PROBLEM BEHAVIOR IN AUTISM
Shared core deficits in the areas of communication, social behavior, and excessive repetitive behavior may predispose children with autism spectrum disorders (ASD) to display problem behavior. That is, problem behavior may result from deficits in children's ability to express their needs, desires, and preferences, or to understand and respond to naturally occurring social cues and norms. In addition to biological factors that increase the risk of problem behavior, environmental factors can lead to the emergence and maintenance of problem behavior. Some reactions of caregivers to problem behavior that may be effective with typically developing children could inadvertently strengthen or reinforce that problem behavior in children with autism. For example, giving a child a break from work when he becomes upset or disruptive may inadvertently strengthen those problem behaviors that are related to working.
Many children with autism don't display problem behaviors that warrant treatment by a professional. However, given the increased risk for problem behavior in autism, it is important to be proactive. It is important for parents to understand that many of the same principles important for dealing with behavioral issues in typically developing children are applicable to children with autism. However, the responsibility on parents (and teachers) of children with autism is even greater because they must take on a more active role in "engineering" the optimal environment, and in teaching adaptive skills that seem to develop naturally in children without disabilities. Early intervention strategies focusing on communication, social skills, and leisure skills, such as how to play appropriately with toys, have been found to be very effective. Early intervention is considered so important that federal law mandates that school systems provide early intervention for children diagnosed with autism. Many early intervention programs teach these skills for educational readiness, but these efforts also can have implications for decreasing the risk of problem behaviors. Other proactive measures include creating an environment that is highly enriched with preferred toys and activities, sticking with a structured routine, and presenting clear cues to make transitions more predictable. Activity boards, photographs, or outlines are particularly helpful in increasing predictability. Parents and teachers also should prompt and reinforce appropriate communication, toy play, and social interaction when these behaviors occur. Other appropriate behaviors such as compliance, cooperation, and coping should be reinforced as much as possible. Caretakers should watch for any signals that indicate increased levels of stress and provide frequent breaks from work before frustration or fatigue sets in. In some cases, parents may need to limit access to toys or activities that result in obsessive or ritualistic play that interferes with the completion of other activities or that cannot be easily interrupted without causing problems.
In general, if a problem behavior is relatively minor, occurs infrequently, and poses no risk to the individual or others, then it simply should be ignored and the child redirected with minimal attention. Stereotypic behaviors that some parents find embarrassing, such as hand flapping, finger snapping, or rocking side to side, generally are best ignored -- unless the behavior occurs excessively to the point of interfering with participation in routines or schoolwork. When problem behavior is severe enough to place the child or others at risk for injury or to interfere with participation in school and family activities, then treatment by a professional is needed. Both behavioral treatments and medication should be applied at a level that is appropriate to the scope of the problem. More severe problem behavior can include the following: self-injurious behavior (for example, hitting, biting, or scratching oneself), aggression toward others, destructive behavior, screaming, and pica (that is, eating inedible objects). The severity of these problems can vary widely, ranging from relatively minor and short-lived, requiring little treatment, to severe and chronic, necessitating intensive intervention. These behavioral problems can stem from biological or environmental factors, or a combination of both. Genetic abnormalities, psychiatric conditions, and neurological dysfunction may predispose individuals to engage in problem behavior. Environmental factors such as level and type of stimulation and reinforcement available, the behavior of others, and the history of the consequences for problem behavior also can play a role in the development and persistence of problem behavior.
Applied behavior analysis (ABA) is the application of basic principles of learning and behavior. This approach is widely recognized as a scientifically supported approach for addressing problems associated with ASD.1 2 Although ABA-based interventions for addressing core deficits and educating children with ASD through early intensive intervention3 are widely known, ABA has long been used for treating problem behavior displayed by individuals with autism and intellectual disabilities. ABA-based interventions for problem behavior focus on establishing and reinforcing new skills, providing access to preferred activities and toys, providing choice-making opportunities, increasing appropriate communication, and making complex situations more predictable using signals, while extinguishing maladaptive patterns of behavior.
Key to developing treatments for problem behavior in children with ASD is understanding what factors may be occasioning and maintaining these behaviors. Research has shown that in the majority of individuals with problem behavior, it can be maintained by reinforcement in the form of attention, access to preferred items, escape from demands, or sensory reinforcement.4 Analysts use functional behavioral assessment (FBA) to identify the events that lead up to or maintain problem behaviors. They also look for any events that reinforce the behaviors after they occur. FBA includes a range of methods used to describe the interaction of children with their environment. One common FBA method involves interviewing parents, teachers, and other caregivers regarding the events surrounding challenging behaviors. Another avenue is to observe the child in various settings for several days and record the frequency, intensity, and/or duration of behavior problems as well as the events that precede and follow the behavior. A third method, termed functional analysis, is a more intensive assessment that involves the behavior analyst actively arranging specific conditions to simulate real-life situations and then observing how the individual reacts. For example, to determine if problem behavior is maintained by escape from academic demands, the child would be given work to complete, but problem behaviors would result in the brief termination of demands. This condition is designed to simulate a situation in which a teacher might give a student a brief break from work if he or she is getting upset (which may inadvertently reinforce problem behavior). Similar conditions are created to examine whether problem behavior is occasioned and maintained by other events such as gaining access to highly preferred items (for example, food, drink, or toys), gaining adult attention, or receiving sensory stimulation. Repeatedly conducting such simulations and analyzing the data can yield objective and reliable conclusions about the variables controlling the problem behavior.
The driving purpose behind FBA is to guide the development of "function-based interventions" by using operant conditioning procedures to establish alternative appropriate behaviors and to reduce or eliminate problem behavior. One type of function-based intervention method is functional communicationtraining. FCT involves teaching the child an appropriate method of communication to access preferred items that were shown to elicit problem behavior.5 6 Teaching functional communication skills helps the child to appropriately ask for a preferred item in the absence of problem behavior. Noncontingent reinforcement is another function-based intervention method that provides free access to the preferred item that is believed to maintain problem behavior.7 Over time, access to this reinforcer is reduced while ensuring that problem behavior remains low. Providing an enriching environment with highly preferred activities and toys can reduce the likelihood of behavioral problems. Also, providing the child with a structured routine by establishing clear times for various activities, giving warnings for transitions, and creating activity boards, photographs, or other picture schedules help to increase the predictability in the child's day.8 9 Interventions developed by a behavior analyst should include a data collection system to permit objective evaluation of the intervention's effectiveness and consider the parents' resources and preferences so that the parents can sustain the intervention.
In conjunction with behavioral techniques, pharmacological interventions have received support in the literature as being effective in treating psychiatric conditions associated with severe behavior problems. Behavioral and psychiatric assessment sometimes reveals the causes of problem behavior as environmental (for example, related to the individual's skills deficits and history of reinforcement), or biological (for example, related to a psychiatric condition), or both. Generally, problems related to environmental/social factors should be addressed with behavioral treatments along the lines discussed, but problems related to psychiatric conditions should be addressed with medication.10 In many cases, both medication and behavioral treatment are needed.
References:
U.S. Department of Health and Human Services. (1999). Children and mental health. In Mental health: A report of the Surgeon General (pp. 124-194). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institutes of Mental Health.
Myers, S. M., & Plauché Johnson, C. (2007). Management of children with autism spectrum disorders. Pediatrics,120(5), 1162-1182. View Abstract
Eikeseth, S. (2009). Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities, 30(1), 158-178. View Abstract
Iwata, B. A., Pace, G. M., Dorsey, M. F., Zarcone, J. R., Vollmer, T. R., Smith, R. G., et al. (1994). The functions of self-injurious behavior: An experimental-epidemiological analysis. Journal of Applied Behavior Analysis, 27(2), 215-240. View Abstract
Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18(2), 111-126. View Abstract
Hagopian, L. P., Contrucci Kuhn, S. A., Long, E. S., & Rush, K. S. (2005). Schedule thinning following communication training: Using competing stimuli to enhance tolerance to decrements in reinforcer density. Journal of Applied Behavior Analysis, 38(2), 177-193.View Abstract
Vollmer, T. R., Iwata, B. A., Zarcone, J. R., Smith, R. G., & Mazaleski, J. L. (1993). The role of attention in the treatment of attention-maintained self-injurious behavior: Noncontingent reinforcement and differential reinforcement of other behavior. Journal of Applied Behavior Analysis, 26(1), 9-21. View Abstract
Mesibov, G. B., Shea, V., & Schopler, E. (2005). The TEACCH approach to autism spectrum disorders. New York: Kluwer Academic/Plenum.
Hagopian, L. P., Bruzek, J. L., Bowman, L. G., & Jennett, H. K. (2007). Assessment and treatment of problem behavior occasioned by interruption of free-operant behavior. Journal of Applied Behavior Analysis, 40(1), 89-103. View Abstract
Hagopian, L. P., & Caruso-Anderson, M. (in press). Integrating behavioral and pharmacological interventions for severe problem behavior displayed by children with neurogenetic and developmental disorders. In Shapiro, B. K., & Accardo, P. J. (Eds.),Neurobehavioral disorders: Science and practice. Baltimore: Brookes Publishing Co.
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