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

Patterns of challenging behavior have long been associated with the diagnosis of autism spectrum disorders (ASD). Anyone who has experience with such children has likely observed problems with toileting, sleep, excessive activity levels, intense tantrums, 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 (pseudonym), a 7-year-old student diagnosed as having an ASD. Randall has been evaluated as also having severe intellectual disabilities, and does not exhibit any functional verbal communication. He displays 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). Randall’s problem behaviors can have a variety of negative physical, social, educational and economic consequences.

Problem behaviors exhibited by individuals with an ASD can result in significant pain, injury and emotional distress for children, families and teachers providing support to these individuals. Participation in educational and other community settings may be jeopardized, and there is an increased risk of admission to more restrictive public residential facilities. Providing necessary support for individuals in such facilities results in greatly increased costs (e.g., $100,000 or more per year for persons with severe self-injury [NIH, 1991]; see also Jacobson, Mulick, & Green, 1998). Challenging behaviors may place children with ASD at greater risk for abusive treatment by support staff (Bromley & Emerson, 1995). Without intervention, these students are at much greater risk for a variety of negative outcomes.

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.