I am the mother of a young boy who was just recently diagnosed with autism. I was referred to a board certified behavior analyst (BCBA) by my pediatrician for a behavioral assessment to help with some problem behaviors my son is having at home, such as biting. I have heard from others that BCBAs don’t “believe in sensory issues,” and these problems are central to autism. Is a BCBA the right professional to help me since he or she won’t even believe my son has a problem?
Carl Sundberg, PhD, BCBA-D
Behavior Analysis Center for Autism
David Celiberti, PhD, BCBA-D
Association for Science in Autism Treatment
We are really glad this question was asked, as it comes up often. Some people believe behavior analysts are “antisensory” — opposed to offering sensory diets, massages, deep pressure, jumping on a trampoline, etc., for individuals with autism spectrum disorders. However, this is not necessarily true, and we would like to take this opportunity to clarify how behavior analysts tend to approach sensory issues. In fact, the term “issues,” in and of itself, can be problematic and ambiguous because it does not specify whether an individual is showing sensory preferences or sensory aversion, nor whether the sensory experience is a “like” or a “need.” These distinctions are significant in developing a treatment plan, as we will highlight below.
First and foremost, it would be beneficial to discuss the many faces of motivation. Each of us, and children in particular, may be highly motivated by sensory experiences that vary in modality, variation, movement and pressure. Ever catch yourself tapping your pencil, twiddling your thumbs, biting your nails, or popping bubble wrap (a personal favorite of the first author)? If so, would you say you have “sensory needs” or “sensory issues?”
It is important to keep in mind that we are all highly motivated by other experiences as well. Sometimes we are motivated by attention such as a smile, a knowing look, or laughter. Other times, it is something tangible and specific which motivates us, such as a new pair of sneakers or a piece of artwork. We all engage in a wide array of behaviors to access these experiences. On the flip side, sometimes we are motivated to avoid or get away from certain forms of attention (e.g., closing our office door or ignoring the incoming call of a telemarketer) or other specific things (e.g., a traffic ticket or non-preferred vegetables).
Why is this important? First, assessment of challenging behavior must carefully investigate the motivation of that behavior (i.e., the “function” of the behavior) in order to have the greatest likelihood of leading to effective intervention. It is through recognition of the function of the challenging behavior that effective behavioral intervention is developed. A “knee-jerk” or “cookie cutter” approach would do a disservice to your son or to anyone else who may be attempting to negotiate their environment in less than desirable ways. Let’s explore a few scenarios using some fictitious children. We intentionally referenced the same behavior (biting) in each example.
- Tommy bites his teacher when she attempts to help him put on boots.
- Gunner bites his teacher as soon as she put his sight word cards on his tabletop.
- Lisa bites her father as soon as he stops playing with her and attempts to leave the room to take a call.
- Sudhir may bite his older brother when the older brother is accessing the iPad.
- Sudhir also bites his babysitter when she asks him to put away his iPad.
- Antonio bites a classmate who sits too close to him during circle time.
- Melanie bites classmates when the fire alarm sounds or her older sister plays music loudly.
- Jennica bites her father’s arm when he wears long sleeve dress shirts.
- Mitchell’s teeth are coming in and he has been seen biting a plastic hanger.
As you can see in each of the examples above, the same behavior (biting) occurs in very different contexts and likely serves very different functions. In some instances, the motivation may be to get or keep a preferred item or activity, whereas in other instances, the child is trying to avoid or escape something they do not like. We hope you can appreciate that a “sensory” explanation based on the fact that they are biting would miss the mark in most or all of the examples illustrated above.
So the first takeaway message is that not every behavior problem should be assumed to have a sensory basis; in other words, sensory stimulation may not be the relevant motivation. So if we mislabel certain behaviors as “sensory,” the recommended sensory intervention will not address it properly.
Secondly, we should differentiate between a sensory need and a sensory preference. A hand washing example may illustrate this distinction. Both April and Alice engage in high rates of hand washing.
- April washes her hands every time she touches a doorknob, wet surface, or uses the office phone. She reports that she is worried about germs and will often appear agitated if hand washing is delayed (e.g., she is in a meeting or there is a line to use the restroom). From a behavior analytic standpoint, hand washing in this instance may serve as a negative reinforcer, because the behavior terminates the discomfort that April associates with unwashed hands. April might say, “I really need to wash my hands and feel so relieved after I do so.”
- Alice, on the other hand (no pun intended), also washes her hands a few times per day. She is a huge fan of a “high-end” salted caramel hand soap that is in the restroom two floors above her office. She will happily wait in line to access this restroom. From a behavior analytic standpoint, hand washing here serves as a positive reinforcer because of the resultant access to an item that she enjoys. Alice might say, “I really like to wash my hands with this particular product. I hope I get this for my birthday.”
As you can see, April has a “need” and Alice has a “like.” To make this distinction more relevant to autism, we could substitute the use of swings here. Like many children, some children with autism often appear to enjoy swinging, may be willing to work hard to earn it and demonstrate pleasure while swinging, whereas other children may start off agitated and appear calmer following swinging, but it is not necessarily an experience they would choose (children experiencing pain relief from taking aspirin may also benefit from it but not necessarily choose it).
So the second takeaway message is that not every sensory-seeking behavior reflects a “need.”
Let’s examine the misuse of the term “sensory need.” It is not unusual to see a person with autism engage in unwanted behaviors such as biting which cease when a vest is applied or a tantrum that stops after a cookie is delivered. In both cases, something was missing from the person’s immediate situation. In both cases, the behavior is likely to decrease once the vest or cookie is delivered. This is evidence that these items may be functioning as reinforcers and the function of the behavior is to access them. Why is it that in the first case (engaging in biting to get the vest), it’s often concluded that the child’s behavior is due to “sensory needs,” however, in the second case (engaging in a tantrum to access a cookie), it is rarely said that the child has “food needs?”
Activities stimulating the senses can serve multiple behavioral functions, depending on the motivation. Jumping on a trampoline is likely to be repeated because of its reinforcing vestibular effects — it is fun. This leads to the question, “Do I jump on the trampoline because I need to jump on the trampoline, or because it’s fun?” Either way, I am going to do whatever I can to get the opportunity to jump on the trampoline (thus, attesting to the reinforcing value). Again, the responses one engages in depend on the history of reinforcement and punishment, verbal repertoire, social contingencies and perhaps the level of deprivation or strength of the motivation. That is, if I had been jumping on the trampoline for extended periods of time, I may be less motivated to continue jumping, and less likely to engage in behaviors that will allow me to jump.
Lastly, any discussion on “sensory issues” would be remiss without some mention of sensory hypersensitivity. We have also observed individuals with autism who have extreme reactions to sensory input (e.g., loud noises, bright lights) and there are those who are extra sensitive to textures or certain clothing (e.g., the tag in the back of a shirt or particular food). These children/adults learn to engage in behaviors that reduce the aversive nature of such stimulation. But this isn’t exclusive to autism – there are also people without autism who are sensitive to certain stimuli as well.
There are some who experience extreme discomfort when exposed to situations which would be considered typical to most of us (e.g., loud music). Some people with the requisite skill-set will engage in behaviors that relieve the anxiety, such as escape behaviors (leaving the situation), avoidance behaviors (skipping the situation entirely), or engaging in some incompatible behaviors (practicing relaxation techniques). In these cases, sophisticated repertoires of skills are in place. Rarely will an adult (who does not have autism) run and scream from a room or become aggressive when confronted with an uncomfortable situation. Most of us have a sophisticated verbal repertoire allowing us to compensate or better negotiate the situation in a more socially accepted way.
Unfortunately, many people with autism do not have the repertoires to engage in the socially accepted methods that relieve the anxiety or discomfort. However, many other non-socially accepted behaviors have been shaped over the years and have proven to be effective in removing the aversive stimulation. If we were in a room where the music is too loud, we would leave or ask for it to be turned down. If those behaviors are not possible, we may have to tolerate the situation. We have learned that behaviors such as biting will result in undesired social consequences. But what if:
- We did not have the language to ask for the music to be turned down?
- We did not know that leaving was an option, or did not know how to ask, or were forced to stay?
- We didn’t value the social consequences as most people? That is, we don’t care how others perceive us or if we get invited back.
If all that were true, we might engage in biting to get the music turned off or get removed from the room.
Now, suppose we do have those skills, and we can always find a way to get out of situations that cause stress or sensory overload; or we tough it out because of the social contingencies that have been shaped up over our lifetime. Chances are, no one would suggest we had sensory issues and put us on a sensory diet or prescribe sensory integration therapy. However, a person with autism who may have the same level of discomfort and escapes the situation in the only way he or she knows how, is often said to have “sensory issues” when perhaps it would better to say they had skill deficits.
So a final takeaway message is that “sensory” concerns have profound implications for the teaching of new skills, skills that can be targeted through behavior analytic strategies.
In summary, we are not suggesting that your son’s biting behavior lacks a sensory basis. Our point is that perhaps there may be other explanations that would emerge during a functional assessment, and that these alternative explanations need to be carefully considered. In order to develop the most appropriate, and individually targeted treatment for your son, one must analyze the function of the behavior, evaluate whether the behavior has a sensory basis (and whether it reflects a “need” or a “like”), and identify skill deficits (e.g., manding) that may either compete with and potentially replace the biting behavior or provide him with coping skills to better negotiate his environment.
We would like to thank Different Roads to Learning for permission to reprint this adapted response from an article written by the first author that appears here. Please visit the DRL website often to peruse their incredible array of books and supplies, as well as their rich library of guidance and strategies from experts in the field of autism.
Citation for this article:
Sundberg, C. & Celiberti, D. (2015). Clinical Corner: Sensory issues: Is a BCBA the right person? Science in Autism Treatment, 12(2), 11-15.