Tuesday, May 5, 2020

Challenging Behavior in Children with Autism


Challenging Behavior

Challenging behavior is any behavior that interferes with a child’s learning, engagement, and social interactions with her peers or adults. Aggression is often observed as one form of challenging behavior in autism. Although aggression is not itself a symptom of autism and not all autistic individuals are aggressive, research suggests that rates of challenging behavior may be higher in individuals with autism compared to typically developing peers and those with other developmental disabilities. Children with autism don’t necessarily express anger, fear, anxiety or frustration in the same way as other children. However, irritability is a symptom of autism that can complicate adjustment at home and other settings, and can manifest itself in aggression, tantrums, and self-injurious behavior. 
Behavior as Communication
Children engage in problem behavior to communicate. The principles of behavior teach us that it does not occur in a vacuum – that is, behavior does not occur without regard to the context in which it is observed. When working with autistic children we should consider problem behavior as a communication attempt, and should determine what skill the child needs to learn in order to reduce the need for the problem behavior or what environmental modification makes the behavior unnecessary. The first step to developing an effective intervention strategy is to identify the function of the behavior. By function, we mean what the child is trying to access by engaging in the challenging behavior. In other words: you first must figure out what it is the child is trying to communicate. For example, a student might exhibit challenging behaviors with the goal of escape or the goal of seeking attention. When the curriculum is difficult or demanding, they may attempt to avoid or escape work through challenging behavior (e.g., refusal, passive aggression, disruption, etc.). Similarly, they may use challenging behavior to get focused attention from adults and peers, or to gain access to a preferred object or participate in an enjoyable activity. Problematic behavior may also occur because of sensory aversions. Because autistic students also have significant social and pragmatic skills deficits, they may experience difficulty effectively communicating their needs or influencing the environment. Thus, challenging classroom behavior may serve a purpose for communicating or a communicative function. 

Common Triggers

Research suggests that common triggers include disturbing breaks in routine, lack of sleep, jarring “sensory stimuli” (noises, lights, or smells) or even undiagnosed mental health problems. Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention. Clearly, it’s important to look beyond the behavior itself to identify the underlying cause or trigger. Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention. The studies also indicate that symptoms of aggression often overlap in patients with extreme anxiety and attention deficit issues. It has been reported that executive function deficits (e.g. issues with inhibition, working memory, planning and flexibility) are associated with anxiety and aggression in autism and may serve as a pathway to comorbid psychopathology (sensory stimuli, a change in routine, transition between activities, or physical reasons like feeling unwell, tired or hungry. Not being able to communicate these difficulties can lead to anxiety, anger and frustration, and then to an outburst of challenging behavior. 

                                                                             Comorbidity

Children with autism experience a number of related difficulties, including sleep problems, gastrointestinal (GI) problems, sensory issues, and self-injury. Many of these problems have been associated with aggression among typically developing children, and emerging evidence suggests a similar relationship in children with autism. For example, sleep problems occur in a large percentage of autistic children, with prevalence rates ranging from 50% to 80%. Sleep problems have been found to be highly associated with aggression in typically developing children. Likewise, research suggests that children with autism and sleep problems are more likely to demonstrate aggression than those without sleep problems.
Sensory problems, including sensory over-responsivity, sensory under-responsivity, and sensory seeking are also common problems in autistic children. In typical children, sensory problems have been associated with aggressive and externalizing behavior problems. Similarly, recent studies have been found correlations between sensory problems and broadly defined externalizing problem behaviors in autistic children. However, research has yet to specifically examine the potential contributing role of sensory problems in predicting physical aggression.

Self-injurious behavior also appears to be relevant to the occurrence of aggression. Individuals with autism are at an increased risk for demonstrating self-injurious behaviors, as compared to those without autism, with prevalence rates ranging from 30% to 53%. Although self-injury and other forms of challenging behaviors have been considered to be distinct forms of behavior, they are often related. For example, physical aggression and self-injury have been significantly associated among individuals with severe intellectual impairment and there is evidence that self-injurious behaviors are precursors of later aggression in this population. However, similar studies have not investigated the relationship between self-injury and physical aggression in autistic children.
Lastly, gastrointestinal (GI) problems may also have relevance to the occurrence of aggression. GI problems are common in autistic children, with prevalence rates ranging from 24% to 70% or higher, depending on symptom definitions. Although there some evidence of an association between behavior problems and GI problems, a population-based study of autistic children did not find significant differences in aggression when comparing children with and without GI problems.
    Predictors
Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with autism. Consequently, it is unclear whether findings from the general population are applicable to autistic children and adolescents. In an effort to investigate the extent of the problem in children and adolescents with autism, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with autism. The results also indicate that age-related decreases in aggression in autistic children are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with autism.
In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with autism. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that autistic children who demonstrate self-injury may be at risk for more severe behavioral problems.
Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with autism, indicating may underlie (and exacerbate) aggressive behavior patterns for many autistic children. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.
Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.
Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.
In regards to potential sex differences, the results indicate that girls and boys with autism were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without autism, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the autistic population.
Implications
This study provides evidence that challenging behavior may be much more prevalent among children with autism than in the general population and that some comorbid problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the autism phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in autistic children. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of autism. Programs for children with autism should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. 

Behavioral interventions, particularly those based upon applied behavior analysis (ABA), have long had empirical support for addressing problematic behavior (for a review, see Schreibman, 2000). A comprehensive treatment plan for treating aggressive behaviors in children with autism begins with a precise and thorough assessment, followed by implementation of a comprehensive treatment plan.
Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention. It is important to take the time to analyze these underlying causes of aggressive behavior in children with autism. By understanding the triggers of aggression, we are able to choose the most effective intervention strategies. Once we understand the function or goal of student behavior, we can begin to teach alternative replacement behavior and new interaction skills. 

Further research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with autism.  
References and Further Reading

Cervantes P, Matson JL, Tureck K, Adams HL. The relationship of comorbid anxiety symptom severity and challenging behaviors in infants and toddlers with autism spectrum disorder. Research in Autism Spectrum Disorders. 2013;7(12):1528–1534.
Chazin, K.T. & Ledford, J.R. (2016). Challenging behavior as communication. In Evidence-based instructional practices for young children with autism and other disabilities. 
Farmer C.A. & Aman M. G. Aggressive behavior in a sample of children with autism spectrum disorders. Research in Autism Spectrum Disorders. 2011;5(1):317–323.
Farmer, C., Butter, E., Mazurek M.O, et al. Aggression in children with autism spectrum disorders and a clinic-referred comparison group. Autism. 2015;19(3):281–291.
Farmer C, Butter E, Mazurek M.O, Cowan C, Lainhart J, Cook E.H, & Aman M. Aggression in children with autism spectrum disorders and a clinic-referred comparison group. Autism. 2014
Fitzpatrick, S. E., Srivorakiat, L., Wink, L. K., Pedapati, E. V., & Erickson, C. A. (2016). Aggression in autism spectrum disorder: presentation and treatment options. Neuropsychiatric disease and treatment12, 1525–1538.
Healy O., Lydon S., Holloway J., Dwyer M. (2014). Behavioral interventions for aggressive behaviors in autism spectrum disorders. In: Patel V., Preedy V., Martin C. (eds). Comprehensive Guide to Autism. Springer, New York, NY
Hill, A. P., Zuckerman, K., Hagen, A. D., Kriz, D., Duvall, S., Van Santen, J., ... Fombonne, E. (2014). Aggressive behavior problems in children with autism spectrum disorders: Prevalence and correlates in a large clinical sample. Research in Autism Spectrum Disorders8(9), 1121-1133. 
Hodgetts, S., Nicholas, D., & Zwaigenbaum, L. (2013). Home sweet home? Families’ experiences with aggression in children with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 28(3), 166-174.
Kaartinen M., Puura K., Helminen M., Salmelin R., Pelkonen E., & Juujärvi P. (2014). Reactive aggression among children with and without autism spectrum disorder. J Autism Dev Disord., 44(10):2383–2391
Kanne, S. M., & Mazurek, M. O. (2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disorders, 41(7), 926-937.  
Love, J.R., Carr, J. E, & LeBlanc, L.A. (2009).Functional assessment of problem behavior in children with autism spectrum disorders: a summary of 32 outpatient cases. J Autism Dev Disord., 39(2):363–372. 
Mayes, S.D., Calhoun, S.L., Aggarwal, R., Baker, C., Mathapati, S., Anderson, R., & Petersen C. (2012). Explosive, oppositional, and aggressive behavior in children with autism compared to other clinical disorders and typical children. Research in Autism Spectrum Disorders. 6:1–10
Pugliese, C. E., Fritz, M. S., & White, S. W. (2015). The role of anger rumination and autism spectrum disorder–linked perseveration in the experience of aggression in the general population. Autism19(6), 704–712.
Schreibman, L. (2000), Intensive behavioral/psychoeducational treatments for autism: research needs and future directions. J Autism Dev Disord., 30(5):373-378.
Shea, S., Turgay, A., Carroll, A. et al. (2004), Risperidone in the treatment of disruptive behavioral symptoms in children with autistic and other pervasive developmental disorders. Pediatrics, 114(5):634-641.
Tremblay, R.E., Nagin, D.S., Séguin, J.R., Zoccolillo, M., Zelazo, P.D., Boivin, M., et al. (2004). Physical aggression during early childhood: Trajectories and predictors. Pediatrics, 114(1):e43–e50.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.

Williams, D. L., Siegel, M., Mazefsky, C. A., & Autism and Developmental Disorders Inpatient Research Collaborative (ADDIRC). (2017). Problem behaviors in autism spectrum disorder: Association with verbal ability and adapting/coping skills. Journal of Autism and Developmental Disorders.

Lee A. Wilkinson, PhD is a licensed and nationally certified school psychologist, chartered psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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