Preventing and Addressing Challenging Behavior in Children with Autism

1. Preventing and Addressing Challenging Behavior in Children with Autism Glen Dunlap and Phil Strain Presented at the 2009 OSEP Early Childhood Conference

2. www.challengingbehavior.org

3. Purpose of Presentation • Describe issues related to problem behaviors and ASD • Present a multi-tiered model of prevention • Discuss implications for practice

4. Agenda • Introduction • Autism and Challenging Behavior • Changing Perspectives • A Model of Prevention • Implications, Directions and Conclusions

5. 4 Main Messages • The best way to address challenging behaviors of children with autism is with a multi-tiered (hierarchical) framework of prevention and intervention • A sensible and effective (evidence-based) approach to intervention is positive behavior support • Families are essential elements of children’s lives, and are deeply affected by challenging behaviors and by interventions* • A vital challenge is to help systems (e.g., schools) establish responses to ASD, and challenging behavior, that are: (a) fully incorporated into the system, (b) effective, and (c) sustainable

6. Autism Spectrum Disorder(s) • A diverse syndrome involving problems with the development of communication and social relatedness… as well as restricted interests and perseverative and stereotypical patterns of behavior • ASD encompasses a great range of abilities and disabilities • For instance, some children with ASD have very serious risks for challenging behavior; others have relatively mild risks

7. Challenging Behaviors • Destructive Behaviors • Aggression; SIB; Property Destruction • Disruptive Behaviors • Long tantrums; Loud, Repetitive Noises; Running, etc. • Irritating & Interfering Behaviors • “self-stim;” repetitive and perseverative speech or actions, etc. • Social Withdrawal • Lack of responsivity and initiations

8. Importance of Challenging Behaviors • Barrier to Inclusion, Community Participation, and Social Opportunities • Most Significant Impediment to Education • Present Physical & Emotional Risk for Individual and for Families, Teachers, Other Professionals, Peers and Friends --------------- • Need to Prevent/Resolve Challenging Behaviors as Early and as Thoroughly as Possible

9. It is important to appreciate that challenging behaviors seriously detract from: • all aspects of social/emotional/intellectual development • opportunities and quality of life of children • quality of life of the children’s family members….

10. Some Changing Perspectives on Autism and Challenging Behaviors

11. Early (1st Generation) Perspectives • Challenging Behaviors are “part of autism” • Not “diagnostic”, but “characteristic” • Intervention = contingency management • Largely reactive • Reinforcement (DRO) for desired behavior (or absence of problem behavior) • Time out, extinction, or punishment for problem behavior

12. 1st Generation Effects • Often, short-term beneficial effects • But usually without maintenance or generalization • Occasionally ineffective, leading to escalating intensity of rewards and negative consequences

13. Changing (2nd Generation) Perspectives • Challenging behaviors are not “part of autism” • Challenging behaviors: (1) are maladaptive ways of responding to inadequacies in the environment, (2) occur due to lack of socially-adaptive skills for controlling environment • Children with autism are at high risk for developing challenging behaviors due to difficulties with learning, communication, and perception

14. Changing Perspectives (continued) • Intervention involves PREVENTING problem behaviors from developing or occurring by: • Arranging the environment so that challenging behaviors are unnecessary (and desired behaviors are encouraged), and • Teaching skills needed to navigate and control the social environment

15. 3rd Generation Challenges • Developing Strategies for Incorporating Effective Prevention Practices into the Systems that Affect our Service Delivery

16. Multi-tiered Prevention Frameworks • Increasingly common (e.g., community health; school-wide PBS) • Basic framework has 3 levels: 1) Universal strategies (primary prevention)--- for everybody; low intensity prevention practices 2) Targeted strategies (secondary prevention) --- for particularly high risk groups; higher intensity 3) Indicated strategies (tertiary prevention/ intervention)--- for individuals already affected by problem; usually intensive and individualized strategies

17. LEVEL 3: Individualized Intensive Interventions Preventing Challenging Behavior for Children with ASD LEVEL 2: Building social and communicative competencies inconsistent with challenging behavior LEVEL 1: Building positive relationships, supportive environments, and healthy physiologies

18. Prevention – Universal (Level 1) • Positive Relationships • Nurturing, caring, secure • Enhances influence of adult caregiver • Physical and Emotional Health • Physical health and nutrition • Social-emotional well being • Safe, responsive, “friendly” and stimulating environment

19. Prevention – Level 1 Practices • Adult-child interactions • Positive attention • Organized environment • Structure, routine, schedule • A comprehensible environment • Instruction • Useful communication • Social skills • Clear, consistent behavioral expectations

20. LEVEL 3: Individualized Intensive Interventions Preventing Challenging Behavior for Children with ASD LEVEL 2: Building social and communicative competencies inconsistent with challenging behavior LEVEL 1: Building positive relationships, supportive environments, and healthy physiologies

21. Level 2 Prevention Practices • Differences from Level 1 Practices • Intensity of Intervention • Planfulness of Intervention • Intensity of Data Collection • Intensity of Family Involvement • For children at risk for challenging behavior: • Parent training classes • Social-emotional teaching curricula

22. Building Functional Competencies • Interventions focused on teaching and building appropriate engagement • Intervention supports for enhancing motivation • e.g., Pivotal Response Training • Group strategies (classroom models) with direct focus on teaching and motivating social interaction • e.g., LEAP; Project DATA; Walden

23. “Active” Engagement Is Key Rethinking Story Time and the “Dead Person”

24. “Active” Engagement Is Key Rethinking Circle and the “Dead Person”

25. “Active” Engagement Is Key Rotations and Novelty Centers Toys Materials

26. “Active” Engagement Is Key • Books as the Glue • The Three Little Pigs go to: • Art Activity • Circle • Free Play • Transitions

27. Reinforcer Assessment Is The Pivotal Assessment • Developmental assessment and wasted time and money • Conducting Reinforcement Assessments • Caregiver interview • Observation as a check • Paired comparisons • Choosing from the hierarchy • Repeated assessments

28. Keeping To A Routine Is Insufficient Routine For Many • Routine = Redundancy • Routine = Restricted Stimuli • Routines within Routines (Circle Example)

29. Circle Time Routine Opening Song • Child passes out prop • Sing song • Child collects prop

30. Circle Time Routine Calendar • Clap out month • Sing Days of the Week song • Count to today with motor movement • Review the pattern

31. Circle Time Routine Child Choice Song • Child chooses song from 3-4 options • Props, Materials and/or Motor Movement are utilized with every song.

32. Circle Time Routine Center Choices • Adult holds up name cards • Children come up and choose a Center • Children go off to play

33. Keeping To A Routine Is Insufficient Routine For Many • Routines should help provide answers to these key questions. • What am I doing now? • Where am I in the Routine? • How do I know when I’m finished? • What comes next?

34. LEVEL 3: Individualized Intensive Interventions Preventing Challenging Behavior for Children with ASD LEVEL 2: Building social and communicative competencies inconsistent with challenging behavior LEVEL 1: Building positive relationships, supportive environments, and healthy physiologies

35. Level 3 Practices - Intensive Individualized Interventions • Are used for children with persistent and severe challenging behavior • Are used when children do not respond to preventive practices, child guidance procedures (e.g., redirection), or social-emotional teaching strategies • Children with multiple, severe risk factors • Intellectual-Communicative Disability (e.g., autism) • Exposure to substances, violence, depression, poverty, etc., etc.

36. Positive Behavior Support Level 3 procedures for children with serious challenging behavior

37. Level 3 - Positive Behavior Support • An approach for resolving challenging behaviors that is based on person-centered values, empirical data and a multi-disciplinary scientific orientation • A pragmatic, data-based problem-solving approach for enhancing development and improving quality of life in natural, everyday contexts • A preventative approach emphasizing teaching and environmental redesign

38. PBS – Components • Team-building, Goal Setting • Person-Centered Planning • Functional Assessment of Challenging Behavior • Individualized Behavior Support Plan • Implementation • Evaluation

39. Core Elements of a Behavior Support Plan Level 3 - PBS (Linked to Assessment Information) Prevention Strategies – Arrangements of antecedent environment Teaching Strategies – Building skills to teach throughout the day to replace the challenging behavior Reinforcers – Providing effective reinforcement schedules (note --- this is the contingency management component) ----------------- + Evaluation strategies

40. Evaluation • All support plans should have some form of evaluation, so team knows if plan (or parts of a plan) is working as intended • Evaluation can focus on desired outcomes AND on extent to which elements of plan are being implemented • Evaluation should NOT be complicated or effortful, but it should be valid…and valued

41. Summary and Conclusions

42. Closing Messages • Preventing and resolving challenging behaviors is extremely important…. • Because of the implications for the quality of life of individual and all those who are close to the individual • Because of opportunities that can be compromised if challenging behaviors persist

43. Implications of the Prevention Model • Some children with ASD will respond well to high quality implementation of Level 1 (universal) procedures • Some additional children with ASD will respond well to high quality implementation of Level 2 procedures • The remaining children with ASD will require implementation of Level 3 procedures

44. The proportion of children with ASD who require some Level 3 procedures may be high, but we can presume that the implementation of high quality Level 1 and 2 procedures will mitigate the intensity with which the Level 3 procedures need to be implemented.

45. What We Need to DO • Early Identification --- because autism presents so many risk factors • Provide ALL identified children/families with supports for Level 1 prevention strategies • Provide ALL child care and pre-K classrooms with supports for implementing Level 1 prevention strategies

46. Need to Do (continued) • Disseminate the rationale and logic of the multi-tiered prevention framework as well as specific procedures associated with all levels. • Conduct research to validate and refine prevention model

47. What We Need To Do • Provide for training and direct technical assistance so that all children/families have access to effective supports in designing and implementing PBS plans • In early intervention programs • In schools • In community agencies • For initial implementation and for ongoing support and evaluation

48. Develop, evaluate and disseminate standardized models of PBS to enable large numbers of school practitioners to implement strategies with sufficient fidelity to be effective