Editor's note: This text-based course is a transcript of the webinar, Interoception, presented by Jeryl D. Benson, EdD, OTR/L, FAOTA.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- As a result of this course, participants will be able to examine a description of interoception to determine how to support parent and team education.
- As a result of this course, participants will be able to differentiate aspects of interoception and how they relate to regulation and participation.
- As a result of this course, participants will be able to examine how the assessment of interoception can be included as part of a comprehensive occupational therapy evaluation and how to apply intervention strategies to support development of interception in children.
Introduction
Welcome to today’s session, where we hope to explore new concepts that can be directly applied to your clinical practice.
Overview of Today's Agenda
To achieve these outcomes, we will cover several topics today:
- Understanding Interoception: We’ll start with defining interoception and how it differs from exteroception.
- Types of Interoception: We’ll explore different types of interoception based on current literature and break them down further.
- Impact of Interoception on Daily Life: We’ll discuss how interoception affects daily activities and how it presents in children.
- Atypical Interoception and Related Diagnoses: We’ll move into atypical interoception and related diagnoses, such as autism and anxiety disorders.
- Assessment and Goal Development: We’ll discuss how to assess interoception, develop and write goals, and apply evidence-based intervention strategies.
- Case Studies: Finally, we’ll apply these concepts through two case studies to see how they can be used in various settings with different children.
Understanding Interoception
Interoception vs. Exteroception
Interoception refers to the nervous system’s ability to represent the body's internal state, while exteroception is our perception of the external world. Exteroception typically involves sensory systems that provide information from outside the body, such as vision, hearing, smell, taste, and somatosensation. In contrast, interoception involves sensing internal signals like hunger, thirst, body temperature, pain, tension, and tightness.
Some sensory systems, such as the tactile and vestibular systems, cross into both categories. For instance, the tactile system processes external stimuli (like touch) and internal signals (such as temperature and pain), while the vestibular system provides balance information, which is more aligned with interoception.
Complexity and Importance of Interoception
Interoception is a complex, multidirectional process involving communication between the brain and various bodily systems. This process is essential for regulation and participation in daily activities, as it helps us understand and respond to our body’s internal states. Scholars suggest that interoception is not just a one-way communication from the body to the brain but a bi-directional and even multi-directional exchange that allows for modulation of our physiological state.
Exploring Types of Interoception
Interoceptive Ability and Atypical Interoception
Interoceptive ability encompasses all aspects of receiving, interpreting, and responding to bodily signals. It’s a broad term that includes various subcomponents:
- Implicit Interoception: Occurs subconsciously, where bodily changes are not perceived until they reach a level requiring attention.
- Explicit Interoception: Involves conscious awareness of bodily states, allowing individuals to recognize and respond to signals like heart rate and body temperature.
Some individuals have atypical interoception, where their sensitivity to bodily signals is either heightened or diminished. This atypical processing can be associated with conditions such as autism spectrum disorder (ASD), anxiety, depression, and alexithymia, a condition characterized by difficulty in identifying and expressing emotions.
Interoceptive Sensitivity and Awareness
Interoceptive sensitivity refers to the degree to which a person accurately perceives the state of their body, while interoceptive awareness involves a metacognitive understanding of one’s interoceptive sensitivity and accuracy. This awareness allows individuals to reflect on their bodily states and how these states influence their behavior and decision-making.
Impact of Interoception on Behavior and Cognition
Interoception plays a significant role in emotional processing, social cognition, learning, and decision-making. For example, recognizing bodily signals related to hunger, thirst, or pain can influence decisions about eating, drinking, or seeking medical care. Classical learning theories, such as operant conditioning, suggest that decision-making is guided by internal states and the value assigned to different options based on these states.
Interoceptive cues are constantly processed by the brain, helping us make decisions and solve problems. However, individuals with atypical interoception may struggle with self-regulation, problem-solving, and social interactions due to difficulties interpreting and responding to these internal cues.
Atypical Interoception and Related Diagnoses
Low Interoception
Low interoceptive ability is often associated with feeding and eating disorders, autism spectrum disorders (ASD), and alexithymia. In individuals with ASD, difficulties with interoception can lead to challenges in emotional recognition and regulation, social interactions, and sensory processing.
High Interoception
High interoceptive ability, on the other hand, is linked to anxiety and panic disorders. Individuals with heightened interoception may interpret bodily signals negatively, contributing to cognitive and behavioral symptoms such as worry and avoidance.
Autism and Interoception
Individuals with autism may experience difficulty integrating interoceptive signals, leading to poor focus on their bodily states and emotions. This can result in challenges in understanding their own emotions and the emotions of others, which are fundamental to social interactions and mental health.
Assessment and Goal Development
Assessment Tools
Several tools are available to assess interoception, including:
- Multidimensional Assessment of Interoceptive Awareness (MAIA): A questionnaire that helps gauge awareness of bodily sensations, available for both youth and adults.
- Comprehensive Assessment for Interoceptive Awareness: This tool is specific to occupational therapy and assesses self-regulation, emotional identification, and social skills.
Clinical Observations and Data Collection
Assessment involves gathering data on a child’s routines, behaviors, and responses to sensory input. This information is crucial for developing an occupational profile and formulating hypotheses about interoceptive challenges. Clinical observations should focus on the child’s ability to perceive and respond to internal cues and how these impact their participation in daily activities.
Intervention Strategies
Evidence-Based Interventions
Interventions include mindfulness, yoga, and deep breathing exercises, which help increase awareness of the body and its responses. These practices can improve self-regulation and emotional control, reducing behavioral challenges and enhancing social participation.
Teaching Interoception
A structured approach to teaching interoception involves:
- Noticing the Sensation: Helping children recognize when something in their body feels different.
- Naming the Sensation: Encouraging them to describe the sensation and its location.
- Linking to Feelings: Connecting bodily sensations to emotions.
- Understanding the Impact: Reflecting on how these sensations and emotions influence behavior.
- Managing the Response: Developing strategies to manage sensations and emotions effectively.
Case Studies
Case Study 1: Peter, a 7-Year-Old with Autism
Peter is a seven-year-old boy diagnosed with Level 1 Autism. His parents are deeply concerned about his behavioral outbursts, which include hitting, kicking, biting, and throwing objects. They reached out for help, hoping to find ways to manage these behaviors.
During the assessment, we identified that Peter struggles with cognitive, sensory, and emotional regulation. He has an elevated arousal level and is a sensory-seeking child. Emotionally, he has difficulty identifying his own emotions and the emotions of others.
We first focused on sensory regulation when considering what interventions might benefit Peter. Here, we rely on well-established occupational therapy interventions. We planned to provide client and parent education, incorporating a sensory diet into Peter’s daily routine. The goal was to help Peter understand which sensory strategies could help him regulate better and to educate his parents about how his sensory system functions.
For emotional and cognitive regulation, we aimed to help Peter identify and label his body’s states and link these to his emotions. For example, noticing that his heart rate increases, his muscles tighten, and his breathing becomes rapid when he’s angry. We introduced a visual system to help Peter identify when he’s in the “panic zone” and what that means—specifically, that it’s when he feels angry and inclined to fight.
We wanted Peter to understand that his actions can hurt those he loves, such as breaking his toys or kicking his mom when he's in the panic zone. Teaching him to manage these sensations involved working through a sequence: noticing the sensation, naming it, linking it to emotions, understanding the impact, and managing it. For instance, we taught him breathing exercises, like triangle breathing, to help him calm down and think through his anger before it escalates to physical aggression.
Case Study 2: Sarah, a 10-Year-Old with Traumatic Brain Injury
Sarah is a ten-year-old girl who suffered a traumatic brain injury (TBI) and is now nonverbal and non-ambulatory. Her TBI resulted in cognitive impairments, but she still has a level of cognition that allows her to understand, even though she can’t articulate her thoughts. Sarah also struggles with significant extensor spasticity, which makes hygiene tasks, such as diapering, extremely challenging. Her muscles become so tight that it takes two people to clean her, and even then, it’s difficult to do so thoroughly, leading to discomfort and hygiene issues.
In Sarah’s case, emotional and cognitive regulation were the biggest challenges. She wasn’t connecting her emotions to the state of her body, which only escalated her anxiety during hygiene tasks.
Our goal for Sarah was to help her identify and label the state of her body and link it to her emotions, all through nonverbal methods. We used visuals and simple choices to help her communicate. For instance, we used visuals of a rock and a pillow to symbolize tightness and softness. We helped her recognize that when her body feels “stiff like a board,” it’s often due to anxiety about being cleaned.
We then began teaching her simple breathing exercises to help her relax her body. This approach helped her become more aware of how her body felt and how she could manage the tightness. The idea was to create a teachable moment where she could understand that relaxing her body would make the process less uncomfortable and scary.
By guiding her through these exercises and using visuals, Sarah started to understand the connection between her emotions and her body’s responses. This helped her manage her anxiety better during hygiene tasks, making the process smoother and less distressing for her.
These case studies highlight the importance of tailored interventions that address each child’s unique needs, helping them and their families manage challenging behaviors and improve their quality of life.
Conclusion
This session aimed to enhance your understanding of interoception and its role in occupational therapy. By integrating interoceptive assessment and intervention strategies, we can better support children's regulation and participation in daily activities. We hope you can apply these concepts and techniques in your clinical practice.
To conclude, we'll launch an exam poll to review the key concepts discussed. This will also provide an opportunity to address any remaining questions.
Exam Poll
1)Interoception is...
The answer is B. Interoception is the internal signals from our body sent to our brain.
2)Hunger and thirst are examples of what type of interoception?
Hunger and thirst are visceral, so the answer is B.
3)What is low interoception associated with?
Low interoception is associated with all of those things.
4)When teaching interoception, what does the child need to do first?
Everybody said C. The first thing they have to do is notice it before we can even move on to naming or managing it.
5)What is a toileting strategy for supporting interoception?
Most of you put in the letter D. That is correct.
Thank you for participating today. I hope you can apply this knowledge in your practice. Now, we will take some questions.
Questions and Answers
Where can participants find the link for the Maia tool mentioned in the presentation?
The link for the MAIA tool can be found in the references section of the presentation.
How might interoception issues be addressed within an SDI (Specially Designed Instruction) rather than as an IEP goal in a school setting?
Interoception issues may not be an IEP goal, but they can be included in SDIs by using language to identify emotions and link them to body signals. Visual aids, especially for younger children, can support the child’s understanding and be incorporated into classroom activities.
What tools, besides breathing exercises and breaks, can be used with older students to help them regulate after identifying body signals and emotions?
Besides breathing exercises and breaks, older students might benefit from physical exertion or resistance activities, which provide somatosensory input and proprioception. These tools help them manage their emotions and bodily responses more effectively.
Can you give an example of an IEP goal for a child recognizing body signals?
An example of an IEP goal could be for a child to notice when their body becomes tight and be able to indicate this to others. This goal focuses on using specific language and noticing physical changes during ADL (Activities of Daily Living) tasks.
How can parents be supported in understanding and managing their child's interoception issues?
Parents can be supported through education, including visuals to explain what is happening in the child’s body and why they may have difficulty with certain signals. Parents should be guided on how to recognize their child’s emotions and assist in selecting beneficial coping strategies.
What role do breathing techniques play in addressing interoception and psychosomatic issues?
Breathing techniques, sometimes derived from psychosomatic medicine, help children notice, label, and manage their bodily sensations and emotions, playing a crucial role in regulation.
References
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Ceunen, E., Vlaeyen, J. W. S., & Van Diest, I. (2016). On the origin of interoception. Frontiers in Psychology, 7, 743. https://doi.org/0.3389/fpsyg.2016.00743
Chen, W. G., Schloesser, D., Arensdorf, A. M., Simmons, J. M., Cui, C., Valentino, R., & Langevin, H. M. (2021). The emerging science of interoception: Sensing, integrating, interpreting, and regulating signals within the self. Trends in Neurosciences, 44(1), 3–16. https://doi.org/10.1016/j.tins.2020.10.007
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Citation
Benson, J. (2024). Interoception. OccupationalTherapy.com, Article 5730. Available at www.occupationaltherapy.com
