Module Outline - kelly-mahler.com

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Kelly J Mahler OTD, OTR/Lwww.kelly-mahler.com

Interoception Assessment: Dilemmas and Practical Solutions

Module Outline

Important Concepts for the Course

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What is Interoception?

Craig, 2002; Critchley et al., 2004

The Receptors in the Body

+

The Insula in the Brain

=

Emotions+ =

Interoception is the Sensory System that gives us information regarding

BODY-EMOTION connections.

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The Two Branches of Interoception

Implicit Interoception

• Unconscious, automatic responses for homeostasis

• For example, blood pressure increases before you stand-up; liver releasing enzymes; etc.

Explicit Interoception

• Conscious experience of body signals and emotions

• aka Interoceptive Awareness

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What is Interoceptive Awareness (IA)?

The ability to:1. NOTICE body

signals2. CONNECT body

signals to the emotion

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WE ALL HAVE UNIQUE INTEROCEPTION EXPERIENCES!

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IA: A Variety of Extremes

(Mahler, 2019; Miller, Anzalone, Lane, Cermak, Osten, 2007; Endow, 2010)

Body Signals

too big

too small

• Strong• Overpowering• Too many body signals noticed all at

once

Characteristics

• Muted• Don’t notice body signals until they are

intense OR• They go completely unnoticed

• Body signals are noticeable, but not clear enough to give specific detail about the exact location or type of feeling

SMD: Over-responsive

DiscriminationDisorder

SMD: Under-responsive

Sensory Processing

Disorder

Module Outline

Current Trends in Assessment

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A Widespread Debate

?What is the Best Way to Measure Interoception?

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A Widespread Debate

Main Categories of Assessments: 1. Objective Measures2. Self-Report3. Observation-based/ Caregiver Report

What is the Best Way to Measure Interoception?

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A Widespread Debate

– Heartbeat Detection Tasks (tracking or discrimination)– Respiratory Tasks (e.g., inspiration resistance

Garfinkle et al, 2016)

Objective Measures

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A Widespread Debate

Strengths:• Objective• Measurable

Limitations: • A focus on 1 body signal

(Unnaturally tells a person what body signal to pay attention to)

• Misses the richness of the whole body experience

• Even if a person can accurately detect their heartbeat in a lab setting, how does that translate to the impact of interoception on function?:

– Can they accurately interpret the signals in order to motivate self-regulation

• Misses a subset of people that are not able to complete these tasks

• Are they actually measuringinteroception?

Objective Measures

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A Widespread Debate

– Porges Body Perception Questionnaire (BPQ; Porges, 1993)

– Multidimensional Assessment of Interoceptive Awareness-Version 2 (MAIA-2; Mehling, et al, 2018)

– The Comprehensive Assessment of Interoceptive Awareness (Subtest 1 & 2; Mahler, 2016)

Self-Report Measures

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A Widespread Debate

Strengths:• Captures the richness

of the whole bodyexperience

• Gathers info on the impact of interoception on daily life (interpreting body signals for self-regulation)

Limitations: • Subjective• Abstractly worded• Misses a subset of

people that are not able to complete these tasks

• Some focus on hypo-awareness but not hyper-awareness

• Are they actually measuringinteroception?

Self-Report Measures

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A Widespread Debate

– The Comprehensive Assessment of Interoceptive Awareness (Mahler, 2016)

– Observations of Interoception Experience (Mahler, 2014)

Observation-Based Measures/Caregiver Report

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A Widespread Debate

Strengths:• Includes a subset of

people that are not able to complete the objective or subjective measures

• Gathers info on the impact of interoception on daily life (interpreting body signals for self-regulation)

• Can be objective (e.g., # of toileting accidents per day)

Limitations: • Can another person

accurately interpret the inner experiences of another person?

• May be measuring something other than interoception

Observation-Based Measures/Caregiver Report

Module Outline

Assessment: Considerations

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Assessment: Capturing the Vast Influence of Interoceptive Awareness

Free Printable:www.Kelly-Mahler.com

(Mahler & McLaughlin,

2019)

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Assessment: Not about Right vs Wrong

Goals of Assessment:• What is the interoceptive experience of the

learner?• How is their interoception experience contributing

to or limiting their ability to utilize their strengths, reach their goals and ultimately flourish?

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Formal Assessment: Is it Needed?

• Dependent on your setting• Value of assessment

BUT…..• Not always possible for many reasons

(time, learner abilities)

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Intervention as Ongoing (VALUABLE) Assessment

Build the learner’s ability to NOTICE body signals in a concrete and slow method

Section 1: BodyLessons 1-16

Guide the learner to CONNECT body signals to emotion

Section 2: EmotionLessons 17-20

Guide the learner to find a variety of feel-good actions that help the learner REGULATE

Section 3: ActionLessons 21-25

BODYEMOTIONACTION

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Assessment: A Norm Issue

• What are the ‘typical’ interoception developmental milestones?

• When does an interoception experience become problematic (in terms of function)?

Module Outline

Assessment: Inspiration from ‘Real Life’

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Assessment: Inspiration from Real Life Interoception

Comprehensive Assessment of Interoceptive Awareness

Observations of Interoception Experience

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• Observing with curiosity—how is their inner experience possibly contributing to what you see on the outside?

• Is further assessment warranted?

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Note: Does not replace evaluation by a healthcare professional

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ToiletingMain Observation: The individual experiences bowel or bladder leakage

Interoception Curiosities: • Does the individual show any signs of noticing the need

to void (e.g., hiding in the corner to poop)?• Does the individual run to the toilet in a last-minute

emergency?• Does the individual notice the feeling of being soiled?• Does the individual go to the bathroom more frequently

than others of the same age?

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Feeding/Eating-Hunger

Main Observation: The individual seeks out food much more/less than others of the same age

Interoception Curiosities: • Does the individual verbally/non-verbally express

hunger before a meal? • Does the individual forget to eat even after long

periods of time?• Does the individual appear to feel hungry more

frequently than others of same age?

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Health Maintenance-Pain/Injury

Main Observation: The individual seems to have a very high/very low pain tolerance

Interoception Curiosities: • Does the individual verbally or nonverbally express

pain when injured?• Does the individual notice when they are sick?• Does the individual experience a lot more

pain/discomfort than others of the same age (e.g., frequent trips to the school nurse/doctor; lingering pain from a minor injury)?

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Emotion Regulation-Anxiety/FrustrationMain Observation: The individual appears to be less aware of signs of building anxiety/frustration


feelings of anxiety or frustration (or similar emotion)? • Does the individual appear surprised by feelings of

intense anxiety or discomfort? • Does the individual memorize regulation strategies, but

doesn’t recognize when they need to use them ‘in the moment’?

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Emotion Regulation-Comfort/Calm/RegulationMain Observation: The individual identifies/seeks out a limited number of activities that appear to create feelings of regulation

Interoception Curiosities: • Does the individual pursue activities that appear to

bring them comfort or regulation?• During a break period, does the individual seek out

activities that appear to leave them feeling regulated?

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Emotion Regulation-Joy/Excitement

Main Observation: The individual identifies/seeks out a limited number of activities that appear to create feelings of regulation


feelings of joy/excitement (or similar emotion)? • Does the individual seek out activities that appear to

bring them joy/excitement? • Does the individual easily fill their free time with

enjoyable activities?

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The Comprehensive Assessment of Interoceptive Awareness

3 Sub-Assessments:1. The Interoceptive

Awareness Interview2. The Assessment of Self-

Regulation3. The Caregiver

Questionnaire for Interoceptive Awareness

Currently Published by AAPC Publishing

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ü Informal Question & Answer Format (mix of open-ended & Likert Scale):

• 18 Main Questions• 8 Likert Scale Questions

ü Only a Guide; not standardized

ü Ages 4ish+ü Use the questions to gain

information during real time occupations

The Interoceptive Awareness Interview

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Sample Open-Ended Questions:1. Main Question: How does your body feel when you are relaxed/calm? Follow-up Questions or Prompts: How do you know when you are relaxed/calm? What makes you feel relaxed/calm? How does your body feel when you are doing_____(insert an answer from the previous question)?

2. Main Question: How does your body feel when you are angry?Follow-up Questions or Prompts: How do you know when you are angry? What makes you feel angry? How does your body feel when you are doing_____(insert an answer from the previous question)?

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Sample Open-Ended Questions:3. Main Question: Does your body feel different when you are a little angry vs. really angry?Follow-up Questions or Prompts: If so, please describe the differences

10. Main Question: How does your body feel when you are hungry?Follow-up Questions or Prompts: How do you know when you are hungry? Do you ever go for long periods of time without eating? Do other people need to remind you to eat?

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Aware vs. Unaware Responses

Aware Unaware

“My heart beats faster” “I don’t know”

“I feel my neck pulse” “When I feel bad”

“My hands clench” “When I hit someone”

“My muscles get tense” “When I throw something”

“My face gets warm” “Happy”

“My toes start to curl and get tight”

“I feel mad”

Optional: Total the # of Aware Responses to serve as baseline

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Adaptations:• Visual Supports• Drawing• Pointing• AAC• Turn it into a game• Allow plenty of response time

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Tips:• Allow plenty of response time• Use Voice Memo to record answers (if

permission is provided)• Total # of ‘aware’ responses to serve as

baseline (an increase in total score may=IA improvements)

• Make note of any adaptations or leading used• Same interviewer pre and post intervention

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Interpreting data

• Please use caution when interpreting the scores of the IA Interview!

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The Assessment of Self Regulation

ü Examines the understanding & thought processes surrounding self-regulation

ü Series of 18 pictures each with corresponding questions

ü Only a Guide

ü Could use as early as 4-5 years

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Angry Pain Sad Frustrated Worried

Sick Cold Hot Nervous Bored

Scared Excited Disgusted

JealousRelaxed Worried

Embarrassed

Surprised

18 Homeostatic and Affective Emotions

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1. Identifying the Emotion in Others: How does this person feel?

2. Identifying Causes of Emotion in Others: What is making him/her feel that way?

3. Identifying Causes of Own Emotion: What makes you feel_____? List at least 3 examples.

4. Interoceptive Awareness: When you feel____, how does your body feel? List at least 3 examples.

5. Strategy Identification & Problem Solving: When you feel _____, what would you do to feel better? List at least 3 ideas.


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Interpreting data


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The Caregiver Questionnaire for Interoceptive Awareness

ü Caregiver Completes

ü 24 Questions (combo Likert Scale plus area for description

ü Circle the questions that apply to the child or situation

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Sample Questions: 4. Can the individual effectively control emotions?6. Can the individual use learned coping strategies ‘in the moment’?9. Does the individual recognize when they are sleepy?12. Does the individual seek out or request food on their own when hungry (rather than needing to be reminded to eat)?16. Does the individual recognize when they need to go to the bathroom in a timely manner (in order to avoid accidents or last-minute emergencies)?

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Tips:

• Total Score serves as baseline (an increase in score may=IA improvements)

• Completed by a person that knows the person well (and knows about interoception if possible)

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The Interoception Curriculum: Direct Evidence

Year 4: n=69 children with mixed diagnoses; school-based & outpatient

• Participants reported IA challenges, BUT the caregivers (both educators and parents) did not score the children as having the same level of IA concerns, despite reporting significant concerns regarding the child's behavior.

• This statistically significant mismatch, improved after an 8-week use of The Interoception Curriculum, resulting in a statically significant match at the end.

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It is OK….

•Not to know what you feel•Not to be in the mood for sharing your feelings

Mahler & Vermeulen 2021

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QUESTIONS & ANSWERS

FOR MORE INFORMATION

www.kelly-mahler.comFacebook: Interoception, The Eighth Sensory

System

http://www.kelly-mahler.com/

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