PANDAS and PANS Sensory Integration and Processing Difficulties

Sensory Ladders – A History

Sensory Ladders came from very early practice to reframe the unmet needs of clients with trauma who were dysregulated – our draft publication in 2009 included a suggestion we rename BPD as a sensory modulation and regulation disorder – but was a little before its time.
The diagnosis called BPD then with EUPD a preferred term nowadays is typical as a direct result of significant childhood trauma.

Here is the often forgotten history of trauma-informed care approaches linked to the direct use of Ayres’ Theory of Sensory Integration in a trauma-informed way. It was built on practice from 1999 onwards and drew on Ayres, King and Alers’ work, in combination with DBT.

We published the first adult adapted checklist in a DBT handbook in 2002. The first About Me Profiles were created in 2001/2002 and included Sensory Ladders. We published about our Be Smart Programme in 2002 in a care plan and presented this locally, in training courses at then at the first-ever conference about ASI including sensory integration in trauma-informed care in MH in 2004.

This mini-conference was delivered in Cornwall, UK. Presentations included work delivering inpatient Sensory Integration in MH (Kath Smith and Angie Turner), Eadaoin Breathnach’s work on attachment in adult LD and Tina Champagne’s work on Sensory Allen’s Levels and her use of sensory approaches to reduce restraint use in the USA.

It was recently pointed out to us our UK development work came from Tina. Tina will confirm this is not true. It appears others believe that we weren’t doing SI as the article used SPD as a term.

This was a period in ASI history after the new nosology was just published by great names in Ayres SI which we all respectfully followed given the authors. It took time to understand the history of this article and we shouldn’t jump to the new term.

Please remember history and context matter. Sensory Ladders were not created out of Zones of Regulation either. The first ones were published long before Zones and taught and presented from 2003 onwards. They were developed initially for adult clients to deliver a mental health and trauma focussed application, with consent from the Alert Program. At the time the Alert Program like SI was almost entirely child focussed practice. The levels to reflect sleep and disassociative states seen in clients with trauma were deliberate addition and the link to DBT is the Ladder – The DBT House of Fire includes a ladder to climb from behavioural dysregulation upwards – the senses can be a key part to this. Please don’t confuse our Sensory Ladders model with other Ladders and think that’s where we ‘borrowed it” from. This was a tricky post to write but one that needs writing to correct myth and legend and some hurtful assertions.

Thinking I will write up the history soon to correct any misperceptions: Borderline_personality_disorder_and_sensory_processing_impairment

On Climbing Sensory Ladders

Sensory Ladders are not linear – people can jump about – and no one person is the same. This is why we need to work with clients to understand each person’s unique presentation – and as you work changing presentations and ways of ‘being’ and moving/shifting between different self-states.


It’s always important to refer to what we know from science to inform practice – this is the science and art of practice. Sleep and lower alertness like when snuggled on sofa a bit comfy and safe very relaxed’ nearly sleepy is not the same as disassociation and shut off self-states in times of stress; like when overwhelmed or triggered.


Being over alert when “psyched up” to play rugby to win with lots of adrenaline is a positive flight and fight, similar but different to similar fight and flight triggered by the smell of the abuser.


The brain is not a simple machine – it is a complex organ influenced by complex interactions between different centres, altered and influenced by neuro-chemicals and hormones, and can be affected and altered by sensory input, cognitive thoughts and even illness.

InspirationPeople may jump between states, miss rungs on the ladder, not even have them on their ladder – one young man only had 2 states when we met.  Another client, a young woman with EUPD and trauma had only only sleep, under and shutdown. 


That’s why each ladder is created and made separately as we explore the person’s own unique presentation. Sometimes we make step ladders and step stools. People can come out of immobilisation via sleep at the bottom too – or go from under to shutdown having no calm and alert.



I am hopefully making this clearer here than in some of my presentations.  Think about the clothes peg on the lolly-stick ladder – that can be moved up and down without going through other states. 


While some colleagues have made thermometers and sliders, I generally don’t – I try to deter colleagues and clients from making them for this reason whenever possible.

You can be at the exploding volcanoes and quickly change to bobbing in a boat in the calm bay.Volcanoes can rumble and grumble for hours and then suddenly be explode – with steam and air and then immediately the island get peaceful again – another young person’s ladder.


We also do animals – and ask what animal are you now?


This is also why we sometimes keep the diary sheet too – to track the changes.

And if we make them on paper, we sometimes fold it up to show people missing spaces like calm and alert waking from sleep into over alert or even shutdown.

This is why ladders are created unique and individual and grow and change with clients as they develop.


The initial time personalising the person’s ladder is important. Do forget going up and down a ladder can be climbed missing rungs, sliding down, jumping off.

Sensory Ladders in Adult Mental Health and Psychiatry

The first Sensory Ladders were made in 2001 for adults with sensory integration difficulties receiving help with mental health difficulties in Cornwall. Influenced by the paediatric Alert Program, they offered therapists a way to combine Dialectical Behaviour Therapy and Ayres’ Sensory Integration, addressing the development of the person’s self-awareness in collaboration with ward staff on an acute psychiatric inpatient unit.

The need to start with the person where they are at, before introducing learning about new ways of being, including the development of new skills, made it necessary for the Sensory Ladder to remain a very individualised and personalised journey within a close safe therapeutic relationship.

Both Ayres’ Sensory Integration(ASI) and Dialectical Behaviour Therapy(DBT) share a common understanding that development and change can only occur within a safe environment. The DBT idea of balancing safety and challenge reverberates strongly with Ayres’ concept of the ‘just right challenge’.

Creating a Sensory Ladder is about creating opportunities for an adult or child to learn to become aware of themselves in a new way – to explore and discover new things about mind, body and brain. It allows the therapist and person to do “curious wondering” together, and for the person to try new things – creating and promoting active but informed risk-taking; testing how we might feel and experience something when we do it differently; new ways of being – new ways of responding.

Making and using a Sensory Ladder is about the journey together within a safe therapeutic relationship. It’s about getting to see and know someone in a very different way, getting underneath the skin of behaviours that are perhaps being described by others as tricky or challenging.

The Sensory Ladder facilitates the reframing of behaviour that are a result of sensory integration challenges, providing the first step of acceptance of the behaviour necessary before strategies and therapy support development and change to happen.


Learn more about how to use these in mental health settings across the lifespan.

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