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By Jennifer Jo Brout, Roianne Ahn, and Madeline S. Appelbaum

This article was published as part of Reframed: The Journal of Self-Reg Volume 2, Issue 1 (2018)

Brout, J.J., Ahn, J.& Appelbaum, M.J. (2018) Reframe: Sensory Over-Responsivity, Attachment, and Self-Regulation: Considerations of the Specific Impact of Auditory Stimuli The Journal of Self-Reg, 2(1), 6-15

This paper explores how the developing infant’s over-sensitivity to sensory stimuli may negatively impact co-regulation and the overall attachment relationship. Research supports that between 5 and 16% of typically developing children experience sympathetic nervous system arousal in response to various kinds of sensory stimuli (Ahn, Miller, Milberger, & McIntosh, 2004; Ben-Sasson, Carter, & Briggs-Gowan, 2009). In order to elucidate how sensory reactivity and the attachment relationship interact we briefly review both areas of research. We then narrow our focus to contemporary attachment theory (Fonagy, Gergely, Jurist, & Target, 2002; Fonagy & Target, 1977) and propose ways in which sensory processing problems serve to inhibit co-regulation, disrupt the child’s ability to understand the mental states of self and other (mentalization), and consequently hinder self-regulation. We note the importance of exploring the auditory modality, as individuals with auditory hypersensitivity may be at higher risk for dysregulation regardless of caregiver efforts (Ben- Sasson et al., 2009). A case vignette is presented to illustrate these processes and how they may be remediated through Infant-Parent Training. Finally, the need for translational research is discussed.

Keywords: mental representational system, affect regulation, sensory processing, co-regulation, self-regulation, misophonia, auditory over-responsivity, sensory over-sensitivity

Sensory Over-Responsivity, Attachment, and Self-Regulation: Considerations of the Specific Impact of Auditory Stimuli

Understanding the complex relationship between sensory processing, the attachment relationship, and the development of self-regulation skills warrants both critical thinking and experimental investigation. Two prominent organizations, Zero to Three: The National Center for Infants, Toddlers and Families and the Interdisciplinary Council on Developmental and Learning Disorders (ICDL), recognize sensory processing disorders in their diagnostic manuals.(4) However, sensory processing disorders are not recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). Consequently, the trajectory of sensory impairment through the lifespan and the interactive relationship between sensory processing, attachment, and self- regulation are rarely investigated.

The purpose of this paper is to integrate attachment theory with sensory processing research. More specifically, we highlight how atypical sensory processing may negatively impact the cognitive processes described in a contemporary attachment model that focuses on successful co-regulation as a necessary precursor to self- regulation (Fonagy et al., 2002; Fonagy & Target, 1977).

We briefly review sensory processing and attachment research and follow this with a discussion of the specific ways in which early sensory processing issues may disrupt the caregiver-child relationship within a contemporary attachment model (see Fonagy et al., 2002; Fonagy & Target, 1977). We then present an illustrative case vignette to showcase effective methods practitioners may use to address these issues and conclude with ways in which empirical research might translate into better interdisciplinary practice.

4.The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, or DC:0–5TM includes the diagnostic category “Sensory Processing Disorders” and the Diagnostic Manual for Infancy and Early Childhood, or ICDL-DMIC, includes “Regulatory-Sensory Processing Disorder.”

For a database of SPD research, visit.

Sensory Processing and Attachment Are Inextricably Intertwined

Sensory processing involves the reception of and automatic neurobiological response to stimuli from the outside environment (Brown, Tollefson, Dunn, Cromwell, & Filion, 2001). Yet, individual variations in sensory processing (that is, sympathetic nervous system arousal in response to everyday stimuli) are often overlooked in attachment theory. This is counter-intuitive since the connection between sensory perception and learning is widely accepted in cognitive developmental theory and in basic neuroscience (Vuilleumier, 2005). For example, in 1958 Piaget described how infants’ coordination of sensory-motor actions forms the foundation of cognitive development. As infants begin to explore the world, through sensory perception, they simultaneously internalize models of self and other through their relationship with their primary caregiver. The role of sensory stimuli as a catalyst to learning is explicit in Piaget’s theory, but while the model addresses early interpersonal relationships, it does so mainly in the framework of cognitive development.

Basic neuroscience has also highlighted the connection between sensory stimuli and emotional responding. Specifically, sensory stimuli serve as an antecedent to emotional responding (Almada, Pereira, & Carrara- Augustonborg, 2013). For example, while stzudying fear learning in rodents, LeDoux (1984) mapped the circuit connecting auditory stimuli and the amygdala – the neural structure where the freeze, flight, or fight response is mediated. The senses, then, are connected to complex and incalculable neural processes, including perception, learning, memory, motor coordination, and emotion regulation (Brown et al., 2001; Kandel, Schwartz, & Jessell, 2000; Shepherd, 1994).

Attachment Theory

A full review of attachment theory is beyond the scope of this paper. Therefore, we briefly summarize highlights of the history of this theory, beginning with Bowlby in 1958. For a comprehensive review of attachment theory and research see Grossmann, Grossman, and Waters (2007) or Marrone (2014). Bowlby (1958, 1969) conceptualized the “attachment system” as a set of infant and maternal behaviours that evolved for survival purposes. The infant seeks proximity to the caregiver because he/she experiences distress upon separation. The distressed (or over-aroused) infant cannot independently regulate his/her affective state and therefore relies upon the caregiver for assistance (Bowlby, 1988). Bowlby frames attachment as an adaptive process conserved by evolution that is shared by all mammals. In doing so, he also brings in the physiological elements of distress that reflect sympathetic nervous system arousal.

Researchers operationalized attachment using the Strange Situation paradigm so that it could be evaluated within an experimental framework (Ainsworth, 1985; Ainsworth, Blehar, Waters, & Wall, 1978; Ainsworth & Wittig, 1969). In this paradigm, a child’s response to separation and reunion with his/her mother reflects the degree to which the child perceives her as a secure base. Using this paradigm, researchers categorized the quality of attachment, which was presumably mediated mainly by the mother (caregiver).

However, Thomas and Chess (1977) refocused the attachment relationship onto the caregiver and child dyad, bringing in infant constitutional qualities that affect the relational dynamics. They used the term “goodness of fit” to describe the degree to which mother and child were temperamentally matched (Chess & Thomas, 1986).

Temperament researchers also utilized physiological measures, focusing on affect, attention, and arousal – each of which impact early affect regulation and personality development. As a result, early temperament literature is replete with terms that imply individual differences in arousal states and how this impacts behaviour. Such terms include intensity of response, level of reactivity, responsivity, soothability, regulation, low reactive, and high reactive (see, for example, Feldman, 2007; Feldman & Eidelman, 2007; Fox, 1994; Marshall & Fox, 2007; Moehler et al., 2006; Woodward et al., 2001; Young, Fox, & Zahn-Waxler, 1999).

Contemporary attachment models (see, for example, Fonagy et al., 2002; Gergely & Watson, 1996) hold that co-regulation is the foundation of eventual self-regulation through a process by which the child learns about the boundaries of self and other (Foley & Hochman, 2006; Greenspan, 1992; Williamson & Anzalone, 2001). Sensory processing as a potential mediating variable, however, is not emphasized even within contemporary attachment models. In order to lay the groundwork for this possibility, the next section focuses on Sensory Processing Disorder, specifically the subtype Sensory Over Responsivity, or SOR.

Sensory Processing Disorder

The term Sensory Processing Disorder (SPD) describes individuals who may over-respond or under-respond to sensory stimulation, or who crave more sensory stimulation than others. Individuals with SPD may also have problems differentiating stimuli with the modalities affected, as well as problems with motor planning and sensory- motor integration. Over the past 20 years, an impressive body of literature has emerged demonstrating individual differences related to the tactile, auditory, visual, gustatory, olfactory, proprioceptive, and vestibular systems. These differences are often associated with various problems related to daily living, including motor planning, visual and auditory discrimination, as well as processing and reacting to sensory stimuli in a graded manner (Bundy & Murray, 2002; Greenspan & Porges, 1984; Reeves, 2001; Schaaf & Anzalone, 2001; Wiener, Long, DeGangi, & Battaile, 1996; Williamson & Anzalone, 2001). These issues are estimated to occur in 40–88% of children with developmental disabilities (Adrien et al., 1993; Dahlgren & Gillberg, 1989; Dunn, 1997; Ornitz, Guthrie, & Farley, 1977; Talay-Ongan & Wood, 2000; Tavassoli et al., 2017) and between 5–16% of children in the general population (Ahn et al., 2004; Ben-Sasson et al., 2009). More recently, using MRI, Owen and colleagues (2013) found that some children with SPD had decreased white matter connectivity, particularly in the parietal regions of the brain, compared to their peers. This finding adds validity to designation of SPD as an independent disorder, but it is derived from a limited study of only boys that did not address the various proposed subtypes of SPD. For the purposes of this paper, we focus on one subtype: Sensory Over-Responsivity. For a more comprehensive review of SPD research, see Miller, Anzalone, Lane, Cermak, and Osten (2007).

Sensory Over-Responsivity

Sensory Over-Responsivity (SOR) describes children who react adversely to sensory stimuli that others find neutral or even pleasant (Miller et al., 2007). In a seminal study, McIntosh, Miller, Shyu, and Hagerman (1999) measured electrodermal activity and vagal tone in SOR and control participants. The researchers found that children with SOR demonstrated greater sympathetic arousal to stimuli. In addition, these children demonstrated difficulties in habituation. That is, they exhibited a diminished ability to return to baseline arousal compared to their typical peers (McIntosh et al., 1999; Schaaf & Anzalone, 2001). This study opened the door to numerous studies replicating high sympathetic arousal in response to different kinds of sensory stimuli, with decreased habituation.

Research examining children with SOR also demonstrates deficiencies in auditory gating (Davies, Chang, & Gavin 2009, 2010; Davies & Gavin, 2007; Gavin et al., 2011). Auditory gating is the ability to detect changes in the frequency and loudness of auditory tones presented sequentially. When auditory gating is impaired, individuals react to repetitive stimuli as if each stimulus were novel. The preconscious ability to become alert to novel auditory stimuli is conserved by evolution as a way to perceive and ready the organism to react to potential danger (LeDoux, 2015). Without efficient gating, each presentation of a repeated sound re-alerts the nervous system, negatively impacting overall habituation in the presence of auditory stimuli.

Auditory gating issues are also implicated in a newly proposed disorder, misophonia, that is phenotypically similar to SOR (see, for example, Brout et al., 2018; Schrӧder et al., 2014). More specifically, Wu and colleagues (2014) reported preliminary convergent validity (r = 0.50) between misophonia symptoms and a self-report item assessing over-responsivity in the auditory domain on the Adult Sensory Questionnaire (Kinnealey & Oliver, 2002). Individuals with SOR, have difficulties related to multiple senses. However, individuals with misophonia mainly have difficulties in the auditory modality. Originally described by Jastreboff and Jastreboff (2001), individuals with misophonia demonstrate increased sympathetic nervous system arousal, accompanied by emotional distress, in response to specific pattern-based sounds, irrespective of decibel level. Although the research on this disorder is in its infancy, preliminary studies using physiological measures such as galvanic skin response and heart rate support expectations of sympathetic nervous system arousal in response to specific sounds (see, for example, Edelstein, Brang, Rouw, & Ramachandran, 2013). In addition, using fMRI, Kumar and colleagues (2017) found hyper-myelination between the parts of the brain that process auditory stimuli and parts of the brain that process emotion. These findings, as well as thephonotypical overlap, suggest that the auditory modality may be of particular importance in the exploration of how self-regulatory skills develop. This is also supported by clinical observation that auditory over-responsivity is more resistant to sensory-based intervention, compared to other sensory modalities, and by the very high levels of distress those with misophonia report (Koomar & Bundy, 2002; Kumar et al., 2015; Brout et al., 2018).

Sensory Over-Responsivity, Mental Representation, and Affect Regulation

Beyond enriching or disrupting personal relationships, the essence of abstract thinking depends upon our ability to make meaning of and internalize language, physical gestures, and the understanding that one’s self and others are distinct entities. As Greenspan and Shanker (2006) state, survival depends upon this ability:

The growth of complex cultures and societies and human survival itself depends on the capacity for intimacy, empathy, reflective thinking and a shared sense of humanity and reality. These are derived from the same formative emotional processes that lead to symbol formation. (p.10)

Fonagy and colleagues (2002) and Gergely and Watson (1996, 1999) specifically describe steps that involve building a mental representational system that allows the infant to interpret his/her own feelings and the feelings of others. The term “mentalizing” describes the ability to think about other people reflectively, and attachment theorists have operationalized this as the “reflective function” (Fonagy & Target, 1977; Fonagy et al., 2002). The infant develops the reflective function through complicated socioemotional exchanges with his/her caregiver (Greenspan & Shanker, 2006). This ultimately enables theory of mind (Fonagy & Target, 1977; Fonagy et al., 2002). Theory of mind is a singularly human quality that allows us to understand that we have a mind that is separate from another’s mind. We use the reflective function to speculate about other people’s thoughts and feelings and because of this we can mediate thought and emotion (Fonagy et al., 2002). Sensory over- responsive children without developmental or cognitive problems do not have problems with theory of mind (Bundy & Murray, 2002). However, even when an infant is able to develop theory of mind, sensory over-responsivity can impede the capacity for emotional learning because of the processes involved in mentalization.

The infant’s expression of affect is the catalyst for a convoluted process of reciprocal communication that serves as the foundation for the symbolic system on which mentalization depends. Through “affect signaling,” a caregiver helps the infant attach meaning to affective states. Reciprocal affect signaling entails the caregiver mirroring the infant’s feelings in a way matches his/her own, or is contingent (Gergely & Watson, 1996). When the infant expresses affect, the caregiver accurately reflects the affective state, so that the child is able to learn to correctly identify it. Through affect signaling, the dyad co-constructs a representational system that allows the developing child to accurately identify his/her feelings (Fonagy et al., 2002).

Further, through this process the child learns to differentiate his/her emotional states from others’, and the child comes to understand that his/her own feelings are separate from the feelings of others (Gergely & Watson, 1996). The infant also discovers a sense of agency due to the increasing awareness that the growing child can mediate relationships through the mind and through thoughts. As such, the growing child’s thinking becomes an internal regulator of affect. As the child begins to use thinking to mediate and control his/her emotional life, affective states are represented in his/her mind, and ultimately this representational system allows for a depth of emotional processing about the self and others. These fine differentiations help to support emotional regulation.

The caregiver ideally responds by mirroring the infant’s affective state in a way that is soothing, so that the infant is not overwhelmed by his/her own emotions. This modulation is known as “markedness” (Fonagy et al., 2002). Markedness is an important element of contingent mirroring. It is a regulatory factor that refers to the intensity of emotion with which the caregiver reacts to the infant (Fonagy et al., 2002). For example, if an infant drops a bottle and cries in distress, a caregiver might exclaim, “Oh my, you dropped your bottle!” However, the caregiver’s well-meaning and common attempt to match a highly distressed cry with the same level of emotional and/or auditory intensity could further arouse and distress the over-responsive infant.

Most attachment models imply that co-regulation will occur if a caregiver responds contingently. However, attachment models do not take into consideration the dysregulation effect of atypical sensory processing. In addition to cueing in ways that are more difficult to read, sensory over-responsive infants and toddlers may not be able to make use of the affect signaling process because they may be overloaded by sensory stimuli. Consequently, this impedes co-regulation and negatively impacts mentalization. The following case vignette demonstrates how SOR, particularly with regard to the auditory modality, may affect contingent responding, co-regulation, and the attachment relationship.

Case Vignette

Vivian, an energetic 32-year-old retail sales clerk, and her husband James, a 40-year-old computer programmer, looked forward to the birth of their first child. Vivian delivered Anna without complications and unconditionally adored her daughter. During the first few days after the birth, however, every little change seemed to distress Anna. She often cried even when she was held. She cried when her clothes were changed. She cried when she was bathed. Anna was calm during breast-feeding and ate often, but never seemed full. Anna often cried for reasons unknown to her mother. Most of all, Anna seemed to either shut down or become highly irritable when she was in noisy environments and/or when her mother was singing lullabies to her.

Anna’s pediatrician told Vivian that Anna was just a sensitive baby who would eventually outgrow her fussiness. Anna’s mother-in-law was certain the baby had colic. At six months, Anna was still fussy. She rejected the bottle as well as solid food, so Vivian continued to breast-feed. Anna screamed and cried intensely when Vivian took her into grocery stores, friends’ houses, or neighbourhood playgrounds. Therefore, Vivian generally avoided these outings. Anna always seemed calm during car rides, however, and Vivian found herself relying on neighbourhood drives for Anna’s naps or to soothe her.

Despite a great deal of distress, Anna also experienced many instances when she was happy and engaged. She sometimes liked to hear Vivian sing, watch Vivian make funny faces, or play peek-a-boo-games with her mother. However, other times the same activities seemed to upset Anna. Anna’s unpredictable responses confused and frustrated Vivian. Vivian became more concerned when Anna, at nine months of age, seemed to prefer being with James.

James was a devoted father and husband, but he worked long hours away from home and was often tired when he came home. Although James didn’t have a great deal of energy to play with Anna, he would happily hold her while watching television or reading. Vivian wanted James to be more active with Anna, and felt that James was not giving Anna enough attention. While James and Anna were together, Vivian would try to engage Anna by laughing, talking, or playing with her, but Anna would grow sullen or turn away from her mother. Vivian found herself growing resentful of her husband and worried about Anna’s increasing quietness.

Vivian took Anna to the pediatrician and explained her concerns. The pediatrician reported that Anna was healthy and was achieving typical developmental milestones. However, the paediatrician told Vivian that if she wanted to look further into Anna’s social-emotional development he would refer the family to a centre for infants and young children.

At the centre, Anna was evaluated by a team of interdisciplinary clinicians led by a pediatrician who specialized in developmental disorders. The pediatrician told Vivian and James that Anna seemed to be “sensitive to environmental stimuli” and scheduled the family to meet with an occupational therapist (OT) specializing in sensory processing disorders. After evaluating Anna, the OT explained that Anna was over-responsive to sensory stimulation and seemed to react the most negatively to sounds. As part of the interdisciplinary team, the OT worked with the family in order to better understand how different sensory-based activities affected Anna’s over- responsivity in order to decrease sensitivity and mediate her arousal states.

In addition, Vivian and James worked with a psychologist trained in parenting who helped them develop and transfer the skills learned through the OT. The psychologist and OT both also suggested ways for Vivian and James to modify the home environment so that Anna was over-stimulated less often. The psychologist also helped Anna’s parents understand that they had not done anything wrong and were not “bad parents.” The psychologist explained that infants are born into the world with variations in the ways they respond to sensory stimuli. Parents often have difficulty assessing this and understanding how to make adjustments.

After visiting the centre two times per week for four weeks, Vivian and James were well versed in the nature of parent and child dyadic regulation. Vivian and James began to understand that levels of sound, sights, and touches they thought were typical were often too much for Anna. They understood that noisy toys and loud voices could over- arouse and distress Anna. In addition, toys with blinking lights with fast rhythms were likely to do the same. As they worked through these issues, both parents began to feela sense of self-efficacy in regard to their parenting skills. Vivian and James reorganized home activities to match Anna’s tolerance for stimulation and found effective sensory strategies to comfort their daughter. They were delighted to discover that Anna smiled more, cried less, and stayed calm for long periods throughout the day. After Vivian and James discontinued therapy, they checked in with the centre on an as-needed basis.

The above case discussion illustrates how, with guidance, appropriate caregiver responses can lead to attunement in spite of an infant’s atypical sensory processing. Initially, Anna’s over-responsive sensory processing mechanisms negatively impacted her family relationships. Vivian, for example, mistook Anna’s distress as boredom and sought to help by playing boisterously with Anna. However, Anna’s sensitivity to sounds caused her to interpret Vivian’s well- meaning gestures as intrusive, over-arousing, and even frightening. Anna’s atypical reactions to sensations led to behaviours that were difficult for her parents to understand. Consequently, Anna’s parents were unable to accurately read her cues, could not respond contingently, and could not engage Anna in co-regulation on a consistent basis. In addition, Anna’s inability to habituate caused her to feel continuously overwhelmed by sensation.

Anna’s over-responsivity to sensory information, particularly in the auditory domain, presented challenges that were beyond her parents’ understanding and ability to refine. James and Vivian were guided to respond contingently to Anna’s distress, which helped soothe and reassure her. This allowed Anna to enter into co-regulated relationships with her parents more easily and consistently. Within the co-regulated relationships, Anna could begin developing the mentalization skills that would help her process and regulate emotion as she continued to grow.


This paper integrates theories of sensory processing and attachment to explore how attachment may be impacted in children who have sensory over-responsivity, particularly within the auditory domain. Studies that better characterize the precise relationships between sensory processing, attachment, and mentalization are needed. Comparisons of the developmental trajectories of typical infants and those with SOR, particularly with intense reactivity to auditory stimuli, would facilitate better understanding of how infant, toddler, and early childhood disorders manifest in adolescence and adulthood. This specification is especially important as attachment theory predicts that infants and toddlers with attachment problems are more likely to manifest psychological and psychiatric problems such as poor emotional and interpersonal functioning.

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