Comparison of Behavioral Intervention and Sensory-Integration Therapy in the Treatment of Challenging Behavior
Devlin, S., Healy, O., Leader, G., & Hughes, B. (2011). Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. Journal of Autism and Developmental Disorders, 41, 1303-1320.
Reviewed by: Jennifer Cote, BS, ASAT Extern, and Karen Fried, PsyD, BCBA-D, ASAT Board Member.
Why research this topic?
For individuals with autism spectrum disorder, challenging behaviors can affect their ability to function at home, in school and in the community. Challenging behaviors can also be dangerous, in the case of aggression and self-injury for example. Given the importance of reducing challenging behaviors, it is essential for parents and professionals to select the most effective intervention. The current study builds upon previous research by comparing the use of a behavioral intervention (BI) to the use of sensory-integration therapy (SIT) to decrease challenging behavior in children with autism spectrum disorder (ASD). BI and SIT are commonplace interventions in school and community settings. Just because two interventions are commonly used does not mean they are equivalent for a particular purpose. Previous research shows that BI is effective in reducing challenging behavior in children with ASD and that SIT shows questionable efficacy for this purpose. It is important to build on previous research to compare and contrast BI and SIT so that children with ASD have the best possible outcomes. BI is commonly delivered by behavior analysts. SIT is commonly delivered by occupational therapists. The second part of this study measured the stress levels of the same children in the BI and SIT conditions by examining saliva samples for cortisol. Cortisol is a component of saliva and is associated with the human stress response. Some researchers have suggested that measurement of cortisol might help assess stress levels in children with ASD.
What did the researchers do?
Researchers studied four males, ages 6½ to 11 years, with diagnoses of ASD. All participants had a history of challenging behavior, in the form of aggression and self-injury. The study took place in a school setting. Functional assessments were conducted for each participant to determine the function of the challenging behaviors prior to the intervention phase of the study. For each participant, a behavioral intervention was designed by a behavior analyst based on the results of the functional assessment. Also for each participant, an SIT intervention was designed by an occupational therapist (OT) trained in designing and implementing SIT procedures. The SIT intervention was not based on the results of the functional assessment but rather on the OT completing direct observation of each participant over a period of one month. Before the intervention phase, researchers measured the challenging behaviors of each participant. Once intervention began, each participant received intervention that alternated randomly between BI and SIT over the course of 10 days. Challenging behaviors were measured throughout. After the 10-day period, the intervention that showed the best results for each participant was repeated alone for another 8 days, during which the challenging behaviors were measured. Before and throughout the alternating intervention phase, researchers also collected several daily samples of each participant’s saliva. Those samples were then analyzed for cortisol according to whether the participant was engaged in BI or SIT.
What did the research find?
During BI, challenging behaviors decreased for all four participants. Conversely, for SIT, challenging behaviors increased for one participant, showed no change for one participant, and decreased for two participants, though to a much lesser degree than the decrease produced by BI. Since BI produced the greatest effect for all four participants, it was continued alone for another 8 days. Over the course of that 8-day period, challenging behaviors decreased further, to zero occurrences for one participant. An analysis of cortisol levels revealed no overall difference between the BI and SIT conditions. Cortisol levels were relatively low compared to normal resting data for children without any special needs.
What are the strengths and limitations of the study?
The design of the study was strong in terms of alternating randomly between BI and SIT across participants. Another strength was that the BI strategies were tailored specifically to each individual based on results of the functional assessment or analysis. Challenging behaviors were clearly defined in ways that were observable and measurable. Yet another strength is that challenging behaviors were measured by more than one observer (i.e., interobserver agreement or IOA) for a large portion of the sessions to make sure measurements were accurate. To improve the study, the researchers could increase the total number of intervention sessions to extend the trends they saw; the current data included possible regression after weekends and unexpected absences in a few participants. The researchers might consider repeating the alternating treatment study with additional participants. Finally, the researchers might improve the study by spending more time describing how they made sure each session of BI and SIT was carried out as intended (i.e., treatment integrity or fidelity).
What do the results mean?
This study builds on previous research supporting the use of BI strategies to effectively reduce challenging behaviors in children with ASD, including aggression and self-injury. Effective use of BI includes basing treatment decisions on the results of a functional assessment or analysis. SIT remains a popular treatment among various consumers despite lack of evidence for its efficacy, especially compared to BI.
Cote, J. & Fried, K. (2016). Review of Comparison of Behavioral Intervention and Sensory-Integration Therapy in the Treatment of Challenging Behavior. Science in Autism Treatment, 13(2), 11-13.