The development of sensory modulation, the ability to execute an adapted behavior in response to the sensory environment, is a complex process which relates to several factors. These include developmental age, temperament, innate regulation ability, and the degree of previous exposure to stimuli (Williamson and Anzalone, 2001). Typically developing children differ in their level of sensory over-responsivity (SOR) and in the degree to which it interferes with their participation in daily activities (Bar-Shalita et al., 2008; Ben-Sasson et al., 2010). Despite the weight of personal characteristics in the ability to regulate and adapt to the sensory environment, the importance of the family environment and reactions should not be underestimated. Families define opportunities for sensory exposure, as well as affective modeling of coping in stressful situations. Families vary in the way they respond to their child’s sensory sensitivities. The current study aimed to develop a tool for quantifying how families accommodate to their child’s sensory sensitivities, and the distress caused to the child and/or family because of these interactions.

Family accommodation describes attempts of family members to reduce their child’s distress by avoiding the source of fear, taking part in rituals, reassuring, and changing their routines and activities. It is important to identify family accommodations as while they may provide immediate relief, they predict greater symptom severity (i.e., higher anxiety levels, more rituals, and compulsions), lower levels of functioning (more avoidant behaviors), and poor intervention outcomes (Storch et al., 2007; Peris et al., 2008; Lebowitz et al., 2012, 2013; Strauss et al., 2015; Feldman et al., 2019; Shimshoni et al., 2019). Family accommodations have primarily been studied among children with OCD and anxiety disorders (Storch et al., 2007; Lebowitz et al., 2013) and to some degree in ASD (Feldman et al., 2019). Research shows that although the types of accommodations among different fear-based disorders may differ, the frequency of accommodations remains the same. These conditions share repetitive, catastrophic thoughts, experiences of fear, avoidance, and seeking a secure state (Reuman and Abramowitz, 2018). Since SOR is associated with heightened anxiety (Ben-Sasson et al., 2009; Conelea et al., 2014), we hypothesized that family members would accommodate some sensory symptoms, even when it comes to families with typically developing children.

Although family accommodations reflect the parents’ intention to reduce their child’s distress, paradoxically these strategies tend to reinforce the child’s distress and avoidance and inhibit the child’s ability to self-regulate (Norman et al., 2015). Many parents report distress when performing accommodations, while when they do not accommodate their child’s anger, distress and worry increases (Reuman and Abramowitz, 2018). Some children cannot complete certain tasks without accommodations, which pressures parents to construct them (Lebowitz et al., 2014). Therefore, understanding the types of family accommodations and their effects on the child and parents is important for understanding the delicate child-family dynamics surrounding a disorder and for facilitating healthier child-family interactions.

Sensory modulation reflects the individual’s ability to respond adaptively to interoceptive and exteroceptive stimuli. This ability reflects continuous information processing of the intensity, duration and frequency of stimulation enabling attention to relevant stimuli while filtering out background stimuli (Brown et al., 2018). Sensory modulation also involves maintaining an arousal level adjusted to the environment and activity (Hong, 2015). Sensory modulation disorder (SMD) is diagnosed when a difficulty in the process of sensory modulation impairs daily functioning. According to Miller et al. (2007), there are three types of SMD: SOR which is an intense and over-sensitive response to mundane stimulation; Sensory Under-responsivity, a lack of responsiveness and inattention to every day sensory stimulation; or Sensory Seeking, a constant sensory search and craving. Sensory modulation traits follow the same classification. The current study focuses on the design of a tool for quantifying the family’s response to the child’s SOR symptoms by studying its distribution in a non-clinical sample.

Children with elevated SOR experience many everyday stimuli at home and in the community as bothersome, unbearable, and overwhelming. This is manifested in behavioral avoidance, elevated distress, anxiety, and/or active resistance of the sensory exposure. Consequently, those with SOR find it difficult to participate in some activities and feel anxious before and during the encounter with stimuli (Parham and Mailloux, 2005). Evidence shows that a child’s SOR is associated with limited participation in leisure activities and requires changes and restrictions in family activities and routines (DeGrace, 2004; Bar-Shalita et al., 2008; Epstein et al., 2008; Bagby et al., 2012). Studies dealing with the implications of SOR on quality of life and family well-being demonstrate the challenges and stress associated with having a child with SOR. Parents of these children report increased restrictions in their personal and social activities (Carter et al., 2011), they experience more burden and challenges, especially when the mothers have sensory difficulties of their own (Turner et al., 2012; Gafni-Lachter et al., 2021).

The increased irritability and distress associated with SOR can lead some parents to try to minimize their child’s distress. To meet the child’s sensory needs, parents build strategies and routines which enable participation in activities within the home (Spagnola and Fiese, 2007). These efforts include changing schedules and finding resources to meet their child’s needs, which can disrupt family cohesion (Spagnola and Fiese, 2007). Parents of children with ASD, described the difficulty that arises from trying to balance responding to the child’s sensory difficulties, while maintaining flexibility in daily routines (Schaaf et al., 2011). The family’s restrictions, adjustments, and adaptations around the child’s SOR, help reduce the child’s exposure to the bothersome sensations and avoid outbursts. Changes in family life due to SOR have not been evaluated from a family accommodation perspective and it is not known whether family accommodations maintain or exacerbate sensory avoidance. Developing a tool to characterize family accommodations for SOR is a first step in enabling such an assessment.

Existing family accommodation scales originated from tools developed for adults with OCD (Calvocoressi et al., 1999). Later, scales were developed for children with OCD (Peris et al., 2008), anxiety disorders (Lebowitz et al., 2013; Benito et al., 2015) and ASD (Feldman et al., 2019). These scales share the assessment of (1) the frequency of accommodations (e.g., enabling child’s avoidance of feared situation). And (2) severity of consequences of not providing the accommodations for child and family wellbeing (e.g., level of distress when accommodation is not delivered). Therefore, the sensory family accommodation tool designed quantified these two aspects.

To summarize, the literature reviewed indicates that having SOR is a cause of child anxiety and avoidance as well as family distress; thus, we predict that it is likely to evoke accommodations. Identifying the specific accommodations associated with sensory symptoms can reveal precipitating, perpetuating, and protective environmental factors. The current research sought to establish the reliability and validity of a new tool, the Family Accommodations Scale for Sensory Over-Responsivity (FASENS), by investigating the:

The idea that a child’s living environment can be changed or reorganized with the help of the family in a way that either maintains difficulties or encourages functioning is reflected both in research and clinically (Salloum et al., 2018). Sensory modulation difficulties and specifically SOR, may provoke family accommodations in the same way that anxiety disorders do. Over-responsivity to certain stimuli, can cause the child to avoid these stimuli, and to express severe distress. In response, the parents can accommodate the avoidance by reducing the exposure to the distressing stimulus and by that increasing the avoidance patterns leading to further restriction of child and family meaningful participation. The current study validated a tool designed for assessing family accommodation in the context of SOR.

The FASENS had excellent psychometric properties: it showed high internal consistency and good convergent validity with the Sensory Profile 2 scores. Family accommodation, as measured by the FASENS accommodation score, was significantly correlated with the severity of all sensory patterns, as measured by Sensory Profile 2. Nonetheless, the relation with SOR was the strongest. The relation between accommodation and children’s severity of the psychopathology (i.e., anxiety and OCD) which the accommodation relates to was also shown with previous family accommodation scales (Lebowitz et al., 2013; Flessner et al., 2017). When scrutinizing the FASENS correlations in our study, the magnitude of difference between groups was greatest for the SOR pattern. Given the association with all three sensory profile scores, it should be noted that families are accommodating children who are dysregulated. Since the tool primarily asks parents to think of their child’s sensitivities and highlights the SOR pattern, it is not possible to determine how much of the accommodation is associated with each sensory pattern. As previously mentioned, SOR symptoms can cause children significant distress and anxiety (Carpenter et al., 2019). The child’s anxiety may cause distress and lead to accommodation behaviors of the family, so it is no wonder that the strongest correlation we found was between the SOR pattern and FASENS scores.

Factor analysis confirmed that the FASENS comprises 3 factors: frequency of accommodations, child impact, and family impact. Previous family accommodation scales differed in their number of factors and subscales loaded. The FAS factors were Avoidance of Triggers and Involvement in Compulsions (Flessner et al., 2011) and the FASA factors were Participation and Modification (Lebowitz et al., 2013). Our results indicated that avoidance/participation versus modification/changes items are distributed on one factor rather than two. Overall, the current results underscore the need to evaluate the presence of accommodations separately from their impact on child and family well-being and participation. Replicating this factor analysis in a clinical sample with higher and variable scores is warranted.

Furthermore, we found that the child impact factor was higher than the family impact across groups but most dramatic for the conditions group. This reflects the higher distress levels of children when family accommodation is not performed. It is important to keep in mind that this distress occurs to some extent in typically developing children. For example, our sample included 10 parents who reported child impact (child impact scores between 0.25 and 0.75) but no accommodations (mean = 0). This may represent parents who are not cooperating with their child’s demands for avoidance or are not taking part in their rituals and thus, stress is higher for the child. The even higher levels of child impact scores in the conditions group may relate to the higher frequency of family accommodations, and the children’s greater difficulty in self-regulating under such conditions of negative emotionality. In this group, the rate of moderate-extreme ratings for family impact was 22–27%, while the rate of child impact items was 30–44%. Similar findings were reported in a pediatric anxiety sample (Lebowitz et al., 2013): lower levels of family distress/impact (70.7%) and higher scores for the consequences of accommodations upon the child (85.3%). This supports the common nature of family accommodations, in which lack of accommodating leads to increased child distress, regardless of the type of disorder.

This study provides a unique opportunity to examine and compare family accommodations in typical and atypical populations. Prevalence of accommodations in families raising typically developing children can serve as a baseline for assessing disability/impairment. As we expected, we found a very low prevalence of accommodation in the typical group; prevalence rating of daily and 3–6 times a week across items ranged from 3.2 to 12.2%. For the conditions group, the prevalence rating of daily and 3–6 times a week across items ranged from 4.2% (avoid places/change schedule or recreation) to 23% (enable child not to perform self-care). Family adjustments and changes in the environment and in routines are part of the normal behavior of a functioning family. Typical accommodations in this sample were providing items to reduce sensitivity and help in avoiding irritating discomfort. Among the conditions group, avoidance was much more common than changes in routines. Performing activities instead of the child was also observed more often among this group. Typical levels and types of accommodation are rarely discussed in the family accommodation literature. This study highlights the notion that family accommodation occurs to some extent in the general population and is not merely an indicator of abnormality. Further research into thresholds for impairing accommodations can enhance the clinical utility of family accommodation scales.

The higher FASENS scores reported in families with children with developmental and medical needs could be due to several reasons:

Accommodation in the current sample tended to occur for younger parents of younger children, consistent with previous family accommodation evidence (Jones et al., 2015). Accommodation was also more likely to occur in families with an older sibling (potentially implying higher burden). It is noteworthy that the current sample represents larger families relative to the world² ; with 2–7 children per family. In addition, the average age of children who were the eldest in our sample was about 5 years. This might explain the significant need for family accommodations, especially with several young children in the house.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by The Ethics Committee of the Faculty of Social Welfare and Health Sciences, University of Haifa, Israel. The patients/participants provided their written informed consent to participate in this study.

AB-S was involved in the research design and management, data collection and analysis, and manuscript writing. TP contributed to the measure design and manuscript writing. EL contributed to the measure design and manuscript preparation. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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