Treating Challenging Behaviors

Communication difficulties are a core symptom of ASD. As a result, individuals on the spectrum often develop coping/communication mechanisms that present as challenging behaviors. It is widely understood and accepted that these behaviors are functions of communication and can be addressed through understanding and specialized treatments. These behaviors can include:

•  Self-Injury
•  Aggression
•  Property destruction
•  Tantrum behavior 
•  Disruptive behavior
•  Noncompliance
•  Repetitive behavior/stereotypy

Challenging behaviors depend on context – that the behavior is not an isolated event but is a function of communication based on surrounding environmental factors. Contemporary behavior intervention strategies focus on understanding context to create a personalized treatment plan. When reasons for a challenging behavior are recognized, clinicians and families can create a timeline of behavioral and environmental factors and decide the most effective strategies. 

Treatment Strategies

There are three general types of strategies used in treating behavioral issues related to ASD: prevention, replacement, and response. As the names allude, each approach occurs at a different point in the progression timeline/context (before, during, after) of a challenging behavior/outburst.

Prevention strategies are used to alter the events leading up to an outburst or other challenging behavior. These strategies help make the environment and activities more predictable and less overwhelming, thereby reducing stress and anxiety. Prevention strategies build on an individual’s strengths to help prepare them for a transition or a disliked activity/task. This makes the transition/stressful situation a gradual process instead of an abrupt change. As a result, the problem behavior is less likely to occur.

Replacement strategies teach an individual how to cope with unpleasant situations. They allow individuals on the spectrum to gain a desired outcome via social, communication, self-regulation, academic, and daily living skills. As individuals learn new skills and become more active agents in their own lives, their self-confidence and success will increase. Replacement strategies focus on providing/teaching different actions and skills to replace challenging behavior instead of simply preventing them.

Response strategies are consequence-based strategies used to reinforce constructive behavior; these center on altering consequences following a challenging behavior. Contemporary practices focus specifically on supporting productive, safe behaviors to increase self-confidence and frequency in the future.

Common Prevention Strategies

Visual schedules

Visual schedules are picture sequences, like “First, Then” cards that show a visual outline of a progression of activities. They can help make tasks more predictable and less overwhelming for individuals on the spectrum and enhance one’s sense of control over the environment by preparing them for upcoming events and transitions.

Visual schedules are used to define an individual task, the tasks in a day, or an individual’s plan for the week; this can help with anything from using the bathroom and morning routines to a weekly schedule for homework and snacks. 

Advanced warnings, timers, and countdowns

Timers and countdowns give individuals time to prepare for a change and make transitions a gradual process rather than an abrupt ending. Marking transitions and giving advanced warnings (i.e., “10 more minutes of TV”) helps increase predictability and thus reduces frustration and anxiety.

For instance, scheduling time for play and desired activities can enhance the individual’s sense of control and self-regulation. Similarly, having timers set for the length of disliked activities help individuals to know when they will be able to do something they prefer. 

Priming and social-stories

Priming is a way of previewing future events, materials, or learning activities in a relaxed environment; this provides more predictability to those who struggle with transitions and new experiences by showing what those situations will be like from their point of view.

Social stories, video footage, or at-home rehearsals are great priming tools to prepare individuals for an unfamiliar environment. For example, you might use a video of an airport to prepare for a family vacation, rehearse the checkout line at the grocery store before you go, or read a story at home before it is read to the group in school. 

Providing frequent choices within a task

Providing options surrounding a particular task allows an individual to become an active participant in a situation; this increases motivation and enhances self-control as they can choose for themselves and are no longer a bystander receiving instructions about what to do. Give choices whenever possible. 

For example, although a child must do homework during homework time, you can offer choices about whether to do homework at their desk or at the kitchen table, with mom or dad, with a pen or pencil, etc. For non-verbal individuals, picture boards are helpful tools for providing visual choices.

Embedding disliked tasks in enjoyable tasks

Embedding allows the individual to intersperse complex or disliked tasks among easy and preferred ones; this enhances motivation and increases the opportunity for personal and behavioral success.

For instance, you can embed three challenging math problems in a set of ten or have someone take two or three bites of a preferred food for each taste of a new food. This way, the individual feels successful and motivated to try new things. 

Incorporating perseverative interests

A perseverative interest is an object, activity, or topic in which an individual is intensely interested. Incorporating perseverative interests allows an individual to complete a task that they don’t like in the context of something they do like. 

For example, an individual might practice handwriting (a task they dislike) by copying lines from their favorite movie. Similarly, one could use legos (something they love) to create math problems. 

Generalized reinforcement

Generalized reinforcement allows the individual to pair a non-preferred task with a wide variety of highly preferred, tangible activities or social reinforcers. Combining preferred foods, music, games, or other supports with a challenging task can help lower anxiety and provide adequate comfort to cope. 

Common Replacement Strategies

Functional Communication Training

Teaching communication skills can help an individual with autism express what they want without resorting to challenging behaviors. Identifying triggers is the first step toward assisting individuals in learning to ask for what they need through language instead of behavior. Every individual is different; the key to effectively implementing a replacement strategy is to provide communication skills that serve the same purpose as the challenging behaviors but are more productive.

For example: Teach the individual to ask, “Am I doing a good job?” to replace outbursts related to attention or, “I need a break” for outbursts related to task avoidance or escape. Individuals with limited speech can learn to use one word instead of several (i.e., “iPad” instead of “I want the iPad”). Augmented communication devices or picture aids can also be helpful.

Coping skills

Coping skills refer to exercises or steps that help an individual manage an uncomfortable or stressful situation. These can include mindfulness exercises such as deep breathing or progressive muscle relaxation, positive self-reinforcement with phrases like, “I can do it!” or thinking of a favorite cartoon or song during an unpleasant situation. 

Tolerance for delay of reinforcement (waiting)

When introducing communication skills, it is important to honor an individual’s request immediately and consistently. Otherwise, the challenging behavior will continue to be more effective than the replacement strategy. Delayed reinforcement begins after the individual develops trust in the effectiveness of the replacement behavior. 

For example, if a child asks for a break, ask them to finish one minute of a given task first. Then, slowly build on this by gradually increasing the waiting time. Timers and visual supports are helpful tools for waiting. 

Daily living skills

Daily living skills include dressing, eating, showering/bathing, etc. These are routine, self-care tasks that can be difficult for individuals on the spectrum due to communication or motor difficulties. Teaching/learning these skills allow individuals to achieve what they want or need without assistance; this innately fuels a decrease in challenging behaviors as body autonomy and confidence levels rise. 

Common Response Strategies

Positive reinforcement

Positive reinforcement should happen right away when an individual uses appropriate behavior in place of problem behavior unless you are teaching waiting.

For example, if instead of throwing a tantrum, the individual asks for a break from doing homework, reward them by giving them a break immediately; this will ultimately teach them that using communication is more effective than challenging behaviors. 

Extinction 

Extinction is a strategy that avoids drawing attention to the problem behavior to avoid reinforcing it. In situations where specific behaviors are attention maintained and are not dangerous – such as blurting out or intentionally dropping an item, instructors can ignore the behavior when it occurs. If self-injury or risk of harm to others occurs, calmly intervening is required; when more complex behaviors happen, it is crucial to identify the specific cause of the problem. The goal is to avoid unintentionally reinforcing the issue and ensure that the correct replacements are taught. 

It is important to note that with extinction responses, challenging behaviors will often increase in frequency, duration, and intensity for a time after implementation begins, known as a behavioral “burst.” Behavioral bursts occur because extinction presents an abrupt change to one’s understood communication strategies. This situation is challenging to navigate for everyone involved. However, the challenging behavior will decrease as individuals learn other communication techniques. 

If you think you or your loved one with autism struggles with challenging behaviors, talk to your clinician or practitioner about a functional behavioral assessment. These assessments include interviews, observations, questionnaires, and functional analyses to assess the causes, consequences, and responses to challenging behaviors. Most individuals respond best to a combination of preventative, replacement, and response strategies, so it is vital to get a proper assessment.

These behavioral strategies were collected from Lauren Moskowitz’s webinar, Assessing and Treating Behavioral Issues in individuals with Autism. View the full presentation.