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Supporting Children and Youth with ASD Who Exhibit Challenging Behavior

By Rob O'Neill

Patterns of challenging behavior have long been associated with the diagnosis of Autism Spectrum Disorders (ASD.) Anyone with experience with such children has likely observed problems with toileting, sleep, excessive activity levels, self-stimulatory or stereotypic movements (e.g., rocking, hand flapping), and more serious behaviors such as aggression towards others (e.g., hitting, kicking), destruction of materials and the physical environment, and self-injury (e.g., hand biting, head hitting and banging). Consider Randall*, a 7-year-old student labeled as having an Autism Spectrum Disorder. Randall has been diagnosed as also having severe intellectual disabilities, and does not exhibit any functional verbal communication. He exhibits a variety of challenging behaviors, including forcefully smacking the backs of his hands on table edges, dropping to his knees on hard floors, and a variety of aggressive behaviors such as hitting, pinching, and scratching others. He spends most of his time in a self-contained classroom for students with disabilities, working on a variety of pre-academic and functional skill training activities (e.g., toileting, dressing, communication skills). Such behaviors can have a variety of negative physical, social, educational, and economic consequences. They can result in significant pain, injury, and emotional distress for children and families, and for teachers providing support to them. Participation in schools, residential programs, and other community settings may be jeopardized and there is an increased risk of readmission to public residential facilities. Providing necessary support results in greatly increased costs (e.g., $100,000 or more per year for persons with severe self-injury [NIH, 1991]). Such behaviors may place children with ASD at greater risk for abusive treatment by support staff. It is clear that challenging behavior is frequently exhibited by children with ASD, and that without intervention they are at much greater risk for a variety of negative outcomes.

Interventions for Challenging Behaviors

The two primary intervention approaches for such behaviors have been behavioral intervention and the administration of psychotropic medications; this article focuses on the former. For many years behavioral strategies predominantly focused upon reinforcement of appropriate behaviors and punishment or extinction for challenging behaviors. In recent years, concerns with such procedures have led to a more positively oriented and comprehensive approach, typically referred to as positive behavioral support (PBS). This approach includes a broader perspective on outcomes, an emphasis on careful functional assessment as a basis for selecting and implementing intervention strategies, comprehensive programs involving multiple components, and consideration of needed skills and systems that need to be in place to support students (e.g., Koegel, Koegel, & Dunlap, 1996).

A Broader Perspective on Outcomes

PBS has its roots in the field of applied behavior analysis. However, along with specific and important reductions in the frequency of challenging behavior, PBS approaches also emphasize that behavior change should result in broader positive changes in educational and community settings for students receiving support. This includes where they spend their time (e.g., more inclusive vs. more segregated classrooms), with whom they spend their time (e.g., more time with typical peers vs. paid support staff), and what they spend their time doing (e.g., engaged in more typical educational, domestic, leisure, and community activities). In thinking about Randall’s situation described above, it would be critical to achieve reductions in his problem behavior, but if that is not accompanied by broader changes in what Randall is doing, where he’s doing it, and with whom, we will not have done the best we can by him.

Functional Behavioral Assessment

A seminal research report by Iwata et al. (1982) is credited with sparking a resurgence of attention to the need for conducting systematic analyses as a basis for implementing interventions. Iwata et al. collected data on the occurrence of self-injurious behavior (SIB) of persons with developmental disabilities while systematically manipulating various environ- mental conditions. These functional analysis manipulations attempted to determine the reinforcement contingencies that were responsible for maintaining the SIB. Since the publication of the Iwata et al. report there has been an increasing frequency of pretreatment experimental and nonexperimental analyses (collectively known as functional assessments) reported in the literature, as well as an increase in the implementation of successful treatment strategies based on such analyses (Johnston & O’Neill, 2001). The success of such approaches led a National Institutes of Health Consensus Conference panel to recommend that interventions for severe challenging behaviors be based on pretreatment assessments (NIH, 1991).

In recent years a number of states have adopted regulations that explicitly call for a functional assessment to be conducted prior to significant behavioral intervention. Along with state level standards, the last two enacted versions of the federal Individuals with Disabilities Education Act (IDEA) explicitly mandated that a functional assessment be done in situations involving serious challenging behaviors. Conducting a functional assessment of challenging behaviors prior to intervention has become an expected professional standard (O’Neill et al., 1997).

Coming back to Randall, school consultants and staff working with him conducted functional assessment interviews, and also conducted structured functional analysis manipulations in his classroom setting. These sessions involved systematically responding in various ways to Randall’s challenging behavior to determine what antecedent and consequence events were setting off and maintaining it. The results indicated that the vast majority of his challenging behavior was motivated by escaping and/or avoiding when he was asked to complete various pre-academic activities. This assessment provided a solid foundation for identifying intervention strategies.

Comprehensive Multi-Element Behavioral Support Plans

It is clear that students with complex histories of challenging behavior require a comprehensive approach including (1) responding to broader setting events such as sleep, diet, medication or social interaction issues (e.g., making sure a child has breakfast before coming to school); (2) more immediate antecedent strategies (e.g., changes in levels of task difficulty); (3) strategies to teach students more appropriate alternative behaviors (e.g., teaching a child to sign “break” when frustrated with a task or activity); and, (4) providing reinforcing outcomes for appropriate behavior (e.g., honoring requests for breaks, providing preferred activities contingent on task completion), minimizing or preventing reinforcement for challenging behavior (e.g., not allowing a child to escape a nonpreferred task), and, in some cases, providing appropriate punishing events contingent on challenging behavior (e.g., blocking aggressive hitting).

In Randall’s case, assessment data indicated that he frequently was allowed to stay up very late at night, increasing problem behavior on subsequent days. Classroom staff worked with Randall’s parents to implement an earlier bedtime routine. Classroom staff also modified curricular activities to more gradually lead to the eventual desired performance (e.g., providing easier tracing activities prior to moving on to more difficult printing activities). They began to provide Randall with choices about which academic or functional skill activities he would work on during a given period. A communication disorders specialist began to teach Randall some basic sign language to communicate his wants and needs in difficult situations (e.g., signing “break,” “help”). Randall was provided with some graphic picture cards signifying “break” and “help”, and received training in how to use those in situations likely to evoke challenging behavior. Classroom staff frequently and consistently provided desired outcomes when Randall exhibited appropriate communicative behavior (e.g., pointing to his “break” card), and provided breaks and preferred activities contingent on periods of problem-free task completion. Staff attempted to minimize or prevent reinforcement for problem behavior by attempting to keep him engaged in task activities. Even if Randall did escape task activities for a brief period, he was redirected to complete them as soon as possible. This comprehensive approach to Randall’s situation produced reductions in problem behavior and an increased frequency of appropriate communicative behavior and engagement in desired tasks and activities (O’Neill & Sweetland-Baker, 2001).

Skills and Resources Needed for Providing Effective Support

We need to think about the broader systems issues that need to be addressed to enable school personnel to support a broad range of students. Support may come either from within the building, or from external resources such as district consultants, but requires some person or persons with significant behavioral expertise who can take the lead in conducting assessments and helping to develop intervention strategies (Sugai et al., 2000). Such schoolwide efforts include (1) strategies for all students in a school as a whole; (2) group strategies for the smaller portion of students at-risk for more significant challenging behavior; and (3) strategies for those requiring more intensive individualized support (e.g., students such as Randall labeled as having ASD exhibiting severe challenging behavior).

In a recent review, Horner et al. (2002) concluded that the literature does not identify any types of behavioral support interventions that are uniquely effective with children with Autism. Providing support for students requiring intensive individualized strategies is best accomplished in a broader schoolwide context. Schoolwide efforts typically involve team-based approaches which should include (1) personnel familiar with the student, including teachers, paraprofessionals, parents/family members, and in appropriate cases, the student him/herself; (2) administrative personnel who can make decisions about resource allocation; and, (3) personnel with behavioral expertise who can conduct functional assessments and develop and implement behavioral support plans. Ideally, someone on the team would also have expertise in the characteristics and performance of students with ASD; however, given the lack of unique behavioral support interventions identified for such students, this may not be critical.

Summary

School-age students with ASD who exhibit challenging behavior may require a variety of behavioral supports to maximize participation in typical classroom and community settings. Perhaps the most critical issue is to focus on the needs of individual students, as opposed to assuming various support needs based on whether or not a child has an ASD label. It is hoped that this article provides some guidance to those school personnel and families providing such support to children and adolescents exhibiting challenging behavior in school and community settings.

*Pseudonym


References

Horner, R.H., Carr, E.G., Strain, P.S., Todd, A.W., & Reed, H.K. (2002). Problem behavior interventions for young children with Autism: A research synthesis. Journal of Autism and Developmental Disorders, 32, 423-446.

Iwata, B.A., Dorsey, M.F., Slifer, K.J., Bauman, K.E., & Richman, G.S. (1982). Toward a functional analysis of self-injury. Analysis and Intervention in Developmental Disabilities, 2, 3-20.

Johnston, S., & O’Neill, R.E. (2001). Searching for effectiveness and efficiency in conducting functional assessments: A review and proposed process for teachers and other practitioners. Focus on Autism and Developmental Disabilities, 16, 205-214.

Koegel, L.K., Koegel, R.L., & Dunlap, G. (Eds.) (1996). Positive behavioral support: Including people with difficult behavior in the community. Baltimore: Paul H. Brookes Publishing.

National Institutes of Health (NIH) (1991). Treatment of destructive behaviors in persons with developmental disabilities. Washington, DC: National Institutes of Health.

O’Neill, R.E., Horner, R.H., Albin, R.W., Sprague, J.R., Storey, K., & Newton, J.S. (1997). Functional assessment and program development for challenging behavior: A practical handbook (2nd ed). Belmont, CA: Wadsworth.

O’Neill, R. E., & Sweetland-Baker, M. (2001). An assessment of stimulus generalization and contingency effects in functional communication training. Journal of Autism and Developmental Disorders, 31, 235-240.

Sugai, G., et al. (2000). Applying positive behavior support and functional behavioral assessment in schools. Journal of Positive Behavior Interventions, 2, 131-143.


Rob O’Neill is Professor in the Department of Special Education, University of Utah, Salt Lake City. He may be reached at 801/581-3913, or at roneill@ed.utah.edu.


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Retrieved from the Web site of the Institute on Community Integration, University of Minnesota (http://ici.umn.edu/products/impact/193/default.html). Citation: Cadigan, K., Craig-Unkefer, L., Reichle, J., Sievers, P., & Gaylord, V. (Eds.). (Fall/Winter 2006/07). Impact: Feature Issue on Supporting Success in School and Beyond for Students with Autism Spectrum Disorders, 19(3). [Minneapolis: University of Minnesota, Institute on Community Integration].
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