Challenging behaviors can be disruptive to daily life for individuals with autism. These include, but are not limited to, self-injury, aggression, property destruction, tantrums, disruptiveness, noncompliance, and repetitive behavior/stereotypy. According to ARI’s E-2 database, approximately 59% of individuals with autism engage in self-injury, aggression, and/or destructiveness at some point in their lifetime.
Further, a recent follow-up study by Laverty et al. found that 44% of children diagnosed with autism engaging in self-injurious behaviors exhibited the same behaviors a decade later (Laverty et al, 2020). Due to larger body size and strength, these persistent behaviors can become more severe with age and impact the quality of life for individuals and their caretakers or parents.
Learn more: Read Challenging Behaviors in Adults with Autism by Stephen M. Edelson, Ph.D. and Marvin R. Natowicz, M.D., Ph.D.
Understanding and addressing challenging behaviors
The root cause of most challenging behaviors can be placed into one of three categories: a biological basis, a social basis, or an initial biological cause later maintained by social consequences.
Biological causes can include anxiety (Casanova et al., 2021), painful medical comorbidities such as GI distress (Muskens et al., 2017), or environmental sensory processing issues (Miller and Misher, 2016). Social causes generally relate to a desire for attention (positive or negative) or a desire to avoid or acquire a certain object or situation (Carr, 1977). Some behaviors can originate from an underlying biological issue, usually associated with pain or discomfort, but continue due to social consequences, like gaining attention, even after the pain has stopped (Carr and McDowell, 1980). Note that some challenging behaviors are caused by underlying genetic conditions (Shirley et al., 2016; Huisman et al., 2018; Kurtz-Nelson et al., 2020) and associated comorbidities.
Though the root causes of challenging behaviors vary, the behaviors themselves are generally understood and addressed as functions of communication. This is especially true for individuals with autism because communication difficulties are a core symptom. These challenging behaviors, as with any other, are learned via modeling, association, and observation. Therefore, given correct positive supports and interventions, they can be modified and replacement behaviors and coping strategies can be learned.
Some challenging behaviors persist to adulthood due to unintentional reinforcement. For example, when self-injurious behavior like head-banging earns an individual their desired outcome, be it maintaining attention, getting a tangible item, or getting to participate in a desired activity, the individual receives reinforcement for that self-injurious challenging behavior. Similarly, when a tantrum leads to an individual getting out of undesirable activities like brushing their teeth or doing homework or making an unpleasant sensory experience stop, such as the sound of a vacuum cleaner or blender, the individual receives reinforcement for the tantrum behavior. In both cases, unintentional reinforcements for the challenging behaviors are given. While this stops the behavior for that moment, it also shows the individual that their social and environmental surroundings understand and respond to that behavioral communication technique. Without understanding the root cause and the communication an individual is trying to achieve, addressing these behaviors is very difficult.
“If we select an intervention based on the child’s behavior only, and ignore the environmental reasons, we can – at best – stop the behavior temporarily. We cannot stop it for good because the reasons for it continue to exist” – Ted Carr
Context, behavior, and consequence
Challenging behaviors “do not occur in a vacuum” (Lauren Moskowitz) but instead depend on context and environmental surroundings. Providers cannot create successful intervention plans without understanding the context within which behavior occurs. Creating a timeline for each behavior allows providers to assess causes and potential support strategies. Elements include:
- Setting events: Environmental/contextual/biological aspects that make an antecedent more or less likely to trigger a certain behavior―i.e., physical discomfort, social settings, tiredness, etc.
- Antecedent: Anything that potentially triggers a specific behavior―i.e., “time to go to school”, bedtime, dinnertime, grocery shopping, etc.
- Behavior: the behavior itself―i.e., self-injury, screaming, violence.
- Consequences: the outcome or type of reinforcement given―i.e., gaining attention or leaving an undesirable activity.
By viewing challenging behaviors in this framework, clinicians and families have options at four different levels where interventions can occur. However, trained professionals must complete a thorough multidisciplinary assessment to select the correct treatment strategies. Treatment depends on the root cause of the behavior.
Functional Behavior Analysis
Functional Behavior Analysis (FBA) is a standard assessment strategy used to discover underlying causes of challenging behaviors. An FBA identifies the context (setting events + antecedent) and function of an individual’s challenging behaviors. Treatment plans and intervention strategies created in concert with a thorough FBA help guide the correct combination of preventive, responsive, and replacement strategies. Functional behavioral assessments generally include:
- Interviews – with the individual, parents/caretaker, and/or teacher (or anyone else involved)
- Direct observation – conducted across multiple settings, using multiple observers. Some helpful assessment tools include:
- MAS (motivation assessment scale)
- QABF (questions about behavioral functions)
- FAC (functional assessment checklist)
- Setting Events checklist
- Contextual Assessment Inventory (CAI)
- Functional analysis – experimenting to verify the function of the behavior. Examples include manipulating consequences in a standard vs. controlled setting or adjusting antecedents to assess the effect on the behavior.
Learn more: Watch Dr. Lauren Moskowitz’s webinar, Assessing and Treating Challenging Behaviors, for detailed examples of these assessment tools and subsequent treatment options.
After a thorough assessment is conducted, clinicians can determine the best intervention methods for individuals exhibiting challenging behaviors. Treatments created in concert with an FBA generally involve a combination of three strategies based on the framework outlined above:
- Prevention strategies focused on changing setting events and antecedents and treating co-occurring medical issues to prevent challenging behaviors.
- Replacement strategies focused on teaching alternative behaviors and coping mechanisms.
- Response strategies focused on ensuring the consequences align with the behavior exhibited.
Learn more: Read Treating Challenging Behaviors for detailed information about treatment strategies.