficulties (Miller et al. 2012). While this is a limitation of the
scale, the same group reported distinct differences on the
SSP, specifically greater impairment on the other subscales, between children presenting with ADHD or
comorbid for both problems versus children with only
sensory processing difficulties (Miller et al. 2012). These
results, combined with findings of Gouze et al. (2009)
reporting significant correlations between sensory processing difficulties and psychopathology despite the
removal of overlapping questions from the SSP, provide
support for utilizing the scale in its entirety. The children in
our sample reside in the poorest urban county in the United
States (Roberts 2011), and the majority are racial minorities and are from low SES backgrounds (using eligibility
for Medicaid as a proxy for income status) (Krieger et al.
2006). In addition, 66.1 % of children were from bilingual
or monolingual Spanish households and 52.5 % of children
in the sample were diagnosed with a speech and language
disorder. It has been shown that these factorschildren
primarily from racial minority groups, children with low
SES, children in bilingual households, and children with
speech and language difficulties may be more frequently
shown to have probable or definite difference scores
on the SSP due to possible measurement problems with the
tool (Gouze et al. 2009; Gunn et al. 2009). Although we did
not find differences in scores due to gender or ethnicity as
documented in previous literature (Gouze et al. 2009), the
lack of difference in our sample may be the result of our
relatively small sample size. This limitation also highlights
the need for this population to be studied more thoroughly,
as well as the need to confirm the entirety of our results in a
larger sample size. Additionally, high parental stress may
lead parents to develop a negative view of their child and
possibly over-report their childrens perceived difficulties
(Epstein et al. 2008). Finally, many of the children who
attend our clinic have experienced trauma, symptoms of
which could mimic sensory processing difficulties, for
example sensitivity to sudden noises or over-reactions to
being touched.
Better identification and acknowledgement of childrens
sensory processing difficulties may lead to more comprehensive treatment in behavioral health settings. In our
clinic and likely many others, the SSP is not routinely
administered at admission. Given the high prevalence of
sensory processing difficulties found in our study, routine
administration of the SSP seems warranted. Better identification may not only lead to better understanding of the
needs of children served but also help to shape and dictate
the interventions applied. For example, a child with severe
sensory avoidant behavior who is not identified as having

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920

sensory processing difficulties might be labeled as noncompliant or as displaying symptoms of oppositional

defiant disorder. Rather than taking a behavioral approach,
such as rewarding for compliance and ignoring negative
behaviors, clinicians who adopt a sensory-friendly
approach might help parents understand the neurological
underpinnings behind their childs avoidance of loud
noises, unwanted touch, or strong tastes. Clinicians might
then support the parent in adapting the environment and
their interactions to reduce stressful sensory input, resulting
in a reduction of their childs previously erroneously
described oppositional behaviors. Using a sensory processing lens in tandem with best practices in developmental
and behavioral assessment and intervention will likely
better explain and address problem behavior and may result
in more expedient and positive treatment outcomes.
As the sensory processing field continues to evolve, we
hope that training of mental health professionals in
assessing and addressing sensory processing difficulties
will increase and improve. Future research should investigate the hypothesis that better identification and treatment
of sensory processing difficulties in young children with
developmental and/or behavioral difficulties could lead to
improved treatment outcomes including a reduction in
behaviors problems and parental stress. As work moves
forward in the area of physiological measures of sensory
processing difficulties we are hopeful that consensus will
emerge regarding SSP cut-off criteria. Additionally, as a
significant overlap between externalizing and internalizing
behavior and sensory processing difficulties was found,
examining the CBCL in hopes of identifying the questionnaire items that are highly correlated with definite
difference scores on the SSP could lead to the development of a useful CBCL sensory subscale. The subscale
could then be used as an initial screening tool for the
prevalence of sensory processing difficulties. Given the
CBCLs wide use in the field, identifying such a scale
seems valuable and useful. Better understanding, screening, and treatment of sensory processing difficulties in the
clinical population will likely lead to improved treatment
outcomes, a reduction in parental stress, and improvements
in the relationship between parents and children with sensory, developmental, and behavioral concerns.
Acknowledgments The authors would like to thank the Bronx
CREED project funded by NIHs National Center for Minority Health
& Health Disparities (grant # P60 MD000514) for their help with
language translational services, Paraic Kenny, PhD for his generous
assistance with statistical analysis, Sarah A. Schoen, PhD, OTR for
her prompt attention in solving a SSP scoring question, Emily Fried,
LMSW, MSEd for her assistance, and the clinicians and families of
the Early Childhood Center who participated in this study. Financial
support for this project was provided in part by a Leadership Education in Neurodevelopmental Disabilities (LEND) fellowship to the
second author.

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