Managing Severe Problem Behaviors in Adults with Autism
As individuals with autism and other developmental disabilities age, some continue to display challenging behavior. This behavior may have continued from childhood or may be new as a result of situations and environments faced by adults.
In either case, adults possess increased strength and size, and these physical changes increase the impacts of problem behavior. For a child, behaviors such as biting, hitting and headbanging, while severe, may be manageable for a parent or caregiver. But as the child reaches adulthood, these same behaviors can require two or more trained persons to manage.
There is no doubt that managing severe problem behavior of individuals with autism and other developmental disabilities becomes more difficult with age, but by following these steps, it can be manageable.
Step 1: Get an Assessment
Have a Functional Behavior Assessment (FBA) conducted by a certified or licensed behavior analyst (BCBA/LBA) that definitively identifies the function (why they are doing it) of the behavior. This process will often involve turning the behavior on and off. For many parents or caregivers this sounds crazy. They often ask, “You mean you’re going to make them hit, kick, bite?” The short answer is yes!
Using an analogy, if you went to the doctor complaining of a sore throat and cough but when you arrived the doctor saw no symptoms (no redness and swelling in the throat and no coughing), it would be difficult for the doctor to make a diagnosis. The doctor may then swab your throat and run a test to determine what’s wrong and determine the best treatment. A behavior analyst must do the same. Behavior must be tested to determine what treatment it will respond to.
Parents and caregivers may feel reluctant to support the on / off approach. This is understandable because the problem behavior can be dangerous. But the problem behavior will likely continue unless a function-based treatment plan is implemented. To ease concerns, it’s important to remember that for the assessment, caregivers and professionals are prepared to safely manage the behavior. In many cases, the behavior analyst may also test for precursor behaviors (those that come before) so as not to have the actual problem behavior occur.
Step 2: Be Realistic
Agree on a realistic treatment approach that involves parent or caregiver training to implement the procedures. A great plan that caregivers don’t implement is worth less than an ok plan that caregivers follow through with. Identify what you and your adult want to get out of treatment and be honest about what you will do. This can save years of wasted time working on unrealistic skill development. An example of this would be teaching an adult to recognize street signs for safety if they will likely never be alone in public. Or teaching them to report their emotions “I’m mad” when what they really need is a way to say, “Stop that!”
Step 3: Coordinate with Other Professionals
Behavioral challenges are often complex. Solving the challenges long-term requires a good team. If a person demonstrates severe problem behavior, they are likely receiving services from other professionals such as a psychiatrist.
Coordination with these professionals will allow everyone access to the behavioral data needed to make informed decisions. This is important because many of the medications that psychiatrists use to help address behavioral challenges may have serious short and long-term side-effects. Sharing information helps the psychiatrist prescribe the lowest dosage and fewest number of medications necessary to manage the issues. In some cases, sharing information can even help transition the individual off medications altogether.
Step 4: Focus on Long-Term Goals
When parents or caregivers see problem behavior, such as repeatedly grabbing items off a store sheIf, it is often easy to stop it and avoid an aggressive confrontation by deciding to no longer take the person the store. But this won’t solve the problem. This is limiting to both the individual and the parents or caregiver and may eventually lead everyone to feel like prisoners in their own home.
Providing reinforcement such as buying items the person grabs may also work in the short run but won’t solve the problem. In both cases, long-term control of problem behavior is much more difficult because the environmental factors that maintain the behavior are likely still there. A good intervention focuses on teaching replacement behavior that accomplishes the same thing, so the problem behavior is more effortful and less likely to be rewarded.
Step 5: Have a Crisis Plan
No treatment works 100% of the time. So, sometimes the intervention isn’t going to work as planned, and problem behavior will occur. It may even occur with greater severity or longer than before. That is a crisis. There should be a plan, agreed upon by the team, for what to do in a crisis.
Calling 911 is always an option, but most of the time won’t provide the assistance the individual or the parents or caregivers need. Authorities take time to get to you, and during that time the problem behavior is still happening. In addition, first responders typically have less training working with individuals with autism than a newly trained Behavioral Instructor from a local agency.
Failure to interact with the individual in a way that encourages the desired response could lead to an escalation in problem behavior resulting in injury, arrest and/or hospitalization, so having a plan that includes trained professionals is probably the best approach.
Step 6: Use Data as a Guidepost
Be sure to work with professionals that understand the value of data and meet with them to regularly review data to see if the intervention is working. Sometimes interventions sound good but don’t work. Best practices suggest meeting with treatment professionals monthly to review progress. Then make decisions based on the data. If the person isn’t making progress on a goal after a few modifications, it is best to consider tabling it and moving to a more attainable goal. This generally avoids six or 12-month meetings that report little or no progress.
If you are the parent or caregiver for someone with autism who is challenged by severe behaviors and want to explore how to get help, request a consult to schedule a complimentary in-person or phone consultation with one of our adult services experts.