The relationship between sensory processing sensitivity trait and emotional and behavioral problems among Egyptian children

Abstract

Background

Sensory processing sensitivity (SPS) is a personality trait that has been linked to various mental health outcomes among highly sensitive children.

Objective

To investigate the SPS trait and its relationship with emotional and behavioral problems among Egyptian children.

Methods

A cross-sectional study was conducted targeting parents of Egyptian children aged 4–17 years. Participants (n = 391) were recruited via different online platforms. Besides a questionnaire on sociodemographic data, parents completed the Arabic version of Strengths and Difficulties Questionnaire (SDQ), and the Highly Sensitive Person Scale (HSPS) for children.

Results

Sampled children’s mean age was 9 ± 3.75 years, and 57.5% were males. Nearly half of them had “at-risk/elevated” total SDQ score (46.3%). The highest “at-risk/elevated” score was on the emotional problems subscale (55%). Prosocial behavior had the lowest “at-risk/elevated” score (12%). Hypersensitivity was found in 10.2% of the sampled children. A higher percentage of hypersensitive children had statistically significant “at-risk/elevated” scores on the emotional problems subscale compared to non-hypersensitive children (82.5% vs. 66.7%, p = 0.04). On the other hand, a lower percentage of hypersensitive children had statistically significant “at-risk/elevated” scores regarding hyperactivity and prosocial behavior compared to non-hypersensitive ones (27.5% vs. 48.1%, p = 0.01 and 7.5% vs. 28.5%, p = 0.004, respectively).

Conclusion

The current study uncovered the substantial presence of the SPS trait among Egyptian children and its association with emotional problems. This calls for further studies to investigate its impact on the child and family, its moderators, and the effectiveness of psychosocial interventions for children with high SPS.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12887-026-07415-z.

Introduction

Highly sensitive person (HSP) was first defined by Aron, who described people showing high sensory processing sensitivity (SPS) as hypersensitive people [1]. SPS is a genetically determined personality trait that reflects an increased sensitivity of the central nervous system, with a deeper cognitive processing of various physical, emotional, and social stimuli [2, 3]. According to Aron and Aron, the SPS trait is present in 15–20% of the population [2].

A key characteristic of high SPS is a low sensory threshold, a feature also observed in other sensory processing (SP) patterns and disorders, such as sensory over-responsivity (SOR) [4]. However, it is important to distinguish the temperamental trait of SPS from the sensory sensitivities associated with sensory processing disorders (SPD) [5]. SPS and SPD/SOR differ in important ways. SPS is generally conceptualized as a stable temperamental or personality trait that persists across the lifespan and is associated with deeper cognitive processing, heightened empathy, and sensitivity to subtle stimuli, without necessarily leading to clinically significant impairment. In contrast, SPD, including SOR, is typically framed as a pattern of atypical sensory modulation that often results in functional difficulties in occupational, educational, or social domains [6].

Individuals with SPS are characterized by being emotional, empathetic, having a heightened awareness of environmental details, and a higher psychophysiological reactivity to stimuli. SPS is linked to difficulties related to coping in different situations and dealing with emotions [7, 8]. Due to overstimulation, increased awareness of environmental details, and cautious processing of environmental information that take place before action, this trait can lead to either more or less adaptive responses based on the circumstances, resulting in anxiety or avoidance behaviors [3]. The SPS trait has been identified as a risk factor for developing internalizing [3, 9, 10], and externalizing problems among children [11–13]. Internalizing problems such as depression, anxiety, and social withdrawal are commonly reported among individuals with high SPS [5, 14]. Externalizing problems include disruptive and dysregulated behaviors such as hyperactivity, impulsivity, aggression, and non-compliance [11–13].

The effect of SPS trait on the development of childhood mental health problems has been linked to the differential susceptibility model in several studies [15, 16]. This model assumes that children differ in their susceptibility to environmental influences, which refer to external developmental experiences and exposures, with a primary focus on parenting and the family environment. It proposes that the same group of children shows disproportionate susceptibility to both positive effects of supportive environments and negative effects of adverse environments [17]. This means that exposure to either negative or positive experiences in children with SPS will shape the outcomes. Empirical evidence has shown that high SPS was associated with higher rates of externalizing and internalizing problems in children, especially when exposed to negative parenting experiences. Meanwhile, lower rates of the same problems were encountered with more positive parenting practices in the same groups of children [9, 18]. Similarly, adolescents with high SPS trait were more susceptible to environmental influences, showing better outcomes when exposed to supportive environments, and adverse outcomes when exposed to negative circumstances [19].

Despite the importance given to SPS and its impact on functioning in life [5], research on sensory processing and its relationship with mental health has largely focused on specific populations or adult samples. In children, much of the existing literature has examined sensory processing difficulties in the context of neurodevelopmental disorders. For example, Levante et al. found significant associations between sensory profile patterns and autistic traits in Italian preschoolers and schoolers with autism, highlighting the clinical relevance of sensory features in this population [20]. Similarly, Joosten and Bundy [21] demonstrated that sensory processing difficulties are closely linked to stereotypical and repetitive behaviors in children with autism and intellectual disability [21]. In adults, research has expanded to examine SPS as a personality trait. Bas et al. [22] explored the lived experiences of adults high in SPS, identifying themes such as heightened emotional reactivity, overstimulation, and the need for coping strategies in daily life [22]. A systematic review by Harrold et al. [23] further established a consistent association between sensory processing patterns and stress in the adult population, suggesting that sensory sensitivity may serve as a risk factor for stress-related outcomes [23]. Despite these important contributions, relatively few studies have investigated the temperamental trait of SPS in typically developing children from the general population [24, 25].

Investigating the SPS trait among children in the general population will enhance our knowledge regarding the prevalence of this trait and will pave the way towards providing appropriate educational and psychosocial interventions to improve coping strategies and promote the psychological and social functioning of those children and their families, aiming at preventing the occurrence of mental health problems and improving their quality of life. Given the scarcity of research on SPS in the Egyptian context, the current study aimed to determine the prevalence of the SPS trait and to assess its relationship with emotional and behavioral problems among Egyptian children by addressing the following research questions:

• What is the prevalence of the SPS trait among Egyptian children aged 4–17 years?

• Is SPS associated with emotional and behavioral difficulties in this population?

Methods

A cross-sectional web-based survey was conducted between October and December 2022 targeting parents of Egyptian children aged 4–17 years of both sexes. The sample size was calculated based on a previous study [5], which estimated that approximately 20% of the population could be classified as highly sensitive. Using a precision of 4% and a 95% confidence interval, the minimum required sample size was calculated to be 384 using Epi-Info version 7 software.

Participants were recruited through convenience and snowball sampling via multiple online platforms, including Facebook, WhatsApp, and Egyptian parenting web forums. Recruitment announcements were posted in parent-focused groups and pages, inviting parents of children aged 4–17 years to participate in a study on children’s emotional and behavioral development. The announcement included a brief description of the study purpose, eligibility criteria (being a parent or primary caregiver of a child aged 4–17 years residing in Egypt), and a link to the online survey. Participants were encouraged to share the survey link with other eligible parents in their networks to facilitate broader reach.

Data collection was managed using Google Forms, and responses were consecutively recorded until the target sample size was achieved. To ensure data quality, we included required fields to prevent incomplete responses. A total of 391 complete and valid responses were included in the final analysis.

To minimize self-selection bias of the sample, the survey link was disseminated across a diverse range of online platforms, including general parenting forums, community Facebook groups, and WhatsApp family networks, rather than in groups focused on mental health. In addition, participants were encouraged to share the survey link with other eligible parents in their networks (snowball sampling), which helped extend recruitment and broaden the representativeness of the sample.

Data collection tools

Data was collected using a web-based survey. The questionnaire was designed using Google Forms.

The first section of the questionnaire included a predesigned questionnaire to collect demographic and socioeconomic data from parents such as child’s age and sex. Data about the child’s family were also collected, including father’s education and occupation, mother’s education and occupation, family size, and income.

The second section included:

The Arabic Version of Strengths and Difficulties Questionnaire (SDQ Parent-form):[26]

The SDQ is a brief emotional and behavioral screening questionnaire. It comprises several forms, including a parent form to assess behavioral and emotional difficulties among children aged 4–17 years old. It comprises 25 items included in 5 subscales of 5 items each. Subscales are namely prosocial (e.g. considerate of other people’s feelings), conduct (e.g. often lies or cheats), hyperactivity (e.g. constantly fidgeting or squirming), emotional (e.g. often unhappy, downhearted), and peer problems (e.g. rather solitary, tends to play alone) subscales. For each of the 5 subscales, the response to items can be not true (0), somewhat true (1), or certainly true (2). The total score ranges from 0 to 10 for each subscale. Total difficulties score is calculated by summing scores of all the subscales except the prosocial subscale. Based on the original UK cutoffs, the categories for the SDQ scores were categorized as “normal”, “borderline”, and “abnormal”. Behavioral and/or emotional problems are recorded (i.e. categorized as abnormal) if the total difficulties score is 17–40, emotional problems score 5–10, conduct problems score 4–10, hyperactivity score 7–10, peer problems score 4–10 and prosocial score 0–4 [27]. In the current study, borderline and abnormal scores were grouped together as “at-risk/elevated” scores. The SDQ was developed by Goodman [27], and was validated and translated into Arabic by Alyahri and Goodman [26]. In the current study, reliability of the Arabic version was measured using the internal consistency (Cronbach’s alpha = 0.71).

The third section of the questionnaire included:

Highly Sensitive Person Scale (HSPS) for children:[28].

The 23-item parent-report HSPS was based on the adult version of the HSPS [2]. It was designed for measuring SPS in children and adolescents. A child is probably highly sensitive if 13 or more of the items are true (items examples: “startles easily”; “wants to change clothes if wet or sandy”; “is very sensitive to pain”). In the current study each item was rated on a five-point Likert scale; never (0), rarely (1), sometimes (2), most of the time (3), and always (4). For each item, a trait is scored as “present” if it is rated “most of the time”, or “always”. Accordingly, each item is endorsed as “absent” (if it is rated 0, 1, or 2) or “present” (if it is rated 3, or 4). Based on the recommended cut-off score by Aron [28], the children were categorized as hypersensitive if scored ≥ 13 “present” items.

The HSPS for children was translated into Arabic through forward-backward translation. Face validity was assessed by the research team. Content validity was assessed by five experts in the field of mental health. They evaluated the clarity and the relevance of the questions, and some modifications were conducted based on their reports. A second round of evaluation was carried out until agreement on the final form of the scale was reached. Reliability of the scale was measured using internal consistency and it was satisfactory (Cronbach’s alpha = 0.73).

Statistical analysis

Data entry and analysis were done using the Statistical Package for Social Science (SPSS, version 20; SPSS Inc, Chicago, USA). The Kolmogorov-Smirnov test was employed to ensure normal distribution. Descriptive statistics were calculated as mean, standard deviation (SD), and range for continuous variables and as frequency and percentages for categorical variables. The chi-square (χ²) test was used as test of significance, and statistical significance level was considered when the p-value was ≤ 0.05.

Results

Characteristics of the sampled children and their parents are displayed in Table 1. More than half of the children were males (57.5%) and their ages ranged from 4 to 17 years, with a mean of 9 ± 3.75 years; the highest percentage of them (62.1%) were aged 4 to less than 10 years. Nearly half of sampled children were in primary grades (49.1%), whereas the lowest percentages were in secondary and play school grades (9% and 6.9%, respectively). Regarding family characteristics, all included parents were mothers of the sampled children. The vast majority of mothers were married (91%). The highest percentage of mothers were of higher education (72.6%) and working (71.6%). As for fathers of the sampled children, the majority of them were of higher education (68%) and were employees (80.1%). The majority of sampled families consisted of 2–4 family members (87.7%). The greatest portion of sampled families had enough income (62.7%), whereas the smallest portion did not have enough income and they borrowed (5.4%). Noteworthy, 21.5% of sampled mothers reported a family history of psychiatric disorders.

Table 1.

Characteristics of the sampled children and their parents (mothers, n = 391)

Characteristics	No.	%
Child’s age (in years):
4–9	243	62.1
10–17	148	37.9
Child’s sex:
- Males	225	57.5
- Females	166	42.5
Range	4–17
Mean ± SD	9.51 ± 3.75
Child’s educational level:
- Play School (Pre-Kindergarten)	27	6.9
- Kindergarten	65	16.6
- Primary	192	49.1
- Preparatory	72	18.4
- Secondary	35	9
Mother’s marital status:
- Married	356	91.0
- Divorced	27	6.9
- Widow	8	2.0
Mother’s education level:
- Read and write	1	0.3
- Secondary education	9	2.3
- Professional education	25	6.4
- Higher education	284	72.6
- Post-graduate	72	18.4
Mother’s work:
- Housewife	111	28.4
- Working	280	71.6
Father’s education:
- Read and write	4	1.0
- Basic education	6	1.5
- Secondary education	8	2.0
- Professional education	41	10.5
- Higher education	266	68.0
- Post-graduate	66	16.9
Father’s occupation:
- Not working	14	3.6
- Vocational	40	10.2
- Handicraft	12	3.1
- Merchant	12	3.1
- Employee	313	80.1
Family size:
- 2–4	343	87.7
- 5–9	48	12.3
Family income:
- Enough	245	62.7
- Enough and save	80	20.5
- Not enough	45	11.5
- Not enough and borrow	21		5.4
Family history of psychiatric disorders
- No	307		78.5
- Yes	84		21.5

Figure 1 illustrates the prevalence of hypersensitivity among sampled children according to their scores on the HSPS based on parents’ reports. Hypersensitivity was found in 10.2% of the sampled children. The total scores ranged from 0 to 21, with a mean ± SD = 8.32 ± 3.78, and 95% CI: 7.60–13.63.

Fig. 1.

Prevalence of hypersensitivity among sampled children according to their scores on the HSPS (n = 391)

Table 2 compares hypersensitive and non-hypersensitive children across sociodemographic and psychiatric characteristics. No significant differences were observed between the two groups on any sociodemographic variable. However, a statistically significant difference was found regarding family history of psychiatric disorders, with 82.5% of hypersensitive children having a positive family history compared to 66.7% of non-hypersensitive children (X² = 4.82, p = 0.02).

Table 2.

Distribution of hypersensitive and non-hypersensitive children according to sociodemographic and psychiatric characteristics (n = 391)

Sociodemographic and psychiatric characteristics	Hypersensitive (n = 40)		Non- Hypersensitive (n = 351)		Test of Significance	P
	No.	%	No.	%
Child’s sex:
- Males	25	62.5	200	57	X2 = 0.45	0.50
- Females	15	37.5	151	43
Child’s age (in years):
- 4–9	24	60	219	62.4	X2 = 0.08	0.77
- 10–17	16	40	132	37.6
Range	4–17		4–17		Z = 0.87	0.38
Median	9.00		9.00
Mean ± SD	10.14 ± 4.05		9.44 ± 3.72
Mother’s marital status:
- Married	34	85	322	91.7	X2 = 5.32	0.07
- Divorced	6	15	21	6
- Widow	0	0	8	2.3
Mother’s education
- Primary education	0	0	1	0.3	X2 = 2.28	0.32
- Secondary education	1	2.5	33	9.4
- High education	39	97.5	317	90.3
Father’s education
- Read & write/Basic education	0	0	4	1.1	X2 = 5.52	0.06
- Secondary/Professional education	1	2.5	54	15.4
- High education	39	97.5	293	83.5
Mother’s work:
- Housewife	8	20	103	29.4	X2 = 1.57	0.21
- Working	32	80	247	70.6
Family Size
- 2–5	28	70	227	64.7	X2 = 0.45	0.50
- 6–9	12	30	124	35.3
Range	2–7		2–9		Z = 0.75	0.45
Median	4.00		4.00
Mean ± SD	4.05 ± 1.15		4.38 ± 1.04
Family income:
- Enough	20	50	225	64.1	X2 = 3.35	0.34
- Enough and save	10	25	70	19.9
- Not enough	7	17.5	38	10.8
- Not enough and borrow	3	7.5	18	5.1
Family history of psychiatric disorders
- No	26	65	281	80.1	X2 = 4.82	0.02*
- Yes	14	35	70	19.9

X² : chi-square test

Z: Mann-Whitney test for two independent groups

^c P value based on Mont Carlo exact probability

* P < 0.05 (significant)

Table 3 illustrates the distribution of sampled hypersensitive and non-hypersensitive children according to their scores on different subscales of the SDQ. The highest percentage of both hypersensitive and non-hypersensitive children had at-risk/elevated total SDQ scores (65% and 62.4%, respectively), with no significant difference between the two groups (X² = 0.10, p = 0.75). As for the emotional problems subscale, a higher percentage of hypersensitive children had at-risk/elevated scores compared to non-hypersensitive children (82.5% vs. 66.7%) with a statistically significant difference encountered between the two groups (X² = 4.16, p = 0.04). Similarly, a statistically significant difference was encountered between hypersensitive and non-hypersensitive children as regards the hyperactivity and prosocial subscales (X² = 6.16, p = 0.01 and X² = 8.15, p = 0.004, respectively), where a lower percentage of hypersensitive children had at-risk/elevated scores regarding hyperactivity and prosocial subscales compared to non-hypersensitive ones (27.5% and 7.5% vs. 48.1% and 28.5%, respectively). As for the conduct problems and peer problems subscales, no significant differences were found between the two groups (p = 0.39 and 0.18, respectively). Regarding age-specific results, Tables 4 and 5 revealed significant differences between hypersensitive and non-hypersensitive children aged 4–9 years old on the hyperactivity and prosocial behavior subscales (X² = 4.35, p = 0.03 and FET = 7.30, p = 0.007, respectively), while older children aged 10–17 years old showed significant difference between both groups on the emotional subscale (FET = 4.12, p = 0.03).

Table 3.

Distribution of hypersensitive and non-hypersensitive children according to their scores on different subscales of the SDQ (n = 391)

SDQ Subscales	Hypersensitive (n = 40)		Non- Hypersensitive (n = 351)		Test of Significance	P
	No.	%	No.	%
Total SDQ a
- Normal	14	35	132	37.6	X2 = 0.10	0.75
- At-risk/elevated	26	65	219	62.4
Emotional problems subscale b
- Normal	7	17.5	117	33.3	X2 = 4.16	0.04*
- At-risk/elevated	33	82.5	234	66.7
Conduct problems subscale b
- Normal	18	45	183	52.1	X2 = 0.73	0.39
- At-risk/elevated	22	55	168	47.9
Hyperactivity subscale b
-Normal	29	72.5	182	51.9	X2 = 6.16	0.01*
- At-risk/elevated	11	27.5	169	48.1
Peer problems subscale b
- Normal	11	27.5	134	38.2	X2 = 1.75	0.18
- At-risk/elevated	29	72.5	217	61.8
Prosocial behavior subscale b
- Normal	37	92.5	251	71.5	X2 = 8.15	0.004*
- At-risk/elevated	3	7.5	100	28.5

X²: chi square Test

* P < 0.05 (significant)

^a Range of score 0 – 40

^b Range of score 0 – 10

Table 4.

Distribution of hypersensitive and non-hypersensitive 4 to 9 years old children according to their scores on different subscales of the SDQ (n = 243)

SDQ Subscales	Hypersensitive (n = 24)		Non- Hypersensitive (n = 219)		Test of Significance	P
	No.	%	No.	%
Total SDQ a
- Normal	8	33.3	84	38.4	X2 = 0.01	0.96
- At-risk/elevated	16	66.7	135	61.6
Emotional problems subscale b
- Normal	6	25	77	35.2	X2 = 0.99	0.31
- At-risk/elevated	18	75	142	64.8
Conduct problems subscale b
- Normal	12	50	117	53.4	X2 = 0.07	0.78
- At-risk/elevated	12	50	102	46.6
Hyperactivity subscale b
- Normal	17	70.8	107	48.9	X2 = 4.35	0.03*
- At-risk/elevated	7	29.2	112	51.1
Peer problems subscale b
- Normal	8	33.3	96	43.8	X2 = 0.97	0.32
- At-risk/elevated	16	66.7	123	56.2
Prosocial behavior subscale b
- Normal	22	91.7	154	70.3	FET = 7.30	0.007c*
- At-risk/elevated	2	8.3	65	29.7

X² : chi-square test

FET: Fisher Exact Test

* P < 0.05 (significant)

^a Range of score 0–40

^b Range of score 0–10

Table 5.

Distribution of hypersensitive and non-hypersensitive 10 to 17 years old children according to their scores on different subscales of the SDQ (n = 148)

SDQ Subscales	Hypersensitive (n = 16)		Non- Hypersensitive (n = 132)		Test of Significance	P
	No.	%	No.	%
Total SDQ a
- Normal	6	37.5	48	36.4	X2 = 0.008	0.92
- At-risk/elevated	10	62.5	84	63.6
Emotional problems subscale b
- Normal	1	6.3	40	30.3	FET = 4.12	0.03 c*
- At-risk/elevated	15	93.8	92	69.7
Conduct problems subscale b
- Normal	6	37.5	66	50	X2 = 0.22	0.64
- At-risk/elevated	10	62.5	66	50
Hyperactivity subscale b
- Normal	12	75	75	56.8	X2 = 3.53	0.06
- At-risk/elevated	4	25	57	43.2
Peer problems subscale b
- Normal	3	18.8	38	28.8	FET = 0.72	0.30c
- At-risk/elevated	13	81.3	94	71.2
Prosocial behavior subscale b
- Normal	15	93.8	97	73.5	FET = 3.18	0.06c
- At-risk/elevated	1	6.3	35	26.5

X² : chi-square test

FET: Fisher Exact Test

* P < 0.05 (significant)

^a Range of score 0–40

^b Range of score 0–10

Table 6 shows positive correlations between hypersensitivity and emotional problems (r = 0.264, p = 0.000), as well as with the prosocial behavior (r = 0.267, p = 0.000). On the other hand, negative significant correlation was found between hypersensitivity and hyperactivity (r = − 0.133, p = 0.008).

Table 6.

Correlations of children’s HSPS scores with scores of SDQ

SDQ subscales	Pearson correlation r(p)
Total score of SDQ	0.060 (0.239)
Emotional problems subscale	0.264 (0.000)*
Conduct problems subscale	0.48 (0.345)
Hyperactivity subscale	-0.133 (0.008)*
Peer problems subscale	0.078 (0.125)
Prosocial behavior subscale	0.267 (0.000)*

^*P < 0.05

Discussion

The current study investigated the trait of sensory processing sensitivity (SPS) and its relationship with emotional and behavioral problems among a sample of Egyptian children aged 4–17 years.

In the present study, the hypersensitivity trait was found in 10.2% of the sample. Various presentations of SPS have been studied in different populations worldwide showing variable prevalence rates.

Other studies using the Highly Sensitive Person Scale (HSP) among the general population reported higher prevalence rates than suggested by Aron and Aron [2]. Dosari et al. [29] assessed SPS among Saudi people aged 18 to 25 years via online survey, and the prevalence of HSP was 29% [29]. Moreover, a higher rate (34.5%) was recorded among Spanish nursing students using the same scale [30].

It is noteworthy that extremely higher rates of SPS and SP difficulties were found in special clinical populations of children. Sensory over-responsiveness in a clinical sample of children aged 3–11 years with prenatal alcohol exposure reached up to 50.2% [31]. Similarly, SP difficulties were identified in 55.2% of Australian children (5–9 years) at risk of developing conduct disorder [11].

Although the prevalence rate of the SPS trait in the present study (10.2%) was comparable to rates found in some studies, it reflects a much more conservative rate in comparison to previous estimates reported in the general population. Variability in the prevalence rates of SPS can be attributed to several factors, such as methods and tools used for diagnosis including parents’ reports versus self-reports, age of participants, cultural differences, and whether hypersensitivity was studied as an isolated personality trait or as a part of other SP difficulties.

In consistency with the evidence derived from other studies [3, 10, 32], a significant positive correlation between SPS and emotional problems was demonstrated in the current study; the frequency of emotional problems was significantly higher among hypersensitive children aged 10–17 years. In their scoping review, Kotsiris et al. [10] concluded that SPS was positively associated with various internalizing conditions among typically developing children from birth up to 22 years of age [10]. In consistency with our findings, a more recent study revealed a relationship between SPS and internalizing problems among adolescents aged 9–18 years that were partly mediated by the impact of COVID-19 [32]. This latter study drew attention to the role of COVID-19 pandemic in mediating the relationship between SPS and emotional and behavioral problems among children, taking into consideration that the current study took place during the pandemic period. The finding that emotional problems are higher among highly sensitive adolescents (aged 10–17 years) is supported by several studies [33, 34]. Mestre Navas [33] found that young individuals (aged 14–30 years) with higher SPS levels experienced more internalizing symptoms, including emotional problems [33].

In the present study, children’s scores on the HSPS correlated negatively with their scores on the hyperactivity subscale of the SDQ which assesses traits related to attention deficit hyperactivity disorder (ADHD). This was specifically manifested among non-hypersensitive children aged 4–9 years. This finding was not in line with the results reported by Fabio et al. [12], who investigated the relationship between ADHD and atypical SP among Italian adolescents aged 14–18 years. Results showed that the ADHD group displayed higher scores across all components of the sensory profile compared to the control group [12]. Fabio et al. explained that individuals who have high SPS would tend to be easily distracted as a result of experiencing difficulty in rapidly responding to low-threshold stimuli. In partial consistency with current findings, Rani et al. [13] revealed that ADHD children with more sensation-seeking, movement, and touch processing difficulties showed more externalizing behavioral problems, while those with more sensitivity and avoidance traits showed more internalizing problems in comparison to typically developing children [13]. According to Dunn [35], ADHD children who manifest high neurological thresholds would have more sensory-seeking behaviors, making them more prone to engage in hyperactive and risky behaviors, which leads to an increase in their externalizing behavioral problems, while ADHD children who show an avoidant and sensitive behavior are having a low neurological threshold which causes internalizing behavioral problems by resisting non-familiar stimuli and feeling more anxious.

In addition, current findings can be explained in light of differential susceptibility and vantage sensitivity, as suggested by Slagt et al. [9]. In their study, highly sensitive preschool children exhibited increased externalizing behaviors in response to both increased negative parenting and decreased positive parenting compared to less sensitive children. On the other hand, highly sensitive children showed the lowest levels of externalizing behaviors when negative parenting decreased and high positive parenting was sustained. Moreover, the pattern reported among the less sensitive children was totally opposite to that found among the highly sensitive children. Similar findings were reported by Lionetti et al. [18]. Another explanation is derived from the findings of Li et al. [36], who concluded that hypersensitive children showed an increase in their externalizing problems when exposed to high environmental unpredictability and a decrease in externalizing problems under low unpredictability.

Based on the above-mentioned studies, the current findings regarding hyperactivity can be explained based on two main reasons: first, high SPS is not inherently pathological; hypersensitive children thrive in supportive environments and may be less prone to externalizing/hyperactivity problems when environmental demands are appropriate. This can be supported by the nature of the current sample (higher socioeconomic status, educated parents) that shows a deviation from the broader Egyptian population. According to data from the Central Agency for Public Mobilization and Statistics (CAPMAS), among the Egyptian population aged 10 years and above, only approximately 10.6% hold a university degree, while a substantial proportion have completed only primary or preparatory education [37]. This characteristic of the sample may reflect a relatively supportive home environment. Second, SPS is more linked to internalizing problems than to externalizing problems. Heightened sensitivity may lead to behavioral inhibition and overcontrol, rather than impulsivity and hyperactivity, which are more characteristic of ADHD.

The current results revealed a significant positive correlation between hypersensitivity and children’s prosocial behavior. Children aged 4–9 years showed a significantly lower rate of non-prosocial behavior compared to the non-hypersensitive children. In consistency with our results, Kiyak [38] revealed that prosocial behavior was positively correlated with SPS among Turkish children [38]. Several studies investigated the relationship between SPS trait and prosocial behavior. While some studies explained this relationship based on the differential susceptibility model, other studies could not. For example, Lionetti et al. [18] reported that children with high SPS showed higher social competence when they received more authoritative parenting and showed lower social competence when they received less authoritative parenting compared to children with low SPS . Similarly, Li et al. [36] found that children’s prosocial behavior was positively correlated with the aesthetic sensitivity (AES) subdimension of SPS and positive parenting behavior, and children high in AES were more sensitive to the influence of low negative parenting in the prediction of prosocial behavior [36]. In contrast, the studies conducted by Slagt et al. [9] and Kiyak [38] to examine the relation between parenting and children’s prosocial behavior failed to find a moderating role of SPS.

The observed age-specific pattern in prosocial behaviors aligns with the developmental trajectory of these skills, which emerge and consolidate rapidly during the preschool period (ages 3–6). Given that the effects of SPS on social development are most consistently observed in early childhood and tend to decline in adolescence, this developmental window (ages 4–9) may be particularly salient for detecting associations between SPS and prosocial behaviors [39, 40].

The significantly higher rate of family history of psychiatric disorders among hypersensitive children aligns with research demonstrating that sensory processing sensitivity and related traits are, at least in part, heritable and share genetic and environmental overlaps with broader psychopathology [41, 42]. This familial aggregation appears to be transdiagnostic: a large-scale population-based study found that parents with any mental disorder increase their children’s risk for a “full-spectrum” of psychiatric conditions [43]. More specifically, a study on families of adolescent twins found that parental depression was significantly related to adolescent sensory over-responsivity (SOR) symptoms [44]. This suggests that the transmission of risk for sensory and emotional problems may occur through pathways potentially involving shared genetic liabilities, environmental factors like parenting, or their complex interaction [45]. Further, a recent review confirms that SPS is a partly hereditary trait, and that highly sensitive individuals with adverse childhood experiences are more vulnerable to stress-related symptoms such as anxiety and depression [41].

It is important to acknowledge that we did not assess environmental factors such as positive or negative parenting practices, which are known to play a critical role in shaping children’s emotional and behavioral outcomes. It is plausible that high SPS children in our sample who exhibited fewer difficulties were living in more supportive home environments, while those with more difficulties may have been exposed to less optimal parenting or greater family stress. Without direct measurement of parenting quality or other environmental moderators, we cannot determine whether the associations observed between SPS and emotional/behavioral difficulties are direct effects of the trait itself, or whether they are amplified or attenuated by environmental context.

It is noteworthy that the extremely high proportion of children scoring above the SDQ cutoff (over 60%) strongly suggests that the UK-derived norms used for classification are not appropriate for this Egyptian population. This finding aligns with the conclusions of a major scoping review on SDQ use in Africa, which found that UK cutoffs were almost universally applied without local validation, leading to a potential over-identification of children at risk and overstated prevalence estimates [46].

The findings of this study carry several theoretical and practical implications. Our results align with and extend the differential susceptibility framework. The observed association between SPS and emotional/behavioral difficulties, particularly in the context of a positive family history of psychiatric disorders, suggests that SPS may represent a vulnerability factor that interacts with familial risk to shape developmental outcomes. This supports the notion that SPS is not inherently pathological but may confer risk when combined with adverse environmental or genetic contexts. Furthermore, our findings contribute to the growing body of evidence on the heritable and transdiagnostic nature of sensitivity, suggesting that SPS shares genetic and environmental overlap with broader psychopathology dimensions. From a practical standpoint, our findings highlight the importance of early identification of highly sensitive children, particularly those with a family history of psychiatric disorders, through screening in clinical, educational, and community settings, alongside targeted interventions such as parenting programs, environmental modifications, and emotional regulation support.

Limitations of the study

A key limitation is the use of an online survey, which may have introduced selection bias by limiting access to more diverse demographic and socioeconomic groups. Consistent with this, our sample was characterized by relatively higher educational attainment and socioeconomic status, which may constrain the generalizability of our findings. However, online recruitment was the most feasible method given the COVID-19 restrictions in place during 2022, and future studies should replicate our results using more diverse sampling strategies. Moreover, the assessment of SPS and emotional and behavioral problems was based on parent-reports only, not considering the child’s and school’s reports in the assessment. Although we used established cutoffs to categorize SDQ scores, both to facilitate clinical interpretability and to align with the study’s aim of providing a descriptive overview of SPS in an understudied population, this approach carries limitations. Specifically, it reduces statistical power and relies on UK-derived cutoff scores that have not been validated for the Egyptian population. Lastly, the cross-sectional nature of our study design precludes any inference of directional or causal relationships. Therefore, our findings should be interpreted strictly as associations between SPS and emotional/behavioral difficulties, not as evidence of a causal effect.

Conclusion and recommendations

This study provides one of the first prevalence estimates of SPS among Egyptian children (10.2%) and demonstrates a significant association between SPS and emotional and behavioral difficulties, particularly in the context of a positive family history of psychiatric disorders. Our findings underscore the importance of considering SPS as a developmental vulnerability factor that interacts with environmental and familial risk.

Our findings highlight the importance of early identification and support for highly sensitive children, particularly those with a family history of psychiatric disorders. Early screening for SPS in pediatric and school settings could facilitate targeted interventions that promote emotional regulation, adaptive coping, and environmental modification to reduce the risk of adverse outcomes. Future longitudinal and population-based research is essential to clarify the mechanisms underlying these associations and to inform targeted interventions for highly sensitive children.

Abbreviations

SPS

Sensory processing sensitivity

SDQ

Strengths and Difficulties Questionnaire

HSPS

Highly Sensitive Person Scale

HSP

Highly sensitive person

SP

Sensory processing

SPD

Sensory processing disorder

SPSS

Statistical Package for Social Science

SD

Standard deviation

X2

Chi-square

COVID-19

Coronavirus disease of 2019

ADHD

Attention deficit hyperactivity disorder

AES

Aesthetic sensitivity

MHRNE

Mental Health Research Network of Egypt

Authors' contributions

Z.N.S. carried out the main part of writing and revising the whole manuscript, and supervising all phases of the research. E.T.B., H.A.O., M.A., and A.H. participated in literature review, developing the questionnaire, designing the web-based survey, and writing the manuscript. A.S. participated in the validation process and the development of the Arabic version of HSPS for children and data collection. S.S.O. conducted the statistical analysis, data presentation and interpretation, and participated in writing the manuscript. All authors read and approved the final version of the manuscript.

Funding

The study was self-funded by the authors themselves.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Approval of the Ethics Committee of the High Institute of Public Health was obtained before conducting the study. The study was conducted in compliance with the International Guidelines for Research Ethics. An informed consent of the study participants (parents) was ensured before participation, as the purpose of the research was stated at the beginning of the form and participants were able to accept or refuse to participate. They were also able to withdraw from completing the questionnaire at any time before submission of responses. Confidentiality was assured as the survey was conducted anonymously, and no form of personal identification was collected.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.