What is interoception?

We all know about the five main senses: sight, smell, taste, sound, and touch. Many people also know about two other very important hidden senses: proprioception and vestibular.

Did you know there’s a third hidden sense, interoception?

Interoception refers to the body and brain’s ability to understand and process internal information. This includes understanding hunger, thirst, fatigue, and temperature. Going even deeper, interoception also includes digestion, respiration, heart rate, and emotions. There are receptors in the internal organs, muscles, and skin that communicate with the brain to process the information from outside and inside the body.

When we think about our daily routines, we move through our day unconsciously processing all of this information. We know when we need to use the bathroom, when we need to eat and drink, when we need to change the temperature because it’s too hot or cold, and when we feel anxious or excited. Our children go through the same experiences, but oftentimes trouble occurs when the brain and the body do not process the information as it should. 

What is interoception dysfunction?

It’s hard to say why a person experiences interoception dysfunction. There can be many factors, including illness or sensory processing challenges. For this article, we will focus on children who also experience sensory dysfunction.

Interoception dysfunction can look like one or more of the following:

• Poor understanding of hunger and thirst - a child may not feel the desire to eat and drink, or they may not feel full resulting in overeating and over-drinking.
• Poor understanding of when to use the bathroom - a child may not “feel” the need to use the bathroom, or they may over-use the bathroom.
• Poor understanding of pain and temperature - a child may feel less or more pain than others; a child may not understand the feeling of cold or hot. This can also become a safety concern.
• Poor understanding of emotions - a child may not understand what it feels like to be happy, sad, angry, anxious, etc. They struggle to connect a bodily feeling with an emotion.

One study from 2018 discussed how interoception is an integral part of emotional regulation.

But why? What is happening inside of the body to cause these challenges? One article from January 2021 reported that “Interoceptive dysfunction at any level of the neuraxis can affect the whole system and is implicated in the expression of psychological and physical symptoms across a spectrum of acquired, developmental, neurodegenerative, central, and peripheral conditions.”

Simply stated, interoceptive dysfunction can go right along with a variety of other diseases or disorders, including (but is not limited to) developmental disorders (i.e., delays), digestive disorders, chronic pain, psychiatric disorders (i.e., autism, ADHD), and neurological disorders (i.e., migraines, epilepsy).

Because everything is connected, the challenges that occur with the above diseases or disorders can affect the ability of the body and brain to communicate successfully, therefore laying the foundation for interoceptive dysfunction.

How to identify interoception dysfunction

If your child struggles to process the sensory world, they likely struggle with interoception as well. A sensory seeker (a child who seeks out more input than others) may not be able to sense when their bladder is full. A sensory avoider (a child who avoids more input than others) may feel intense pain from an incident that is not typically painful.

Let’s look at some specific examples of interoception dysfunction:

• Challenges with toilet training - the child may seem disinterested in using the toilet or may not notice when their diaper is wet/soiled (or may not seem to care); they may hold their BM/urine to the point of infection and/or frequent accidents.
• Challenges with feeding - the child may seem disinterested in mealtime, they may exhibit signs of picky eating, or they may attempt to overeat due to never feeling full. This also applies to drinking enough water or too much water.
• Note: Excessive feelings of thirst may indicate an underlying medical condition and should be discussed with your child’s pediatrician.
• Poor tolerance to pain - the child may express pain during preferred activities, specifically when other children do not.
• High pain tolerance - the child may never express pain, to the point where they may have a severe injury but do not tell anyone because they do not feel the pain.
• Anxiety attacks - the child may experience intense anxiety but cannot identify the feelings internally associated with it, thus resulting in an anxiety/panic attack. Along these same lines, there may be challenges with regulating a regular heart rate.
• Too high or too low arousal/energy levels - the child may not be able to successfully achieve and maintain an appropriate level of arousal/energy for a certain situation.
• Understanding emotions - the child may not understand their own emotions and the emotions of others.

Strategies for Improving Interoception

It is always a good idea to talk with your child’s pediatrician if you suspect challenges with sensory processing, especially if safety concerns have been identified (which is often the case with interoception dysfunction).

There are also strategies that you can implement to help your child improve their ability to identify and process the inner workings of their body. It can also be helpful to work closely with your child’s Occupational Therapist (OT)/Occupational Therapy Assistant (OTA), as they may be able to identify the specific origin of challenges and individualized strategies and tools.

Below we'll run through some examples of strategies for improving interoception, particularly in some common situations.

Strategies Using The Bathroom

Use a visual schedule.

• Include the time of day and location where your child will be when it is time to use the bathroom.
• Make the visual schedule fun and motivating.
• Use pictures, velcro, whatever your child will enjoy using.
• Make it portable. This ensures that you can take the visual schedule with you / your child (especially helpful if your child is in school).
• Include your child’s team and family members. This is so important for consistent carryover!

Not sure how long your child should go in between bathroom visits? Take a couple of days to track when your child voids to identify a typical time frame. You can also track food and fluid intake (specifically fluids, as they pass faster) to determine how long after eating/drinking your child will need to use the bathroom.

Discuss the importance of regularly using the bathroom, but not too much. This is ideal for a child who can communicate verbally and understands the concept of using the bathroom.

For the child who holds and/or experiences frequent accidents, this conversation can venture into the social implications. If your child is holding due to poor interoception and anxiety, it may be beneficial to look into specific strategies for anxiety.

Using a positive reward system can help. Children often respond better to positive rewards, as well as this decreases the likelihood of the child feeling shame from a negative experience.

Sticker charts along with a visual schedule can be beneficial for young children.

Use a “bathroom toy box” - these toys are only available after the child has successfully attempted to use the bathroom at the scheduled time (or using the bathroom instead of holding). The toy then gets put back into the box at the end of the day or after a specified amount of time.

Strategies Eating and Drinking:

Maintain a regular meal and snack time.

This includes a regular breakfast, lunch, and dinner time; include drinks into this schedule as well. Use a visual schedule and/or some sort of indicator on your family clock so your child knows when meals and snacks are. Try not to veer too much or too frequently (life happens!).

If a child has not experienced regular meals/snacks - perhaps they “graze” throughout the day - they may never experience the feeling of hunger or thirst.

Feelings of hunger and thirst are normal and are signs that our body is ready for nourishment. Decreasing the amount of time your child spends “grazing” can be very beneficial.

If your child is a picky eater, it can be very difficult to attempt regular meal times due to the concern for overall nourishment and getting enough calories. Talk with your pediatrician and seek out a therapist trained in feeding therapy if this is the case.

Keep water bottles filled and take them with you. Allow your child to choose their own water bottle - this helps with motivation to take the water bottle with them!

Set expectations for how much water your child drinks. If possible, discuss with your child why it’s important to drink enough fluids (specifically water) throughout the day. Also discuss why it’s important not to over-drink.

As mentioned previously, if your child complains of constant thirst, talk with your pediatrician, as this may be a sign of an underlying medical condition. Talk about nutrition and model what you want your child to do.

Stay consistent!

Some foods make us feel more full than others. Have a conversation around this topic. Set up an experiment at mealtime - identify which foods make your tummy feel full and which ones do not. Keep track in a journal. Talk about foods that fuel the body and foods that are “just for fun.”

Try to keep it positive and fun!

If a child struggles to understand feeling hungry and/or full, mealtime may not be a fun experience. Create a fun mealtime routine that is engaging and motivating. Eat together and have fun conversations during mealtime.

Strategies for Improving Pain Tolerance:

If your child experiences pain during activities that other children complete without pain, the first step is empathy. Your child may truly be in pain, even if we cannot understand why or how.

Discuss what they did that caused the pain. Try to find alternatives and/or strategies so your child can engage in the activity without pain. If your child has a very high pain tolerance and it is causing safety concerns, talk with your child about safety precautions (if possible).

A social story about the activity is a great place to start. For example, if your child is walking barefoot on hot asphalt, and it is hot enough that the child may get burned, write a social story talking about what to wear for different types of weather. “When it is 90 degrees outside, we wear shoes/sandals when walking outside because the ground becomes so hot it can burn my feet.”

Role play different scenarios where your child may become injured due to lack of feeling pain.

Primitive reflex integration.

If primitive reflexes are still present, this may affect the child’s sense of interoception. Seek out and work with a therapist who is trained in primitive reflex integration training.

Mindfulness practice.

Interoception and emotions

One newer area of study is how interoception is related to emotions and arousal/energy levels. This includes our ability to understand our own feelings and emotions and understand others' feelings and emotions. Many children who experience challenges with the above-mentioned areas also experience challenges with emotional intelligence.

Emotional intelligence is defined as a type of intelligence that involves the ability to process emotional information and use it in reasoning and other cognitive activities (APA Dictionary of Psychology).

An article in 2018 discussed emotions related to interoception as

“...the ability to accurately detect and evaluate cues related to physiological reactions to stressful events, accompanied by appropriate regulation strategies that temper and influence the emotional response. There is compelling evidence demonstrating links between poor or disrupted awareness of sensory information, or interoceptive awareness, and difficulties with emotion regulation.”

These challenges can look like (but are not limited to):

• Anxiety
• Fight, flight, or freeze response
• Too high or too low arousal/energy levels
• Poor ability to make and keep friends
• Frequent outbursts/meltdowns

If your child is struggling in this area, here are some strategies to try:

• Chat with your child’s OT, OTA, or Speech-Language Pathologist about beginning to work on emotional intelligence.
• Model emotional regulation and identify feelings regularly.
• Children don’t know how to identify feelings if they don’t see us doing it first. They learn by observing those around them, so begin identifying how you feel in specific situations.
• For example, if you are cooking in the kitchen and a dish breaks, talk about how you feel - “Wow, I feel kind of frustrated about breaking that dish.”
• Then, talk about what you will do - “I think I need to take a break before I can come back because I feel frustrated. I’m going to take some deep breaths.”
• Teach that all feelings are “normal.” There are no good or bad emotions; it’s what we do with our feelings that matters. We all feel mad or sad sometimes. We all feel happy sometimes.
• Empathize! Your child’s emotions are real and should not be pushed aside. Validate their feelings, then move on to strategies.

Check out our video on the Top 5 Activities for Interoception

Final note on interoception

Interoception can be a tricky situation. There are many components, and your child’s challenges with interoception may change as they grow. Just remember, there is nothing wrong with your child, and they do not need to be “fixed.” Your job is simply to teach the strategies they need to move successfully throughout their day!

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