International journal of child development and mental health

Laumkha & Prathanee

ISSN: 2286 - 7481; E-ISSN: 2586-887X Vol. 7 No. 1 January – June 2019 (34-42)

The Effect of Integration Activities for Reduction

Repetitive Behaviors in Children with Autism
Pakaon Laumkha1, Benjamas Prathanee2*
1
Curriculum and Instruction in Special Education, Faculty of Education,
Khon Kaen University, Khon Kaen, Thailand
2
Department of Otorhinolaryngology, Faculty of Medicine,
Khon Kaen University, Khon Kaen, Thailand
*Corresponding author: Benjamas Prathanee,
Tel: 66-43-363565, e-mail: bprathanee@gmail.com

Received: 11 February 2019

Revised: 19 March 2019
This article was “partially” presented at The 6th Child Development and Accepted: 24 April 2019
Mental Health (CDMH) International Forum & The 4th Asia Pacific Neurofeedback/
Biofeedback Conference held September 6-7th, 2018 in Chiang Mai, Thailand

Abstract
This study aims to determine the effectiveness of integrated activities to reduction repetitive
behavior in children with autism. The participants were students, age ranged from 4 – 10 years old, who
were clinically diagnosed as autism and enrolled at Special Education Center, Loei Province. Research
was single subject design with AB design. The participants were selected by purposive sampling. Over
the course of 13 weeks of the study, integrated activities were designed for individual program for
reduction repetitive behaviors that were negative effect to learning. These behaviors include head
butting, hand flapping, finger knocking, finger banding, body shaking and hand gesturing.
The behaviors in academic class were video recorded for further analysis where the frequency of the
behaviors can be recorded at 1st (A), 5th (B5), 9th (B9), and 13rd (B13) Week. Video recordings were
individually replayed by 2 evaluators (inter-observer reliability = 98.3%), the main researcher and
research assistant who are teaching special educators and counted number of repetitive behaviors.
Data were consensused and analyzed by using descriptive analysis for general information and The
Wilcoxon Signed- Rank Test for analysis median difference among number of repetitive behaviors at
A1, B5, B9, and B13. The result revealed that integration activities significantly decreased repetitive
behaviors for children with autism between the 1st (A) and 13rd (B13) week (Median difference = -32.5,
95% confidence interval = 24.09-38.78).

Keywords: Children with Autism, Repetitive Behaviors, Repetitive Behaviors

which can result in many problematic behaviors

Introduction (Prathanee, 2011) Core features of autism
Autism spectrum disorder (ASD) is a spectrum disorder (ASD) include defcits in
neurodevelopment condition diagnosed on the social-communication skills and the presence
basis of social and communication impairments of clinically significant rigid and repetitive
plus restricted and repetitive interests and behavioral patterns (American Psychiatric
activities. Children with ASD have neurological Association, 2013). They usually present with rigid
disorders which result in lack of learning ability, and repetitive patterns of behavior and/or
recognition, perception and emotional development, interests (RRBIs) (Raulston, Hansen, Machalicek,

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Integration Activities for Reduction Repetitive Behaviors Vol. 7 No. 1 January – June 2019 (34-42)

McIntyre, & Carnett, 2019) Repetitive behavior is not related to brain function. Repetitive
is widely known to be one of three core and behaviors can be the result of sensory
defining features of autism. Of specific interest integration or the brain’s inability to process or
here, the repetitive behavior domain involves manage sensory stimuli from themselves and
compulsive behaviors, unusual attachments to the environment (Saenthaweesuk et al., 2011).
objects, rigid adherence to routines or rituals, There are many interventions for treatment of
and repetitive motor mannerisms such as repetitive behaviors such as sensory integration
stereotypies and self-stimulatory behaviors therapy (SIT), differential reinforcement of
(Insel, O’Brien, & Leckman, 1999). Repetitive, incompatible behavior (DRI), differential
apparently purposeless behavior “stereotypy” or reinforcement of other or zero rates of behavior
“perseveration,” and such behaviors are actually (DRO), differential reinforcement of variable
described as symptoms of autism in the DSM-5 behavior (DRV), environmental enrichment,
(the official diagnostic manual) (Lai, Lombardo, functional communication training (FCT),
Chakrabarti, & Baron-Cohen, 2013; Mattila non-contingent or time based schedules of
et al., 2011). Stereotyped or repetitive motor reinforcement (NCR), overcorrection, physical
movements, use of objects, or speech. exercise, response blocking, response cost,
Hyper-reactivity or hypo reactivity to sensory response interruption and redirection (RIRD)
input or unusual interest in sensory aspects of (Raulston et al., 2019). A survey of behavioral
the environment. Repetitive behaviors in autism practices revealed that reinforcement-based
can vary radically from person to person. No one practices, punishment-based practices, and
really knows what causes perseveration in people a group of commonly packaged antecedent
with autism, though there are a variety of and consequence-based package components
theories. However, a recent study found that are the common interventions for decreasing
restricted and repetitive behaviors contributing repetitive behaviors in autism (Raulston et al.,
to a diagnosis of ASD at age 2 years are 2019). Sensory integration therapy (SIT) is a
associated with structural properties of commonly used treatment (Mandell, Novak, &
callosal and cerebellar white matter pathways Levyd, 2005). For Frequency of treatments, 33%
measured during infancy and toddlerhood. We used interventions sometimes (approximately
further identified that repetitive behaviors and 25–50% of cases) or often (more than
unusual sensory response patterns co-occur approximately 50% of cases). Most of
and share common brain-behavior relationships. practitioners reported SIT as effective, 62 %
These results were strikingly specific given the (Raulston et al., 2019). Previous studies used
absence of association between targeted duration and frequency of intervention varied
pathways and social deficits (Wolff et al., 2017) from 3 to 90 minutes, 2- 5 sessions a week
Lacking of social interaction, language for 5-12 weeks, depended on designing. For
and communication, and learning limitation, TEACCH (Treatment and Education of Autistic
especially repetitive behaviors such as rocking, and Relate Communication Handicapped
head shaking or banging, flicking, clapping, hand Children) in autism, designing integrated
biting, and tiptoeing that are learning obstacles activities to increase or decrease the perception
for children and withdraw their attention from of feelings in correspondence with specific
the surroundings. It also interrupts them from problems in each systematic classroom
maintaining interactions with other people, management (Siriratrekha, 2017) by adopting
as well as continuing with their daily routines. TEACCH principles can be adapted for process
Moreover, it affects their sensory and learning of creating a balance in recognition processing,
development. Children who experience these decrease repetitive behaviors, and promote
behaviors tend to be underdeveloped in perceptual learning (Sudalak, 2012). TEACCH is a method
cognitive abilities, as their physical coordination called “Structured Teaching, those strengths

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CDMH Development and Mental Health 35
 Laumkha & Prathanee
in visual information processing. It provides repetitive behaviors in children with autism by
strategies and tools for teachers to use in the comparison pre- and post - number of repetitive
classroom, which help students with ASD to behaviors after using the integrated activities in
achieve educational and therapeutic goals. This classroom.
method supports meaningful engagement in
activities. It also works to increase students’ Methods
flexibility, independence, and self-efficacy.  The study was a single subject design,
TEACCH strategies can be used alongside other AB Design The proposal had been submitted
approaches and therapies. It also considers the for review by the committee of research ethics
child’s interests, making learning functional for in human research, Center of Ethics in Human
them (Mesibov & Shea, 2009). The effectiveness Research, Khon Kaen University (HE603022).
of the TEACCH intervention has been previously The participants were six students with autism
synthesized by some studies across different experiencing repetitive behaviors age raged
ages and within repetitive behavior, providing from 4 – 10 years old who received education
positive outcomes and high parental satisfaction at Special Education Center, Loei Province,
(Eikeseth, 2009) semester 2 of the 2018 academic year (January
– May) (six months) The purposive sampling
was done to recruit participants for the study.
Objectives Participants’ general characteristics, repetitive
This was to determine the effectiveness of behaviors and comorbid, medication, and other
integrated activities for reduction numbers of intervention were shown in Table 1.

Table 1: General characteristics and repetitive behaviors

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Integration Activities for Reduction Repetitive Behaviors Vol. 7 No. 1 January – June 2019 (34-42)

Procedure while video was recorded in 5th, 9th, and 13rd

The procedure is divided in two phases; weeks as shown in Figure 1. The researcher and
phase A, and B, respectively. For phase A, before research assistant independently kept track of
the study 1st week (baseline), repetitive behaviors the frequency of the repetitive behaviors shown
of students in academic classes without in the video (inter-observer reliability = 98.3%).
integrated activity arrangement were video The two sets of data were comparatively analyzed
recorded. Later on, phase B (intervention) was and discrepancy of the data was discussed to
conducted by implementing integrated activities achieve the consensus.

6 Students with autism

Phase A (Baseline)
Week 1 Observing repetitive behaviors in academic skills
classes
(Mon – Fri, 10.30-11.30 am.)

Week 5, 9, 13 Phase A (Baseline) Observing and keeping

Observing repetitive behaviors in academic skills record of repetitive
classes ◄ behaviors in academic classes
(Mon – Fri, 10.30-11.30 am.) (Mon – Fri, 10.30-11.30 am.)

Figure 1: Study design

Designing integrated activities for optimal effectiveness in reducing repetitive behaviors of

each student required corporation between parents, special education teachers, students’
teachers, and occupational therapists. Afterwards, the designed activities were submitted for
reviewing from two occupational therapists, and a special education educator, followed by
amendments (index of item objective congruence = 0.80) before implanting them for students
in classroom. Accordingly, students were informed of the order of the activities for the implementation
of integrated activities, and
what to expect to happen
during classes. These activities
were illustrated in pictures for
each student and followed
the TEACCH principles which
used structure pictures
(Figure 2) to guide the
visual inspection process of
each activity of sensory
integration (Table 2).

Figure 2: Structure pictures for inspection process

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CDMH Development and Mental Health 37
 Laumkha & Prathanee
Table 2: Integrated activities for the focused group of students with autism

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Integration Activities for Reduction Repetitive Behaviors Vol. 7 No. 1 January – June 2019 (34-42)

The frequency of repetitive behaviors Results

of students with autism in both before (A), and
after using of integrated activities (B5, B9, B13) The results revealed integrated activities
were rated frequency by 2 special educators, reduced repetitive behaviors among 6 students
principle researcher and research assistant with autism as shown in Table 3.
(inter - observer reliability = 98.3%, then
consensused and analyzed by using the Wilcoxon
Signed Rank Test.

Table 3: Median and mean frequency of repetitive behaviors

Table 3 displayed median and mean frequency of repetitive behaviors and it clearly appeared
that the occurrence of the behaviors was less frequent after implementation of integrated activities.
appeared that the occurrence of the behaviors was less frequent after implementation of integrated
activities.

Table 4: Comparison frequency of repetitive behaviors during phase A and B

A: week 1, B5: week 5, B9: week 9, and B13: week 13, *p<0.05, **95% CI = 95% confidence interval

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CDMH Development and Mental Health 39
 Laumkha & Prathanee
The Wilcoxon Signed Rank Test revealed that repetitive behaviors among students with
autism had reduced after the arrangement of integrated activities, at the statistically significant level
p< 0.05.

Discussion autism. This study aimed to investigate the effect

The results of this study supported The of using activity sets to stimulate the sensory
results of this study supported on the previous system and movement through sensory
study by Sorntamart (2015)on utilization of cyclic stimulating activities of the muscles, tendons,
model movement activities based on the sensory and joints such as hand walking, a game in
integration theory to reduce repetitive behaviors which students have to connect parts of body
in a child with autism were implemented to and move coordinately and moving through
reduce stereotyped behaviors of one autistic obstacles. Moreover, sensory stimulating
pre-schooler at age 3. The student was observed activities such as playing with dough, throwing
while doing cyclic model physical activities on a ball in the basket; as well as sensory
multiple sensory carpet floors, on a balancing stimulating activities of balance and movement
board, with a big ball and on a trampoline, three such as stair climbing, rolling and picking up a
times a week, and lasted 60 minutes per session. ball, and back riding were also included for 30
After 8 weeks of the study, the results showed minutes a day, with an average of 10 minutes per
that cyclic model physical activities based game. These activities were arranged in order
on sensory integrations theory could reduce to decrease hand playing in students with
repetitive behaviors in pre-schoolers with autism aged of 4 over the course of 9 weeks.
autism. Additionally, consistently employing Likely, finding of a previous study (Daly, Rioux,
integrated activities in academic classes at Schaffner, Hudson, Lander, 2001) that explored
certain periods with specific patterns can reduce the effects of a weighted vest on attention
problematic stereotyped behaviors, particularly to task and self-stimulatory behaviors in
those considered obstacles in classroom preschoolers with pervasive developmental
management. More importantly, it can promote disorders with ABA single-subject design and
students’ interaction in learning activities and found that a weighted vest resulted in an
improve learning and development. Systematic increase in attention to task and decrease in
review presented sensory integration therapy be self-stimulatory behaviors. The most consistent
limited to experimental contexts in single case improvement observed was the decreased
design studies (Leong, Carter, & Stephenson, number of distractions. Additional research is
2015) however, the current finding supported necessary to build consensus about the
most previous studies including meta-analysis effectiveness of wearing a weighted vest
study and that found the positive effects for to increase attention to task and decrease
on psychoeducational and motor categories self-stimulatory behaviors for children with PDD.
(Vargas & Camilli, 1999 ) sensory processing, For summary, it is important that
concentration, motor control, bilateral activity leaders such as teachers or
coordination, and reflex integration (Kim, Bo, occupational therapists select suitable tools
& Yoo, 2012), as well as gross and fine motor and equipment for each activity and respond
skills. (Abdel Karim & Mohammed, 2015). These to the developmental issues and learning
indicated that integrated activities could difficulties among students with repetitive
directly reduce repetitive behaviors among behaviors. In doing so, students’ repetitive
students with autism. It also agreed with behaviors will be decreased and had abilities
Juanongwaeng, (2012) for using sensory motor to learn should be promoted. Limitation of this
activities to reduce fingers flicking in a child with study was duration of observation was 13 weeks,

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it suggested that with AB design which might not

cover effect of integrated activities in withdrawn
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