Managing behavioral problems in children and young people with ASD

Behavioral disturbances in children and young people with autism spectrum disorder (ASD) are one of the aspects that most concern both professionals and family members , not only because of the difficulties present when intervening, but also because of the discomfort they can generate.

These disturbances are a "set of learned, culturally inappropriate behaviors that, depending on their intensity, duration, and frequency, and their impact on the person and the environment, generate a significant limitation in their learning and social inclusion, and put their physical integrity or that of others at risk" (Emerson, 1995). They can also be defined as "adaptive responses to the person's environment, which often constitute a means of communication" (Carr, Horner, & Turnbull, 1999, 2000). Furthermore, Tamarit (2011) defines behavioral disturbances as "the expression of the interaction of the person with their physical, social, and cultural environment, understanding that the behavior is not a problem of the individual but something that affects the context and challenges it to propose responses that promote appropriate behaviors."

In short, behavioral problems should always be understood from a biopsychosocial model , which takes into account that they are produced by the interaction of the person's personal and psychological characteristics with the environmental conditions in which they develop.

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In the case of children and young people with autism spectrum disorder (ASD ), school is one of the places where behavioral problems are most likely to arise . This is because it is often a highly sensory environment with constantly changing activities, where learning and materials are often not focused on the interests of children and young people with ASD, where continuous mental effort is required, and where many social situations occur that are often unrewarding in their interactions with other children and young people (Hervás & Rueda, 2018). All these aspects, related to environmental conditions, interact with the socio-, cognitive, sensory, and emotional characteristics of individuals with ASD and can produce serious behavioral problems.

Intervention in behavioral disorders

When addressing behavioral problems, we must distinguish between two aspects of behavior: form and function. What we observe in these problems is how they manifest, but it is essential to understand their function. If we don't intervene considering this function—the underlying cause of the behavior—our intervention could be flawed and ineffective. To understand the function of inappropriate behaviors in individuals with ASD, many tools can help us, such as interviews, questionnaires, and other methods and records of direct observation (ABC charts or scatter plots ). The results obtained using these tools, always keeping in mind the specific characteristics of autism spectrum disorder, will provide the starting point for effective intervention in the behavioral problems of children and young people with ASD.

Regarding intervention , it is usually based on the consequences of the behavior; that is, the intervention occurs after a behavioral problem has arisen. This approach leads to a "negative" perception of the behavior, considering that "the person with behavioral problems is a problem" (because they do it on purpose, so I punish or threaten them), provoking feelings of anger or defiance. A shift in perspective is necessary, recognizing that "the person with ASD who exhibits behavioral problems has a problem." This changes our thoughts, behaviors, and feelings toward the child or young person exhibiting these behavioral problems (because they feel frustrated, discouraged, or have no other way to cope, I must support, encourage, and teach them functionally equivalent alternative behaviors so they can achieve what they want or need).

One of the most effective ways to bring about this change is through intervention based on the principles of positive behavioral support , an evidence-based intervention model that posits that:

• Problematic behaviors are directly related to the context in which they occur.
• Problematic behaviors have a very specific function for the person who exhibits them.
• The most effective interventions are based on a deep understanding of the person, their social contexts, and the function that their problematic behaviors perform in these contexts.
• Interventions should be based on values that respect the dignity of the person, their preferences, and their individual goals.

Positive behavioral support plans should have the following characteristics (Diputación Foral de Álava, 2011):

• Based on a functional assessment.
• Include multiple interventions.
• Be proactive .
• Emphasize lifestyle improvements.
• Reflecting people-centered values.
• Be applicable in common environments.
• To pursue the reduction of problematic behavior, the improvement in the use of alternative skills, and the improvement of quality of life.
• To be structured within the framework of person-centered planning.

Intervention strategies

Some evidence-based intervention strategies that can be included in positive behavioral support plans for children and young people with ASD with behavioral disturbances are:

Proactive intervention strategies based on context:

• To provide an autism-friendly environment that allows children and young people with ASD to develop in the most positive, productive, and autonomous way possible.
• Respect the sensory, proprioceptive, and vestibular characteristics of people with ASD.
• Simplify and disambiguate the language, facilitating explicitness.
• Facilitate anticipation by creating an environment that is as predictable and clear as possible (using visual schedules and timetables) and preparing for transitions.
• Organize and structure tasks and activities, respecting the visual thinking of people with ASD.
• Avoid cognitive overload by eliminating unnecessary demands and facilitating accessibility.
• Organize and structure the space in relation to people, activities, and objects.
• Organize and structure time.
• Remove or modify problematic events, and, if that is not possible, intersperse them with pleasant ones or minimize their impact.
• Adjust the environment, reducing factors of hyperexcitation or dysregulation and using distractions that help to create a more positive and balanced state.

Proactive intervention strategies based on teaching alternative skills:

• Make use of alternative and augmentative communication systems whenever necessary.
• Encourage the use of functionally equivalent alternative behaviors.
• Explicitly work on aspects related to social cognition (social stories, visual aids and reminders).
• Facilitate self-regulation strategies.
• Use visual rules and clear limits, explicitly stating what can be done.

Consequence-based intervention strategies:

• Use behavior modification techniques for the enhancement, refinement, and maintenance of behaviors (reinforcement, shaping, chaining, and fading of help), whenever possible.
• Avoid using techniques for reducing and eliminating behaviors, such as punishment, since many times the person is not aware of their behaviors.
• Make use of extinction of problematic behaviors, always accompanied by differential reinforcement of incompatible and alternative behaviors to reduce unwanted behavior.
• Use combined techniques such as token economies, behavioral contracts, or training in self-instruction, self-control, and problem-solving.

Intervention strategies based on lifestyle improvement:

• Adaptations in quality of life (relationships, choice and control, preferred activities and inclusion).
• Maintenance strategies.

Often, despite using the strategies mentioned, difficult situations may arise that will need to be addressed through the use of reactive strategies to respond to the crisis.

Therefore, it is important:

• To provide proper verbal support.
• Increase personal space and change environmental stimuli.
• Use, if necessary, psychopharmacological treatment, always prescribed by the corresponding physician.