How to Tell if Your Pediatric Bowel and Bladder Patients Have Interoception Differences

Have you been treating pediatric patients for bowel and bladder dysfunction without you knowing whether or not they have impaired interoception?

Probably…

We’re constantly learning as a profession, and although interoception has been studied for decades, it seems this system is just now making its way to clinical and practical application, which is great news for you if you’re in the clinic!

We know enough today about interoception to start making meaningful changes to our treatment approaches, and address our patients even more holistically (yes, this includes treating the interoceptive system).

In my last blog I introduced the topic of interoception — the sense that gives us awareness of the internal sensations in our bodies and helps us regulate bodily functions such as breathing, heart rate, and bowel and bladder control. Today, we’re going to take a closer look at how interoception presents in the clinic, what to look for, and how to know if your patient is appropriate for an OT referral.

Impaired interoception can manifest in various ways, and some common signs in children include difficulty recognizing and describing internal sensations, atypical responses to environmental stimuli, and challenges with regulating emotions and behaviors. A child with impaired interoception may also have difficulties with daily living activities, such as eating, dressing, and sleeping.

It likely doesn’t come as any surprise to you as a pediatric pelvic floor therapist that interoception differences can also affect the function of your bowel and bladder. The gut-brain axis tells us how intricately connected we truly are, so it only makes sense that a system aiming to maintain homeostasis in response to stimuli would affect the genitourinary and digestive systems. You can guess that at least some of your patients have impaired interoception.

Our professional “cousins”, occupational therapists (OTs), are typically the go-to experts in sensory changes, and your closest OT friend may or may not have gone through some additional training in interoception. Either way, it’s important you know some things to look for and feel confident about referring your patients out as needed.

These are questions you can ask parents when you’re evaluating your patient to give you an idea of the status of their interoceptive system:

• Does your child go more than 3 hours without asking for food or drink?
• Does your child need to be reminded to drink liquids throughout the day?
• Does your child seem to get overtired quickly or easily?
• Are “bedtime battles” frequent in your home (more than 4x/week)?

This difficulty in recognizing internal sensations can lead to challenges with regulating emotions and behaviors. For example, a child with impaired interoception may become irritable, agitated, or aggressive when they are hungry, tired, or in pain, without realizing that these sensations are the cause of their discomfort. These children don’t have any idea that they’re becoming overwhelmed. They simply hit that “breaking point” and lose control.

When someone with normal interoception is becoming annoyed, as an example, they may feel their heart start to beat faster, they may feel their body temperature rise, and they may notice their breathing patterns change. These body changes afford that person the opportunity to make a change and decrease how annoyed they are. Maybe they walk to a different room, take some deep breaths, or speak up about how they’re feeling.

For someone with impaired interoception, none of the “I’m getting annoyed” signals are registered by their brain. The changing state of their body isn’t something they’re even aware of. They don’t get the chance to make any changes to their internal or external environments because they don’t know the changes are indicated. This can make it challenging for parents and caregivers to meet the child’s needs and provide appropriate support. They’re as much in the dark as their child.

OTs can work with children to improve their interoceptive awareness and develop strategies to help them recognize and respond to internal sensations. This can involve activities such as mindfulness exercises, sensory exploration, and sensory integration therapy. With appropriate support and intervention, children with impaired interoception can learn to better recognize and respond to their internal sensations, improving their overall well-being and quality of life.

Children with impaired interoception may also exhibit atypical responses to environmental stimuli. They may overreact or underreact to sensory input, such as loud noises, bright lights, or certain textures or smells.

For example, a child with impaired interoception may cover their ears or become extremely agitated in response to a loud noise that others find tolerable, or they may seek out intense sensory input, such as spinning or jumping, to feel more grounded and connected to their environment.

You may recognize these children in your clinic as those who gag when they see or smell their own stools, or those who just can’t seem to sit still long enough to complete their treatments.

These atypical responses can make it challenging for children with impaired interoception to navigate their daily lives and participate in social situations. They may avoid certain activities or environments that trigger sensory discomfort, or they may engage in repetitive behaviors or self-stimulatory activities (also known as “stimming”) to cope with sensory overload.

Pediatric therapists may use sensory integration therapy to assist these children with regulating their responses to their environments. This type of therapy uses specific sensory activities and exercises to help children better process and respond to sensory input.

By developing strategies to manage sensory input, children with impaired interoception can improve their ability to engage in daily activities and participate more fully in their environment.

For example, a child with impaired interoception may not recognize when they are feeling overwhelmed or anxious, leading to emotional outbursts or meltdowns. They may also have difficulty transitioning between activities or adjusting to changes in routine, leading to rigidity in their behaviors and resistance to new experiences.

It’s not uncommon for children with a history of trauma to have bowel or bladder dysfunction. As such, it’s not surprising that these children are also particularly susceptible to interoception changes. Their bodies likely shut down their feelings (their interception) as a means of protecting themselves to endure their trauma.

This shutting down/protective mechanism seems as though it can be non-discriminate — there is no need to feel the pelvic floor or the body’s fear reaction, so everything gets “turned off”. This adds an additional layer of challenge to their healing process.

Incorporating deep breathing, mindfulness, and sensory integration therapy with your treatment plan for bowel and bladder dysfunction can be very beneficial to these patients. These activities can help children better recognize and respond to their emotions and thus reduce stress and anxiety.

So much of what we know about treating interoceptive differences is often already being incorporated into your treatment plans.

• You’re probably already checking in with your kiddos to see how they describe their urges to urinate or have a bowel movement
• You already adapt your treatment plans to meet your patients where they’re at, whether that means slower progress, different activities, or something else
• You’re already helping children to become more mindful when you have them engage in diaphragmatic breathing exercises to help relax the pelvic floor

For example, an OT may adapt mealtimes by using sensory cues to help a child recognize when they are hungry or full. This may involve using visual cues, such as pictures of different foods, or tactile cues, such as placing a hand on the child’s stomach to help them recognize when they are full.

This interoception intervention can be implemented alongside urotherapy, assuming the family’s schedule allows for multiple appointments.

Of course, there are treatments these children need to help the function of their interoceptive systems that don’t fall into your “wheelhouse”. If you notice that some adaptation of ADLs may be helpful for your patients, or you feel like their interoceptive needs outweigh those of the pelvic floor, get in touch with your local OT and team up to provide your patient with the best possible plan of care with all professional disciplines considered.

You likely already make recommendations about the bathroom environment which are also beneficial for the interoceptive system. This may involve using a specialized toilet seat or step stool (which also helps the child feel more grounded and secure) while using the bathroom, or it could include using visual cues, such as pictures or labels, to help the child recognize and navigate different bathroom activities.

By adapting toileting activities in these ways, you’re able to help children with impaired interoception develop healthy bathroom habits and improve their overall well-being and quality of life. Pelvic floor therapy is about much more than exercises, as you know!

1. Sources
   Aziz Q, Thompson DG. Brain-Gut Axis in Health and Disease. Gastroenterology. 1998;114(3):559-578. doi: 10.1016/s0016-5085(98)70540-2
2. S.S. Khalsa, R. Adolphs, O.G. Cameron, H.D. Critchley, P.W. Davenport, J.S. Feinstein, J.D. Feusner, S.N. Garfinkel, R.D. Lane, W.E. Mehling. Interoception and mental health: a roadmap. Biol. Psychiatry, 3 (6) (2018), pp. 501-513