Outcomes-Based Intervention Approaches: Supporting Children and Youth with ASD Who Exhibit Challenging Behavior

Interventions for Challenging Behaviors

The two primary intervention approaches for problem behaviors include behavioral intervention and the administration of psychotropic medications; this article focuses on the former. The earlier development and implementation of behavior strategies predominantly focused on reducing challenging behaviors. Over the last 15-20 years, concerns with these traditional behavior modification interventions have led to a more positive and comprehensive approach. This approach includes a more diligent focus on outcomes, selecting intervention strategies based on careful functional assessment of problem behavior, comprehensive programs involving multiple strategies, and consideration of what supports should be in place to support students and others to be successful (e.g., Bambara & Kern, 2005). For students with ASD, these models can include modifications to the environment to reduce the likelihood of problem behavior, behavioral support plans (BSPs) to teach appropriate behaviors to replace problem behavior, a system of minimally intrusive consequences to address problem behavior and, if necessary, a crisis plan.

A Broader Perspective on Outcomes

Along with prioritizing the reduction of challenging behavior, contemporary models of Applied Behavior Analysis (ABA) place equal emphasis on teaching appropriate social behaviors. Rather than simply employing strategies to respond to behavior problems as they occur, these models teach and reinforce the skills students with ASD need to utilize to succeed in the home, educational environment and community. One such model, Positive Behavior Support (Bambara, Dunlap, & Schwartz, 2004; Journal of Positive Behavior Interventions, 1999–present), focuses on other important outcomes, including where students with ASD 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, reducing problem behavior is of critical importance. However, if this behavior change does not contribute to improvements in what Randall is doing, where he’s doing it and with whom, there may be minimal improvements to quality of life for Randall, his parents and his teachers/caregivers.

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 environmental conditions. These functional analytic manipulations attempted to determine the reinforcement contingencies that were responsible for maintaining the behavior, often referred to as the function of the behavior. In other words, what does the individual appear to be gaining by engaging in the problem behavior (e.g., getting attention, avoiding or escaping less-preferred activities or situations)? Since the publication of the Iwata et al. article, there has been an increasing frequency of pre-intervention experimental and non-experimental analyses (collectively known as functional behavioral assessments [FBAs]) reported in the literature. Basing intervention strategies on functional assessments of behavior has contributed significantly to an increase in the success of those interventions (Hanley, Iwata, & McCord, 2003). This type of success led a National Institutes of Health Consensus Conference panel to recommend that interventions for severe challenging behaviors be based on such pre-intervention assessments (NIH, 1991).

In recent years, a number of states have adopted regulations that explicitly call for an FBA to be conducted prior to implementing significant behavioral interventions. Along with state-level standards, the last two enacted versions of the federal Individuals with Disabilities Education Act (IDEA) explicitly mentioned that an FBA be done in situations involving serious challenging behaviors. This practice has become an expected professional standard (Johnston & O’Neill, 2001; O’Neill et al., 1997).

Coming back to Randall, school consultants and staff working with him conducted functional assessment interviews and 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 instigating and reinforcing the problem behavior. The results indicated that the vast majority of Randall’s challenging behavior was motivated by the desire to escape or avoid un-preferred activities, such as when he was asked to complete various pre-academic activities. This assessment provided a solid foundation for identifying a variety of intervention strategies (see below).

Comprehensive Multi-Element Behavioral Intervention

Plans Students with complex histories of challenging behavior require comprehensive approaches to intervention, 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 s/he is 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 non-preferred task), and, in some cases, providing appropriate punishing events contingent on challenging behavior (e.g., saying “no” and blocking aggressive hitting).

In Randall’s case, assessment data indicated that he frequently was allowed to stay up late at night, increasing problem behavior on subsequent days. Classroom staff worked with Randall’s parents to implement an earlier bedtime routine. They 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 also 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 (e.g., block building) contingent on periods of problemfree task completion. Staff attempted to minimize or prevent reinforcement for problem behavior by keeping 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).

Systems and Personnel Support Issues

Consideration should be given to how school personnel can be enabled to support a broad range of students, including what systems of support are required. Support may come either from within the building or from external resources such as school district consultants, but requires some person or persons with significant behavioral expertise who can take the lead in conducting assessments and developing intervention strategies (Sugai et al., 2000). Collaborative schoolwide efforts include (1) strategies to establish behavioral guidelines and prevent problem behavior 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 students requiring more intensive individualized support (e.g., students with a diagnosis of ASD who exhibit severe challenging behavior, such as Randall) (Hawken & O’Neill, 2006).

Skills and Resources Needed for Providing Effective Support for Students with ASD

In a recent review, Horner et al. (2002) concluded that current literature does not identify any types of behavioral support interventions that are uniquely effective only with children with ASD. Supporting students who require intensive, individualized strategies is best accomplished in the context of a broader schoolwide system. Schoolwide efforts typically involve team-based approaches that should include (1) individuals familiar with the student, including teachers, paraprofessionals, parents or family members, and, in appropriate cases, the student; (2) administrative personnel who can make decisions about resource allocation; and (3) personnel with expertise in ABA who can conduct functional behavioral assessments, and develop and implement behavioral support plans. Ideally, someone on the team would also have expertise regarding 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 a critical feature.

Summary

It is crucial that students, family members and school personnel receive guidance in providing support to children and adolescents with ASD who exhibit challenging behavior in school and community settings. The effectiveness of behavioral interventions are maximized when 1) interventions are based on an assessment of why problem behavior is occurring (i.e., to obtain a tangible item, to gain attention, to avoid or escape a situation); b) interventions include teaching and reinforcing appropriate social and communicative behaviors that serve the same function; c) interventions include consistent strategies for responding to problem behavior that ensure these behaviors are not being inadvertently maintained; d) consideration is given to environmental factors that may be impacting the individual with ASD; and e) there is frequent communication and collaboration among parents, caregivers, teachers and other school personnel.

References

Bambara, L.M., Dunlap, G., & Schwartz, I.S. (Eds.) (2004). Positive Behavior Support: Critical articles on improving practice for individuals with severe disabilities. Austin, Texas: Pro-Ed.

Bambara, L.M., & Kern, L. (Eds.) (2005). Individualized supports for students with problem behaviors: Designing positive behavior plans. New York: Guilford.

Bromley, J., & Emerson, E. (1995). Beliefs and emotional reactions of care staff working with people with challenging behaviour. Journal of Intellectual Disability Research, 39, 341-352.

Hanley, G.P., Iwata, B.A., & McCord, B.E. (2003). Functional analysis of problem behavior: A review. Journal of Applied Behavior Analysis, 36, 147-185.

Hawken, L.S., & O’Neill, R.E. (2006). Including students with severe disabilities in all levels of school-wide positive behavior support. Research and Practice in Severe Disabilities, 31, 46-53.

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.

Jacobson, J.W., Mulick, J.A., & Green, G. (1998). Cost-benefit estimates for early intensive behavioral intervention for young children with autism: General model and single state case. Behavioral Interventions, 13, 201-226.

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.

Journal of Positive Behavior Interventions. (1999–present). National Institutes of Health (NIH). (1991). Treatment of destructive behaviors in persons with developmental disabilities. Washington, D.C.: 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, Calif: 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., Horner, R.H., Dunlap, G., Lewis, T.J., Nelson, C.M., Scott, T., Liaupisin, C., Ruef, M., Sailor, W., Turnbull, A.P., Turnbull III, H.R., & Wickham, D. (2000). Applying positive behavior support and functional behavioral assessment in schools. Journal of Positive Behavior Interventions, 2, 131-143.

About the Authors

Robert O ’Neill, Ph.D., is Professor in the Department of Special Education, University of Utah, Salt Lake City. He may be reached at (801) 581-3913 or at rob.oneill@utah.edu.

S. Lillian Adolphson, M.Ed ., is a doctoral student in the Department of Special Education, University of Utah. She may be reached at lillian_adolphson@yahoo.com.