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. Another professional suggested a sensory diet since she was under the impressions that BCBAs don’t “believe in sensory issues”. Is a BCBA the right professional to help me since he or she won’t even believe my son’s biting is a sensory problem?
Carl Sundberg, PhD, BCBA-D / Behavior Analysis Center for Autism and
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 “anti-sensory” — opposed to offering any sensory-based experience 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 often approach sensory issues. The term “sensory” can be problematic and ambiguous because it assumes no other possible explanation for challenging behavior (e.g., biting). In addition, it does not specify whether an individual is showing a sensory preference or sensory aversion, nor whether the sensory experience is a “like” or a “need.” These distinctions are significant when developing a treatment plan, as we will highlight below.
Not every behavior problem should be assumed to have a sensory basis.
It would be beneficial to discuss the many faces of motivation. Each of us, not just children with autism, may be motivated by sensory experiences that vary in modality, intensity, and duration. 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?”
We are all 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 that 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 escape certain forms of attention (e.g., closing our office door or ignoring telemarketer calls) or other specific things (e.g., a traffic ticket or non-preferred vegetables). Why is this important?
First, assessment of challenging behavior must carefully uncover the motivation for that behavior (i.e., the “function” of the behavior) in order for it 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 navigate their environment and communicate their wants and needs. Let’s explore a few scenarios using some fictitious children. We intentionally referenced the same behavior (biting) in each example to help make the distinction between form of the behavior (e.g., biting) and its function or purpose (e.g., to escape a demand of gain sensory input).
- Tommy bites his teacher when she attempts to help him put on his snow boots.
- Gunner bites his teacher as soon as she places 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 phone call.
- Sudhir may bite his older brother when the older brother is using 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 he or she does not like. A “sensory” explanation based on the fact that they are biting would miss the mark in most of the examples illustrated above. If we mislabel certain behaviors as “sensory,” the recommended sensory intervention will not address the targeted behavior properly and may prevent access to more effective intervention. In other words, it won’t work!
Not every sensory-seeking behavior reflects a “need.”
Let’s examine the misuse of the term “sensory need” and differentiate a sensory need from a sensory preference. A hand washing example using adults without autism 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 am 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 available only in the restroom two floors above her office. She will happily wait in line to access this particular 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. Other children may start off agitated and appear calmer following swinging; 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).
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, “Does the student jump on the trampoline because he or she needs to jump on the trampoline, or because he or she likes to jump on the trampoline?”
“Sensory” concerns have profound implications for the teaching of new skills that can be targeted through behavior analytic strategies.
Any discussion of “sensory issues” would be remiss without some mention of sensory hypersensitivity. We have observed some 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. In some cases, caretakers and providers may intervene at the first sign of discomfort, preventing the individual from habituating.
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 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 from a room or become aggressive when confronted with an uncomfortable situation. Most of us have sophisticated verbal repertoires allowing us to compensate or better navigate the situation in a more socially accepted way.
It is unfortunate that many people with autism do not have the skills to engage in the socially accepted methods to relieve the anxiety or discomfort. However, some challenging behaviors may have been shaped over the years and have proven to be effective. 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 did not comprehend the advice from others such as “this will be over in two minutes.”
- We didn’t value the social consequences as others so? That is, we didn’t care how others perceive us or if we get invited back.
If all those were true, we too, might engage in biting to get the music turned off or get removed from the room because we know it works!
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 we learned to habituate to the unpleasant circumstance. 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 be more helpful to say they had skill deficits. Although beyond the scope of this brief article, skill deficits can be addressed by teaching communication skills, such as requests (“Please turn down the music”) and comments (e.g., “This alarm is loud,” which may result in an empathic/validating response, such as “You are handling this so well. It will be over in two minutes.”). Systematic desensitization may also be considered to build tolerance.
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 comprehensive 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 skills, such as requesting that may either compete with and potentially replace the biting behavior, or provide him with coping skills to more appropriately meet his needs.
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 vast 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: Is a BCBA the right person to help with my child’s sensory issues? Science in Autism Treatment, 12(2), 11-15.