Autism is not a single disorder, with every child exhibiting the same behavior. Rather, autism is a spectrum of closely related disorders with a shared core of symptoms. Every child on the autism spectrum struggles with social interaction, communication, empathy, and flexible behavior. But the level of problem behaviors and combination of symptoms varies tremendously from child to child.
For parents of children with autism, terms such as high-functioning autism, atypical autism, autism spectrum disorder, and pervasive developmental disorder can be confusing. Not only are there many terms to describe differences in children on the spectrum, but doctors, therapists, and other parents often use the terms in different ways.
But regardless of what anyone else says, it’s YOUR child’s unique needs that are truly important. There is no such thing as a label that will tell you exactly what challenges your child will have and what you should do about them. What’s most important is to find the autism treatment that addresses the individual needs of your child. For parents dealing with severe problem behavior, this is even more important.
We sat down with Megan Michell, BCBA, one of our clinicians at The Autism Therapy Group to talk about what parents need to know if their child is exhibiting especially destructive behavior. Megan has been in the field of ABA therapy for 8 years. During that time, she’s worked with all different types of children and behaviors in a range of settings and has a lot of great information to share about dealing with severe problem behaviors.
This is our conversation.
Q: HOW DO YOU DEFINE WHAT CONSTITUTES SEVERE BEHAVIOR CHALLENGES IN CHILDREN WITH AUTISM?
Megan: In many cases, severe behavior challenges can be defined in terms of safety. If the child is exhibiting behaviors that affect the child’s safety or the safety of others, we typically define that behavior as severe. Another marker is a family struggling to experience what might be considered “normal” activities like going to the movies, or out to dinner, or on a family vacation because of severe behavior in a child with autism.
In these situations, the behaviors can become difficult and may serve as roadblocks to learning important basic skills that children need in order to navigate the world around them. As BCBA’s, our primary objective is to address those behaviors right from the start.
Q: HOW HAVE YOU SEEN SEVERE BEHAVIORAL ISSUES AFFECT THE FAMILY AS A WHOLE?
Megan: It differs from family to family but in general the more challenging the behavior, the more difficult the family dynamics. I’ve worked with families that were afraid to take their child out into any public or social situation because of serious safety concerns. For some parents, they simply get tired of trying to explain their child’s behavior to others. In these cases, simple activities that most families don’t think twice about, like visiting other family members, are off-limits.
When the family has a child with extreme behavior challenges, it’s easy to allow the entire family dynamic to revolve around the problem behavior. The more problematic the behavior, the more the family is controlled by the behavior. This can develop into a cycle that the family doesn’t know how to get out of.
For most parents, it’s heartbreaking to see their child going through so much emotional distress and not know how to help them. Often, parents will feel like they are constantly walking on eggshells and go to great lengths to prevent the problem behavior from happening. Unfortunately, this reaction might actually be reinforcing the problem behavior.
Q: HOW CAN A FAMILY’S BEST EFFORTS TO MANAGE A CHILD’S BEHAVIOR ACTUALLY REINFORCE IT?
Megan: Every one of us exhibits behavior. Behavior is simply the things that we do. For all of us, the things that we do are maintained by something. We receive reinforcement or punishment for our behavior and that influences our future behavior.
Children with autism generally struggle to communicate what they want. Because of this, when they happen on behavior that works to get them what they want, they are prone to go back to that behavior again and again regardless of whether it’s destructive.
In some cases, inconsistency can strongly reinforce the behavior. When the child doesn’t get what they want, they simply intensify their efforts, and a minor fit becomes a major tantrum. This behavior will continue until it eventually gets them what they want. Over time they are learning how much problem behavior they have to do in order to get the outcome they’re seeking.
Q: WHAT ARE YOUR TOP PRIORITIES WHEN YOU FIRST BEGIN WORKING WITH A CHILD EXHIBITING EXTREME BEHAVIOR?
Megan: As clinicians, the first step is to conduct a functional assessment that helps us understand what’s causing the behavior. We want to do our best to understand why the child is behaving this way and what’s maintaining the behavior. There’s a variety of ways the BCBA might gather this information including direct assessments where they observe the child in different situations and settings, and indirect assessments in which they interview key people in the child’s life. A BCBA might also conduct a functional analysis, which involves the BCBA systematically manipulating the environment in order to determine how those changes directly affect the behavior of interest.
If the child’s behavior changes drastically in frequency or intensity, or if a new type of problem behavior arises, the BCBA is ethically required to recommend that the family seek medical attention because it’s important to know if the behavior is the result of an underlying medical condition. It’s also important to rule out medical factors so that the child’s individualized behavior plan can be effective without unknown physiological interference.
Once the initial assessment is complete, and medical reasons are confirmed or ruled out, an intervention plan will be implemented. It’s so crucial that the consistency of the plan is carried out by everyone who is involved in the child’s life. This can be challenging for families who have other obligations and responsibilities, such as providing for the needs of other children. So, we work hard to create a plan that is realistic to the situation. After all, it’s not helpful if we create a plan that the parents can’t maintain outside of ABA therapy sessions.
Behavior plans generally include proactive measures designed to prevent the problem behaviors from occurring in the first place, and reactive measures designed to deal with the problem behavior after the fact. One of the most important things for the child to learn is how to generalize replacement behaviors across all situations, with all different people, and in all different environments.
Q: CAN YOU SHARE SOME EXAMPLES OF SEVER BEHAVIOR PROBLEMS AND STRATEGIES THAT A BCBA MIGHT EMPLOY TO DEAL WITH THEM?
Megan: Severe behavior challenges look different across people and families. It really has a lot to do with how the behavior directly affects the child and those around him or her. Behavior can take the form of physical aggression, self-stimulation, property destruction, repetitive behaviors, verbal aggression, self-injury, elopement, and more. The ones we consider more severe are the ones that directly impact the child’s safety or anything that hinders learning opportunities. The severity of behavior is influenced by factors such as skill deficits (i.e. communication), a medical diagnosis, or reinforcement history.
For example, elopement– when a child has a tendency to run away – is a particularly difficult behavior because of the obvious safety concerns. I’ve also worked with clients that have caused severe self-harm to their own bodies.
In some situations, the BCBA might have to try several different types of interventions before finding what works. I worked with a child who engaged in hand flapping to the point of dislocating joints in his wrist. To deal with this issue, we used a combination of response blocking, in which we physically stopped him from flapping his hands and offering him a replacement behavior. Once the behavior was blocked, we gave him an object that was similar to a stress ball. Manipulating the replacement object provided him with a similar emotional outlet but in a much safer way.
I specifically wanted to share this example because I think that many people immediately think of physical aggression when they think of severe problem behavior, but that’s not always the case as severe behavior can take many different forms.
Regardless, dealing with behaviors like this can be terrifying for parents – especially when they have to send their child to school or to a day program. Many of these children are non-verbal. It can be extremely frustrating for parents when their child has a difficult day and they can’t talk to them about what happened. This is one of the biggest reasons why open lines of communication between the family and all of the child’s care professionals must be kept open.
While implementing any behavioral intervention, it’s crucial for clinicians to remain calm and create a positive environment. Little to no language should be used during a crisis situation with a child because he or she will most likely not be receptive to verbal input. In most cases, talking or shouting can escalate the situation. If language must be used, a neutral tone of voice is most effective, as well as making positive statements such as instructing the child about what he or she should be doing rather than on what he or she should not be doing.
Other strategies that can be utilized during a crisis include modeling and prompting appropriate replacement behaviors, and response blocking which involves physically blocking the client from engaging in a behavior, but only if it is safe to do so. With severe problem behaviors, the dignity and safety of the child, the clinician, and the child’s family is the main priority and any behavior intervention plan will be designed to promote both of those for the client.
When behaviors occur that severely affect the safety of the client or anyone else, the therapy team may implement a behavioral safety program called Safety Care. This program is designed to de-escalate clients during a crisis situation. Additionally, Safety Care teaches replacement behaviors and provides clinicians with skills to decrease and manage severe behavior that may occur during and outside of therapy sessions. The great thing about Safety Care is that it can also be utilized in order to prevent challenging behavior, so BCBAs may incorporate pieces of the program into the behavior plan as proactive measures.
Q: WHY IS ABA THERAPY AN EFFECTIVE SOLUTION FOR EVEN THE MOST DIFFICULT BEHAVIOR?
Megan: ABA therapy focuses heavily on the reinforcement of behaviors. Behavior plans differ from child to child, but the basic concept is the same. For example, let’s say a child wanting attention from someone learns that if they hit the person on the leg, they’ll receive the attention they want. Teaching that child a replacement behavior such as gently tapping someone’s leg is an effective method for helping them develop positive ways of getting what they want.
Parents who are feeling discouraged should know that ABA therapy will help, and the future will be better IF consistency is maintained. It’s a highly collaborative approach proven to be extremely effective largely because it’s so individualized based on what each child needs.