Dressing And Sensory Over-Responsivity: A Guide For OTPs

Editor's note: This text-based course is a transcript of the webinar, Dressing And Sensory Over-Responsivity: A Guide For OTPs, presented by Kathryn Hamlin-Pacheco, MS, OTR/L, ASDCS.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Identify 8 approaches to supporting a child with tactile defensiveness in dressing.
• Describe appropriate regulatory strategies to use while supporting a child with tactile defensiveness in dressing activities.
• Explain how neuroplasticity can play a role in supporting a child with tactile defensiveness in dressing.

Introduction: Translating Neuroscience into Practice

Thank you so much for being here. I am truly excited to share this information with you today. Before we jump in, I want to introduce myself the way I genuinely think about my own work: I am a translator of neuroscience. Before I became an occupational therapist, I was an educator in a public school classroom. I have carried that background with me into practice every single day, and I think about my role now as taking the powerful, and often very dense, science of how the brain and nervous system work—and making it directly useful for the children and families that we serve.

I say that deliberately, because the topic of today's course may feel narrow at first glance. Dressing. Tactile defensiveness. Clothing. You might be thinking, how much is there really to say? I want to promise you that once we look at this topic through a neuroscience lens, we will discover an expansive depth of information that can genuinely transform how you approach these kids and these moments in your practice. I think it is always good to start a journey with a map, so let me orient us before we get going.

Our goals today are twofold. First, we are going to understand tactile over-responsiveness and defensiveness as it relates to dressing—really unpacking the neuroscience of what is happening in these children's nervous systems. Then, once we have that foundation, we are going to move into application. Specifically, I am going to introduce you to eight different concepts and approaches you can bring to the children and families you support. I want to be upfront with you: this is an introductory course. The big goal today is to open the door to these concepts and get them on your radar. But I have deliberately structured this content so that you can take it into your practice tomorrow, because we are all clinicians and we all want to help the children we are seeing right now.

I also want to ground us at the very outset in language from the AOTA Position Paper on a Sensory Integration Approach for Children and Youth (2023), because I love working in sensory integrative practice and I think it is essential that as this area grows, we maintain the integrity of the science. Whether you intended to specialize in sensory integration or not, if you work in pediatrics, you are likely seeing these children. The science is growing fast, and I think starting with AOTA is always a good place. The paper states that when registering, processing, and integrating sensory information interferes with a child's performance in everyday activities, they may have difficulty self-regulating their emotions and behavior, engaging in coregulation with trusted peers and adults, performing everyday activities, and participating in different environments. Every piece of that statement is exactly what we are targeting today, which means we are right at the center of evidence-based practice as we get started.

Understanding Tactile Over-Responsiveness and Dressing

Who Are We Talking About?

Before we get into the neuroscience and the strategies, I want us to think carefully about who these children are, because I think it helps to have a clear picture. I am specifically talking about kids who have difficulty dressing and wearing clothing items due to over-responsiveness to the tactile information they receive from their clothing.

These are the children whose parents come into your office and say, "They throw tantrums every single morning when it is time to get dressed, and I don't know what to do." These are the kids who avoid specific activities if those activities require certain clothing—maybe they will not go to a birthday party because it means dress shoes, or they refuse to participate in a sport because of the uniform. They are always uncomfortable in their clothing. They may have a small handful of items they can tolerate each day, and they are often unable to wear seasonally appropriate or activity-appropriate clothing. That is why they show up in occupational therapy. It is interfering with their everyday life.

Clarifying the Terminology

Sensory integrative practice has a history of evolving terminology, so I think it is always worth pausing to make sure we are working from the same definitions before we dive in.

When we talk about sensory modulation, I appreciate how the SI Theory and Practice textbook (third edition) describes it—as something somewhat abstract, a twofold process. On one hand, it involves the neurological tuning in to the right sensory information at the right intensity. On the other hand, it involves the behavioral response that follows. This process happens at a cellular level—enhancing or dampening neuronal activity in response to various inputs and demands—as well as at a systems level, involving the limbic system and higher-level brain functions. The neurological and behavioral dimensions of modulation are so closely intertwined that we cannot fully separate them (Brown, Tse, & Fortune, 2019; Bundy & Lane, 2020; Lane, 2020a; STAR Institute, n.d.).

Today, we are specifically talking about sensory over-responsivity, a type of sensory modulation disorder in which responses to sensations are exaggerated, prolonged, or more intense than the situation warrants. And here, I want to be very clear: the evidence points to understanding this as a heightened emotional, physiological, and behavioral response to stimuli—not simply a heightened ability to detect them. It is not that the person is over-responding; it is that their nervous system seems to over-respond. The STAR Institute, which is truly a leader in sensory integrative practice, has moved toward the term "heightened responsivity" as more inclusive and respectful language. That said, most of the evidence base still uses the term 'sensory over-responsivity,' so you will see it used throughout this course.

Within that, we are focusing specifically on heightened responsivity to tactile sensation —tactile defensiveness. I love this term because, as we are going to unpack together, these children really do go into a defensive state in response to the feeling of their clothing.

One more important distinction: when is this a disorder or dysfunction, and when is it simply a preference? We all have sensory systems and sensory preferences. The literature is clear that it becomes a disorder or dysfunction when it interferes with everyday life (AOTA, 2023; Miller, 2014). When a child's difficulty with clothing consistently interferes with their daily participation, that is when we, as OTPs, say yes—this warrants clinical attention and treatment.

Eight Approaches to Supporting Children with Tactile Defensiveness in Dressing

What I am going to walk you through now are eight concepts, all viewed through a neuroscience lens, that we can apply to support children with heightened responsivity in dressing and putting on clothing. You will see these concepts build on each other, and that is intentional. This is not a list of disconnected strategies—it is a framework. Let me walk you through each one.

1. Arousal

The first concept, and where I like to start, is arousal. Arousal is the nervous system's state of alertness. I think of it this way: arousal is the nervous system asking, "How much energy do I need to invest in this moment?" And the nervous system, as part of our physiology, does not want to waste energy. It is always conserving because we never know what might come next. So the nervous system will assess: how much energy do I need right now? And that answer is the arousal level.

What is critical to understand is that high arousal and low arousal are not inherently good or bad. What we are looking for is an optimal arousal level—a just-right fit for whatever we are doing. Cheering loudly for your favorite sports team calls for a very different level of arousal than falling asleep at night. And the key insight here is that arousal and sensory input are incredibly closely related (Bundy & Lane, 2020; Lane, 2020a; Wilbarger et al., 2020).

Let me give you a few examples to get you thinking. Imagine you have a warm cup of tea and a cozy blanket. The tactile feeling of that warm mug, the softness of that blanket—for most people, that is going to decrease arousal. You feel comfortable, calm, and relaxed. Now imagine you are at a rock concert. There is loud music, flashing lights, people singing, and moving around you. That enormous amount of incoming sensory information is going to increase your arousal—your nervous system needs a lot of energy to engage with all of it. If you are driving with the windows down on a cold day, that brisk air on your face and hands will increase your alertness. If you are sitting inside savoring a warm bowl of homemade soup, that warmth and flavor tend to bring arousal down.

You can probably already see where I am going with this when it comes to clothing. If I am wearing my softest, most comfortable sweatshirt and my oldest, worn-in sweatpants, my arousal level may well decrease. I am relaxed, comfortable, at ease. But if I am in something itchy, tight, scratchy, or uncomfortable, my nervous system immediately says something is not right. I need to invest more energy to figure this out. Arousal goes up.

For children with tactile defensiveness, the sensation of their clothing can significantly drive up their arousal level in a way that quickly becomes dysregulating. And this brings us to something actionable: because the relationship between sensory input and arousal is bidirectional, we can use sensory input on purpose to influence arousal state. This is a powerful clinical tool.

As a general guideline, types of stimulation that typically increase arousal include fast and changing rhythms, new or novel stimuli, and challenging stimuli (Bundy & Szklet, 2020; Case et al., 2021; Lane, 2020a, 2020b; Lane et al., 2019; Maula et al., 2023; Miller, 2014). When I think about children with tactile defensiveness, many of these triggers are already in the dressing routine—new clothing items, fast-paced morning routines, and the challenge of an uncomfortable sensation. No wonder arousal escalates.

Types of stimulation that typically decrease arousal include slow, rhythmic, and gentle sensations, removal of excess sensory stimulation, and deep touch pressure and proprioception (Bundy & Szklet, 2020; Case et al., 2021; Lane, 2020a, 2020b; Lane et al., 2019; Maula et al., 2023; Miller, 2014). These are the inputs we can intentionally build into our intervention.

Case Study: Managing Arousal — Sam

Sam is a six-year-old boy who loves riding his bike, hiking, and going to the store and school with his family. He is often excited to leave the house for these outings, but when it comes time to put on his socks, he frequently has a meltdown. Sam has a history of difficulty with wearing certain clothing, and over time, his family has found that soft, loose-fitting pants and shirts work well for him most days. But socks remain a major challenge. He struggles to position them correctly and often tries multiple pairs. After several unsuccessful attempts, his frustration escalates—he throws the socks and shoes, yells, and occasionally hits his parents. At times, he retreats to his room entirely. This behavior regularly results in the family canceling plans or one parent staying home with Sam while the other takes the siblings out.

So how do I apply my understanding of arousal to help Sam? My first step is to get to know Sam specifically—how does his nervous system respond to different sensory inputs? I have given you the general guidelines, but I want to get precise about this particular child. If it is the sensation of his socks that is increasing his arousal, can I get more specific about what it is? The seam? The tightness? Is it the process of putting them on? I want to understand this at an individual level.

Then I use that information to decrease his arousal on purpose and with consistency—before and during sock donning, and if needed, after. Maybe for Sam, slow rhythmic movement works really well. Maybe it is deep pressure through his feet and legs first. Maybe it is a specific song he loves, or rocking in a preferred way. I want to get very specific. This does a few things at once: it helps me regulate Sam in the moment, it gives his nervous system practice moving into a calmer state, and it teaches his parents exactly what they can do at home to support this process before it ever reaches a meltdown. We go to a quiet room, we remove excess sensory stimulation—siblings, TV, bright lights—and we use the regulatory inputs on purpose. That is how we begin using neuroscience to influence practice.

2. Fight, Flight, and Shutdown

The next concept is deeply connected to arousal, and it is one that I think completely reframes how we understand children's behavior around dressing. We are going to look at physiological states through the lens of Polyvagal Theory.

Polyvagal Theory, developed by Dr. Stephen Porges, is an evolutionarily informed neurophysiological framework for understanding how the state of our autonomic nervous system supports or impedes social engagement, emotional resilience, and adaptive physiological responses. What I love about this framework is that it allows us to reconceptualize behaviors and symptoms—not as signs of a child being difficult or noncompliant, but as adaptive expressions of autonomic state (Porges, 2025a, 2025b).

Within Polyvagal Theory, there are three primary physiological states. The first is the Safe, Engaged, Connected state. When I feel safe, I am able to connect to others, feel calm or even excited, tune in, explore, and be flexible and resilient. This is where health, growth, and restoration happen. This is where we want to be, and this is where learning happens.

If, however, the nervous system detects a cue of danger or threat, we enter the Fight-or-Flight state. This is sympathetic nervous system activation—mobilization for protection through action. The heart beats faster, breathing quickens, and we become hypervigilant. We are getting ready to either fight off the threat or escape from it. This is high arousal in the service of survival.

And then there is a third state—Shutdown. This is the nervous system's last resort when the threat feels so overwhelming, so insurmountable, that fight-or-flight is not enough. The system says, "We cannot overcome this." So instead, we collapse, become numb, withdraw. We conserve energy and try to protect ourselves by shutting down. You have seen this in children—the ones who go completely quiet, limp, or dissociated during dressing. That is not defiance. That is shut down.

It is important to note that these are not discrete boxes. They exist on a spectrum, and small cues help us identify where a child is. Maybe this child isn't punching you, but he is argumentative, and his body is tense. That is a small degree of fight-or-flight response. Tuning into these subtler signals is part of what Polyvagal Theory gives us.

Neuroception and Dressing

Within Polyvagal Theory, the mechanism that constantly monitors for cues of safety or danger is called neuroception—the subcortical detection of cues of safety, danger, or life threat that triggers autonomic shifts without conscious awareness (Porges, 2025a). Critically, these cues come from inside our bodies, from our external environment, and from our relationships with others. And here is where dressing becomes deeply significant: evidence shows that individuals who are sensory over-responsive may activate a sympathetic nervous system response—fight or flight—in response to non-noxious stimuli (Lane, 2020; Lane et al., 2019; Miller et al., 2007; Parham & Mailloux, 2020; Porges, 2025a).

What this means is that for these children, the sensation of their clothing can be genuinely perceived by the nervous system as a threat. Not interpreted through logic. Perceived, subcortically, as danger. I find it incredibly validating to have research language to support this. In a qualitative study examining the experiences of individuals with sensory defensiveness characteristics related to clothing and fabric, participants shared statements like: "I am always aware of everything, but I don't want to feel that uncomfortable." "The tightness of it can be overwhelming." "I'd gradually get more and more agitated, and the more agitated I get, the more stressed I get, and the more I move, the less clearly I think because it goes round and round in circles." And of body sensations: "It is a bad experience when you feel like there are lots of little needles picking into you." "My hands will physically sting, and it will make me highly anxious" (Kyriacou, Forrester-Jones, & Triantafyllopoulou, 2023).

These descriptions are not exaggerations. This is true distress. This is a fight or flight response. And when we understand that, it completely changes how we approach the child and the family.

The Role of the Amygdala

There is another layer of neurological complexity I want to add here, because it helps explain why dressing can become increasingly difficult over time rather than easier. Part of how we detect danger or threat is through the amygdala. When the amygdala perceives a threat, it rapidly triggers a survival response—sympathetic nervous system activation, the release of adrenaline, and the release of cortisol. And it does this fast, and without logic (LeDoux, 2015).

Here is the key function: the amygdala pairs memories with threat. It is designed to act even more quickly next time it encounters a similar situation. Think of the classic example—you hear a rustle in the bushes and a bear emerges. From that moment on, the amygdala says: The next time I hear a rustle, I am going to respond even faster, because I know it might be a bear.

Now think about a child who is tactilely defensive about dressing. What emotional memories might the amygdala be building and storing around clothing? Distress when it is time to dress. A parent or caregiver raising their voice out of frustration. A sibling crying in the chaos of a morning meltdown. Being held down or physically forced to dress. The sensation of discomfort or even pain from a tag or seam. The amygdala is recording all of this. And with each subsequent dressing experience, it responds even faster and stronger. The result is that even the sight of clothing, the mention of getting dressed, or the start of a morning routine can trigger a full fight-or-flight response before a single clothing item has been touched.

This is a critical reframe: those tantrums, the hitting and kicking, the running away, the child who goes limp and refuses to move—these are not choices. These are the behavioral expressions of a nervous system that perceives genuine danger. And as OTPs, when we understand that, we approach everything differently.

3. Co-Regulation

Understanding that these children are operating in states of fight, flight, or shutdown brings us directly to the next concept, because the question immediately becomes: what can we do? And my first answer is always co-regulation.

I think about co-regulation in two connected ways. The first is this: if you cannot self-regulate in this moment, can I help you regulate? If we are doing this together, that is co-regulation. Polyvagal Theory defines co-regulation as reciprocal autonomic stabilization via social cues—supporting physiological synchrony and emotional resilience within safe relationships (Porges, 2025a). Dr. Porges himself has said that "co-regulation is not optional—it is a biological imperative." We are literally wired for connection, and a child in distress is wired to pick up on cues of safety from a regulated adult.

This means two things for our practice. First, we can use tools and sensory strategies to help a child regulate their emotions. Second—and this one is equally important—we ourselves are a tool to help a child regulate.

Sending Cues of Safety

I love to explain this concept with what I call the deer example. Imagine you are on a hike and, out in a meadow, you see a herd of deer. The lead deer has her head down, grazing—relaxed, content. All the other deer read her body language and said, "Okay, we are safe." We can relax too. But if in that moment the lead deer spots you, her head comes up, her body tenses, she snorts. She has not said a single word, but every other deer in the meadow raises their head, becomes erect, and starts scanning. Why? She has sent cues through her face, her body, and her vocalizations that signal danger.

This is what happens across mammals, including with the children we work with and the parents they live with. As a clinician or caregiver, what cues am I sending through my body, my face, and my vocal prosody? Am I signaling safety—or am I, however unintentionally, signaling danger?

Think about a busy morning when a parent is trying to get out the door for work and school. The child is struggling with getting dressed. The parent—understandably—is stressed. Their body is tense, their eyes a little wide, their voice carries urgency or frustration. None of this is their fault; parenting is genuinely hard. But from a neuroception standpoint, every one of those cues is signaling danger to the child. And that child's nervous system is already primed to perceive the dressing routine as threatening. You can see how quickly the whole situation can escalate.

On the other hand, when a parent or clinician understands this concept, they can use their body, face, and voice on purpose. Here are the specific co-regulatory cues I teach: soften and relax your face; relax your body; slow your movements; position yourself low—I sit on the floor with kids, because being at their level and making myself smaller sends a very different signal than towering over them; and adjust the prosody of your voice. Instead of saying "It's time to get dressed, we need to get out the door" in a clipped, urgent tone, try: "Hey... It's time to get dressed." Same words. Completely different nervous system impact. The first version, with the tension in the voice and face, can cue a fight-or-flight response alone. The second signal: I am calm. You are safe. We have got this.

And here is something remarkable about co-regulation: as you intentionally send these cues of safety, you are actually also sending those cues to yourself. You are helping yourself regulate in the same moment.

The second dimension of co-regulation involves modifying the environment and activity to support the child's regulatory state. If fast and changing rhythms increase arousal, we slow everything down. If new clothing is too novel, we do not introduce it during a meltdown. We reduce excess sensory stimulation—turn off the TV, move to a quieter room away from siblings, and lower the lights if needed. We use slow, rhythmic, predictable inputs. We narrate what is happening so there are no surprises. And I use simple language that communicates safety: "We are safe here. I know this feels hard, but I am right here, and we are in this together."

Case Study: Fight/Flight/Shutdown and Co-Regulation — Keisha

Keisha is a 4-year-old girl who comes to an OT evaluation because her mother reports intense meltdowns every morning at dressing time. Her mom is a single parent, and she is crying during the evaluation. She tells me that, to get out the door for school and work—because she has to work and Keisha has to be at school—many mornings she has had to hold Keisha down, screaming and crying, and force clothing onto her. She does not know what else to do. Over the following weeks, as we work together, Keisha's mother shares that she dreads mornings entirely. Keisha's outbursts regularly cause her younger brother to cry. Mom says she tries to be calm, but she often loses her patience. She is not sure whether Keisha is doing this on purpose, and she genuinely does not know how to help her.

This is heartbreaking. And it is so common. Here is how I apply my understanding of physiological states and co-regulation to support Keisha and her mother.

My first step is to provide parent education on physiological states. I want Mom to understand that Keisha is truly in distress. She is not manipulating anyone. She is not being defiant for the sake of it. Her nervous system is perceiving the dressing routine as a genuine threat and responding with the full force of a fight-or-flight response. The behaviors we see—screaming, going rigid, the intensity of the meltdown—are the behavioral expression of that physiological state. This is not a behavioral problem. This is a nervous system problem. And when mom understands that, everything shifts. The guilt decreases, the frustration decreases, and a new question opens up: Okay, so what can I actually do?

My second step is to coach Mom on how to send safety cues. We practice together. I model what co-regulation looks and sounds like. We talk about her face, her body, her voice. We talk about the morning environment—what can be reduced, what can be simplified, how we can make the whole routine feel more predictable and less threatening. And importantly, I teach mom that by doing these things, she is not just helping Keisha—she is helping herself regulate too.

My third step is to model co-regulation directly in sessions and coach mom to practice it. Seeing it is so different from hearing about it. When Keisha and I are working together, and she starts to escalate, I want Mom right there, watching as I slow down, soften, get low, and use my voice to bring her back to a place of safety. Because she is the one who will be there every morning, and these skills need to live in her hands and her voice, not just mine.

4. Meaningful Participation and Play

The three concepts we have covered so far—arousal, fight/flight/shutdown, and co-regulation—set the stage for what comes next. Once we can help a child access a state of relative safety and regulation, the question becomes: what do we do with that? And my answer is play.

Play is a primary occupation and one of the most critically important parts of a child's development. Through play, children develop skills, learn to cope with challenging situations, challenge themselves, and problem-solve. The OTPF states that play is intrinsically motivated, internally controlled, and freely chosen, and may include exploration, humor, risk-taking, contests, and celebrations (AOTA, 2020; Tanta & Kuhaneck, 2020). For our purposes today, play is also the most powerful vehicle we have for changing the brain.

Here is the neuroscience behind that claim. When an object or event is not attended to—when a child is not genuinely engaged—the brain shows only modest activation, and little to no learning occurs. But when conscious attention is engaged, there is a massive amplification and prolongation of neuronal activation. This is exactly what synapses need to change their strength—a process called long-term potentiation. In other words, focused attention during a meaningful activity is neurologically synonymous with learning (Dehaene, 2020). Play, by its very nature, captures conscious attention in a way that no directive activity can match.

There is also a Polyvagal prerequisite to play that I think is essential to name: for play to be possible, a child needs to feel safe. Play is a safe-state behavior. If a child is in fight, flight, or shutdown, they cannot play—not truly. This is why arousal regulation and co-regulation come first. We have to get them to a place of safety before play becomes possible, and once we do, play becomes an extraordinarily powerful tool for building new neural associations with clothing and dressing.

So how do we play with clothes? Because I get this question all the time. The thing to remember is that we are not asking them to tolerate clothing—we are creating positive experiences with clothing in a safe, fun context. I might dance with a piece of fabric draped over my shoulders. We might do an obstacle course where one station involves putting on a hat and crawling through a tunnel. We might play tag, where the person who is "it" wears a vest or a specific item. We might do doll play, dressing up dolls, and giving them voices about what they are wearing. We might bring out mom's or dad's clothes and play dress-up, which is inherently low-stakes, silly, and joyful. For older kids, it is about incorporating their interests and making the clothing connection feel meaningful and chosen.

Case Study: Play — Keisha (continued)

Let's go back to Keisha, our four-year-old. After working on the physiological state and co-regulation pieces, I introduced the concept of play to her and her mom.

The first thing I tell mom is: start small. Do not jump to a situation where Keisha must put on a complete outfit to participate. If the condition of play is wearing something uncomfortable, that is not play—that is compliance dressed up as play, and it will not work. Instead, we start with the smallest, lowest-stakes interaction with clothing that still feels like play.

Keisha loves Taylor Swift's "Shake It Off." So we put it on. I spread out a variety of items around the room—some of them clothing—and we put them on and try to "shake" them off. We dance around, we laugh, we try scarves and hats and gloves, and the goal is simply to make clothing part of something joyful. When Keisha does this, her brain is building something new: a positive, playful experience involving clothing. That is neurological gold.

I also encourage mom to do pretend play at home with dolls. The dolls do not want to get dressed. What do they do? Maybe they try on different options, maybe they feel worried at first, but then feel proud, maybe there is a whole narrative around it. Through play, Keisha can explore the story of getting dressed from a safe, fictional distance. On the weekends, mom can bring Keisha into her closet, and they can play dress-up together—wearing mom's clothes, laughing at the oversized sleeves, trying on shoes that are too big. These small moments are not incidental. They are an intervention. Every positive experience with clothing and dressing is building something new in Keisha's brain, and I want parents to know that and to do these things with that intention.

5. Improving Modulation Skills: The Triune Brain Model

Now we are going to go deeper into the neuroscience, and this is the part I find most exciting to share with clinicians. This is where everything we have been building really comes together. To understand how we can actually improve a child's ability to process and integrate tactile information from clothing, I want to introduce you to the triune brain model.

Tactile information is detected by receptors in the skin, translated into a neural signal, and then conveyed to the brain. The triune brain model provides a useful—if simplified—way to think about what happens to that information as it travels (Lanius et al., 2025).

The first and most foundational level is the reptilian brain, comprising the brainstem and midbrain. This is our survival-oriented brain. It governs respiration, heart rate, blood pressure, and instinctual arousal through the reticular activating system (RAS). It is subconscious, instinctive, and heavily involved in fight-or-flight and shutdown responses.

The second level is the limbic system—our emotional brain. This is where emotional learning happens, where memories are stored, where the amygdala lives, and where hormonal release is regulated. The limbic system is deeply involved in how we experience and respond to the emotional weight of situations.

The third level is the neocortex—our cognitive, reflective brain. This is where higher-level thinking happens. It is also where the somatosensory cortex lives—the primary area of the brain responsible for processing and making sense of tactile information.

These three levels are tightly interconnected. Dr. Ruth Lanius (2025) describes it beautifully: think of the survival brain as the foundation of a house, the emotional brain as the frame, and the cognitive brain as the roof. If something goes wrong with the foundation, it creates a domino effect throughout the whole structure. The hierarchy is not perfectly strict—things can flow in multiple directions—but the interconnection is real and clinically meaningful.

Here is the implication that genuinely excites me as a clinician. If a child is in fight-or-flight mode, the reptilian survival brain is highly engaged. The emotional and cognitive levels of the brain can still function to some degree, but not optimally. And if the emotional limbic level is also in distress—if this child is carrying fear, upset, and grief about the dressing experience—then the cognitive brain, including the neocortex and the somatosensory cortex, is further compromised.

Now ask yourself: where does the brain process tactile sensation? The primary somatosensory cortex—part of the neocortex, part of the cognitive brain. The highest level of the brain. So if a child, every time they are faced with getting dressed, immediately goes into fight-or-flight mode, what happens to the sensory information they receive from their clothing? It cannot reach the cortex optimally. The lower brain levels are firing, the threat response is dominating, and the information needed to actually understand and integrate the feeling of that clothing—the very thing we need to process to get better at this—never reaches the part of the brain that can make sense of it.

I get so excited about sharing this because it reframes everything. These kids may never have had a chance to understand clothing. Not because their somatosensory cortex is incapable, but because the threat response has been so consistent that the information has never had a clear path to get there.

Case Study: Improving Modulation Skills — Mason

Mason is an eleven-year-old boy who loves music. He has been asked to play trumpet in the local children's band—something he desperately wants to do—but he declined because he does not believe he can wear the required uniform. Mason has been working with me in OT for three months to address tactile defensiveness in dressing. He and his family have made meaningful progress: they understand what is happening in Mason's nervous system when he dresses or thinks about dressing. They know how to support his arousal levels, how to co-regulate, and how to reduce the fight-or-flight response.

Now we are at a new stage: facilitating opportunities for Mason to actually begin to understand the tactile sensation of clothing.

My first step is to explain the triune brain model to Mason and his parents in an empowering way. I do not want this to feel like a diagnosis or a limitation. I want Mason to understand: your brain has been so busy protecting you that the part that makes sense of sensation has never really had a chance to do its job. And now—with all the tools we have built together—we are going to give it that chance.

My second step is to work with Mason to develop strategies for exploring the feeling of clothing while managing his arousal and physiological state. We use the regulatory and co-regulation tools we have already built together as scaffolding—not as an endpoint, but as the conditions under which new exploration becomes possible.

My third step is to lead Mason in directed, curious exploration. As he is able to touch, feel, and eventually wear pieces of fabric for short periods of time in a state of relative safety, I engage his higher-level brain. I ask him: What does this feel like? What words would you use to describe it? How does this fabric compare to that one? What do you notice? By inviting his neocortex into the conversation—by asking him to observe, describe, and reflect—we are actively engaging the very brain level we have been trying to reach. And for many kids like Mason, this is the first time that cortical level has ever really gotten to participate in the experience of clothing. That is powerful.

6. Building Mental Models

This next concept is incredibly generative for clinical practice and comes from cognitive neuroscience. Stanislas Dehaene defines learning as the formation of an internal model of the external world (Dehaene, 2020). We build mental models of everything we encounter, and we reference those models when we encounter them again.

Let me give you an example. If I ask you, is the Eiffel Tower tall or short? Where are the arcs in the structure? I am willing to bet that as soon as I said "Eiffel Tower," an image arose in your mind. That is your mental model. You built it through photographs, through descriptions, maybe through visiting it. And now, the moment I name it, you call forth that model and use it to answer my questions.

Let me try another one. What does the Statue of Liberty hold in her right hand? Again, your mind probably just generated an image. That is your mental model of the Statue of Liberty, built through every experience you have ever had of seeing, reading about, or discussing it. Your mental model and mine will share many commonalities because we have similar experiences with these structures. But our models will also reflect individual differences shaped by our personal histories.

Now, let's bring this into the realm of clothing and dressing. What is in your mental model of getting dressed? You probably have concepts like items that go on your body, fabric that protects your skin from the elements, dressing for different occasions, dressing for sports, and dressing for celebration. We all share common elements of this model because we have common experiences of clothing as a normal, neutral, or positive part of life.

But what might be in the mental model of a child with heightened tactile responsivity? What have their experiences with clothing taught them? Discomfort. Distress. Someone yelling. Crying. Being forced. Fear. Someone is feeling disappointed in them. When we say "time to get dressed," or we hold up a pair of pants, or the morning alarm goes off, that child calls forth their mental model. And their mental model of dressing is saturated with negative emotion. That is how they understand clothing. That understanding is stored in the brain, and it shapes every subsequent experience before it even begins.

So our job is to build a new mental model. A positive one. A mental model of clothing and dressing that includes safety, fun, connection, and success. And how do we do that? The same way all mental models are built: through experience. Positive experiences, intentionally created, consistently offered.

Here is what I tell parents: every single time you create a situation where your child has any kind of positive interaction with clothing or the dressing process—no matter how small—you are building a new mental model. You are not waiting for the child to "get over it." You are actively reconstructing what clothing means in their brain. That is not soft language. That is neuroscience. And it is empowering, because it means every moment counts.

Case Study: Building Mental Models — Personal Reflection Exercise

For this one, I want to make it personal. Think of a child you are currently working with, or have worked with, who has difficulty dressing due to sensory over-responsivity. Hold that child in mind.

How do I use the concept of forming a positive mental model of dressing to support this child?

My first step is to explain this concept to parents, caregivers, and the child, if developmentally appropriate. I use language they can hold onto: "Every positive experience with clothing is literally changing how your child's brain understands what getting dressed means." For many parents, this is the first time dressing has been explained to them as a brain-level experience rather than a behavioral problem. That shift alone can be transformative.

My second step is to empower parents and caregivers to understand their role. They are not bystanders in this process—they are builders. Every time they create a low-stakes, positive, playful moment involving clothing, they are contributing to a new neural model. That might mean practicing dressing in the afternoons when there is no time pressure, instead of only during the high-stress morning routine. It might mean incorporating the child's favorite activities, songs, or characters into the dressing experience. It might mean celebrating every small win genuinely and warmly.

My third step is to support parents in being intentional about this—not just waiting for it to happen organically, but building it deliberately into their daily or weekly routines. And I teach them play-based approaches so they have specific tools to use.

7. Neuroplasticity

Neuroplasticity is the brain's ability to change. We know this. As occupational therapy practitioners (OTPs), we believe neuroplasticity is foundational to what we do. But I want to apply it specifically here, because I think when we do, it changes how we talk about this work—with each other, with families, and with the kids themselves.

The brain works by connecting neurons. When neurons repeatedly connect, the pathway between them becomes stronger and more efficient. Information flows more easily along well-worn pathways than along new or infrequently used ones. Imagine a diagram of neural pathways—some thick and well-established, some thin and barely formed. Information flows naturally and rapidly along the thick ones. The thin ones require more effort and more repetition before they become fluent.

Now think about what this means for a child who has experienced dressing negatively, consistently, for years. The neural pathway from "dressing" to "threat, distress, and negative emotion" is thick. It is well-worn. Information flows there automatically and fast. The moment dressing is mentioned, the brain slides along that familiar groove. The associations are strong. And this is not the child's fault. It is simply what neuroplasticity looks like when an experience has been consistently negative.

What we do with this understanding is: we build a new pathway. We create positive neural experiences connected to clothing and dressing, we repeat them, and we strengthen them. We are not erasing the old pathway—neuroplasticity does not work like that. But we are building an alternative route, and with enough repetition, we can make that new positive pathway stronger and more automatic.

Dressing is particularly powerful for this work, and I love pointing this out to families. From a neuroplasticity perspective, dressing has two characteristics that make it ideal: it holds meaning, and it happens every single day. Every day, there is an opportunity to either reinforce the old negative pathway or build the new positive one. That is not a burden—that is an opportunity. Every morning becomes a chance to say: we are building something new in this child's brain.

Case Study: Neuroplasticity

Here is how I bring neuroplasticity into practice with any family I work with.

First, I explain the concept to parents and caregivers, and to the child if developmentally appropriate. I use simple, visual language—I often draw it out or use an analogy they can hold onto. I have an eBook in the course resources that can support this conversation and serve as a take-home tool.

Second, I empower them with this understanding: every time you create a positive experience with dressing, you are changing your child's brain. You are literally building new neural pathways. That is not a figure of speech. That is what is happening at a biological level. For parents who have felt helpless and guilty, this message is often one of the most meaningful things I can offer.

Third, I support parents in intentionally creating these opportunities. Afternoons instead of mornings. Play-based practice instead of rushed compliance. Moments that are chosen rather than forced. And I repeat this message consistently: small, positive, and intentional.

Fourth, where appropriate, I teach the kids themselves about neuroplasticity. For children who are old enough to grasp the concept, understanding that their own brain is changeable—that they are not broken, that their brain just learned something hard, and now we are going to teach it something new—can be profoundly empowering. I have watched children shift from shame to curiosity when they understand their own neuroscience. That shift alone is therapeutic. There is also an eBook available in the course resources that goes through some of these concepts in a way that is accessible both for clinicians deepening their own understanding and as a take-home tool for families. I encourage you to explore it and share it as part of your parent and caregiver education.

8. The Compensatory Bridge

The final concept I want to introduce is the compensatory approach, and I want to be clear about what it is and what it is not—because I think it is sometimes misunderstood.

Everything we have covered so far—arousal, fight/flight/shutdown, co-regulation, play, improving modulation skills, mental models, neuroplasticity—these all fall under what we call a habilitative approach. A habilitative approach focuses on improving the child's innate sensory processing and integration skills. We are building and strengthening neural models, facilitating the progression through stages of integrating and applying sensory information, and helping the child's nervous system develop a greater capacity to understand and use tactile input from clothing. The goal is that over time, through consistent, positive, play-based, neuroplastically-informed work, this child will genuinely improve. The sensation of clothing will be better understood, better tolerated, and less threatening. That is habilitation (Bundy & Lane, 2020).

A compensatory approach is different. It focuses less on long-term neural change and more on supporting the child in the moment to facilitate participation. Modifications and adaptations to the activity or environment—tagless clothing, seamless socks, softer fabrics, looser fits—either enhance or diminish sensory stimulation to create a "just right" fit for the child's current needs. The compensatory approach provides a bridge: it helps the child get from where they are right now to functional participation in an activity they do not yet have the long-term skills for (Bundy & Lane, 2020).

I think of it this way: the diagram of sensory integrative function moves from sensory intake through processing, integration, and organization to adaptive interaction and functional participation. The habilitative approach works through each of those steps. The compensatory approach is a shortcut—a bridge—that hops over the middle steps to get the child into participation right now. That is not a failure. That is a tool. But it is important to understand that compensatory strategies alone will not help the brain get better at processing and integrating sensory information. They help the child participate today, while the habilitative work helps them improve over time.

The seamless socks, the tagless shirts, the soft waistbands—these are wonderful. They reduce distress and allow a child to engage in life while we do the deeper work. But if we only compensate and never habilitate, we have provided a temporary fix rather than a lasting change.

Case Study: Compensatory Strategies — Myla

Myla is a fifteen-year-old girl who wants to play on her school's soccer team. She has been practicing for months and even hired a personal coach. The school's soccer coach encourages her to try out. Myla wants to, but she knows she cannot wear the required uniform—specifically, the required socks.

Here is how I approach this with Myla. On one track, we continue the habilitative work: I am working with Myla to develop her sensory integration and processing skills, to build her capacity to understand and tolerate tactile input from her clothing, using all the approaches we have discussed. That work continues.

But on the other track, simultaneously, Myla wants to play soccer now. She cannot wait for the habilitative process to be complete. So we compensate. We look for seamless socks in the required color. We trial different sizes to see which fit is more acceptable. We try applying seam tape along the inside of the sock at the seams. We examine whether wearing a thin, seamless sock beneath the uniform sock makes the experience tolerable. We problem-solve and adapt.

The compensatory approach is the bridge that lets Myla play soccer—to participate in something meaningful to her—while the habilitative work continues in the background. Both tracks matter. Both have a role. The art of OT practice is knowing which tool to use when, and being honest with families about what each approach is designed to accomplish.

Involving Parents and Caregivers

Before I wrap up, I want to say clearly and emphatically: involving parents and caregivers is not an add-on to this work. It is the work. Parent and caregiver education, coaching, and collaboration are among the most important and effective things we do as OTPs, and nowhere is this truer than in sensory integrative practice around dressing. In my experience, this is truly the most important thing we do—because parents and caregivers need to understand this information to carry it into daily practice. When we talk about changing the brain through neuroplasticity and building new mental models through consistent positive experience, that cannot happen in a therapy session alone. It has to happen every day. And that means families need to understand what we understand.

Helping parents and caregivers understand a child's sensory experiences and needs is a crucial component of treatment (Parham & Mailloux, 2020). Taking a family-centered approach to sensory over-responsivity that supports parents' and families' experiences of distress is critical for the overall well-being of the entire family unit (Ben-Sasson & Zisserman, 2025). Research also tells us that parents' learning needs are rarely adequately considered in OT practice—but they are a crucial part of supporting children with sensory integrative challenges (Porter et al., 2023).

I also want to gently acknowledge something here: parents like Keisha's mom are not failing. Parenting a child with sensory over-responsivity is genuinely hard. Morning routines that should take fifteen minutes can consume an entire hour. Plans are canceled. Siblings are disrupted. Guilt accumulates. When we take time to educate parents about the neuroscience—when we help them understand that their child is not making a choice, that the nervous system is doing exactly what it is designed to do in response to perceived threat—we often see visible relief in the room. The guilt softens. A new curiosity and compassion open up. And from that place, they are so much better able to become the co-regulators and positive experience builders their child needs.

Think about what we are asking of the brain when we talk about neuroplasticity and positive mental models. We are talking about consistent, daily, intentional positive experiences with clothing and dressing. That cannot happen in a single weekly therapy session. It has to happen at home, in the morning routine, on the weekends, at every dressing moment throughout the week. That means parents and caregivers need to understand what we understand. They need to believe what we believe about their child's experience. And they need specific, practical tools to carry this work forward in daily life.

Every concept we have covered today—the arousal guidelines, the physiological states, the co-regulation cues, the play-based approaches, the mental model framework, the neuroplasticity message—all of it needs to be translated into the hands and hearts of the people who are with these children every day. That is our job as translators of neuroscience. And it is one of the most meaningful things we do, I think.

Conclusion

I know this has been a lot of information, and I want to bring it together before we close. We started by understanding tactile overresponsivity and defensiveness through a neuroscience lens—what they are, who these children are, and what is actually happening in their nervous systems when clothing becomes a genuine source of distress. We clarified our terminology and grounded ourselves in the AOTA position on sensory integrative practice.

Then we worked through eight interconnected concepts: arousal and how sensory input influences the nervous system's state of alertness; fight, flight, and shutdown as the physiological states driving so much of what we see in these children's behavior; co-regulation as a biological imperative and a clinical tool that lives in our bodies and voices; meaningful participation and play as the vehicle for changing the brain; improving modulation skills through the lens of the triune brain model and what it means for sensory information to finally reach the cortex; building positive mental models of clothing and dressing through intentional experience; neuroplasticity as the mechanism by which consistent positive experience literally reshapes the brain; and the compensatory bridge as the parallel track that supports participation right now, even while the deeper habilitative work continues.

These are not isolated strategies. They are a framework—one that allows us to meet these children and families where they are, understand what is happening beneath the surface, and bring our most informed and compassionate practice to bear on a challenge that, while it may look like a behavioral problem, is in its essence a nervous system challenge.

I hope that you leave today with both a deeper understanding of the neuroscience and a renewed sense of what is possible for the children you are serving. If you have questions I did not get to, please do not hesitate to reach out. This information matters, and the children and families navigating it deserve our best.

Questions and Answers

Are these dressing strategies more appropriate for a clinic or a home setting?

These strategies are highly effective in both settings. While the home environment often makes parent and client education more natural, they are absolutely applicable to the clinic. When practicing in a clinic, the key is to bring the parents back with the child to ensure they are educated throughout the process.

How do you implement the "mental model" concept with a toddler?

Toddlers are constantly building mental models as they learn and grow. To implement this, focus on positive engagement. Every time a child has a fun or successful experience with clothing—whether through play or a small win during dressing—you are contributing to a positive mental model. Focus on those small, positive interactions to build their confidence.

What is the average amount of time it takes to bring a child out of "fight or flight"?

There isn't a universal "average" time, as it varies significantly by individual. The best approach is to focus on arousal levels and truly get to know the specific child. By observing and understanding a particular child's triggers and soothing needs, you can determine how much time they specifically need to regulate and return to a calm state.

References

See additional handout.