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Addressing Setting Events to Make Behavior Plans More Effective for Individuals with Autism Spectrum Disorders

Challenging, disruptive, and potentially dangerous behaviors frequently are a concern for caregivers and family members of individuals with Autism Spectrum Disorders (ASD). In recent years, the methodology of Functional Behavior Assessment (FBA) has come to be recognized as one of the most effective means of addressing these behaviors (Carr, 1994). The technology of this approach has been developed through the efforts of practitioners working under the Positive Behavior Supports (PBS) model, building on research that has grown out of the scientific endeavors of Applied Behavior Analysis (ABA).

What this approach has come to show is that even behaviors that look the same to a casual observer (physical aggression, self-injury, destruction of objects) may actually be quite different depending on who performs the behavior, what setting it occurs in, and a variety of other conditions or circumstances. For example, self-injury exhibited by one person might be motivated by escape from a task demand, while another person might be motivated by an effort to alleviate pain or discomfort. Through systematic analysis, behavioral scientists have been able to identify circumstantial factors that help in understanding what influences the motivation and/or meaning of the behavior for the person the individual (Wacker et al., 1990).

The value of this approach is that researchers have come to recognize that effective intervention strategies need to be individualized and based on the function. This involves adapting behavior plans based on recognition of the identified needs and using that insight, first to focus on meeting those needs in order to prevent problem behavior. Once this has been accomplished, efforts are directed to teaching and supporting the development of more positive alternative behaviors that meet the same needs. In this way, behavior specialists have the opportunity to individualize the development of behavior intervention and support plans, much in the way that clinicians individualize the treatment of mental health disorders based on the feelings and past experience of the patient.

Since most individuals who engage in problem behavior either don’t know or can’t communicate why they engage in the behavior, it is necessary for support providers to assess the behavior in order to determine the function of the behavior. This is true both for individuals with strong cognitive skills, as well as those who have some degree of intellectual disability, because most of us are not very good observers of ourselves. In order to do this objectively and effectively, researchers have demonstrated that in most cases, the function of a behavior can be discovered by identifying the typical antecedents that immediately precede the behavior, and the consequences that typically follow these the behavior (Carr, 1994). The circumstances that precede the behavior are considered to serve as triggers for the behavior, while the conditions that follow the behavior have come to be understood as rewarding, or in behavioral terms, reinforcing the behavior. The reinforcement occurs because the outcome of the behavior either meets a felt need, or provides some type of physical, social, or emotional pleasure or satisfaction. A cornerstone of behavior intervention involves developing an understanding of the various factors that help to explain why the problem behavior occurs. This includes the identification of: (a) the settings events, described below, (b) the antecedents, which specifically cause the behavior to occur, (c) an operationally defined problem behavior, and (d) an outcome or consequence that results from the behavior, which the person finds rewarding and motivates them to engage in the behavior again. These four elements are sometimes are referred to as the “four-term contingency.”

For example, an individual may be prompted to perform a task s/he does not wish to complete, and they may respond by engaging in problem behavior. When the caregivers shift their attention to managing the behavior, it may be difficult to follow through on efforts to get the person to complete the task. If the individual does not complete the task, the behavior is reinforced by the individual’s escape from the demands. Researchers have identified a variety of other functional patterns in addition to escape, which include: gaining or avoiding social attention, gaining access to items or activities the individual desires, and creating patterns of sensory stimulation that are satisfying or comforting (Carr, 1994).

Accurate identification of these functions often leads to individualized strategies, and when these are applied systematically, proactively, and in conjunction with a wide array of educational and other support programs, can make a tremendous impact on effectively reducing the frequency and severity of problematic behaviors, and supporting more positive behavioral alternatives. One challenge in applying these strategies with individuals who have ASDs though, is that characteristics of the ASD may serve to increase the likelihood that the individual will engage in a particular behavior.

This type of influence on behavior would be classified as a setting event. These are conditions which alter what a trigger or stimulus means to the person (e.g., a reinforcer is more available), or influence the attitude, capacity, or need that a person brings to the circumstances in which a behavior may occur. While the antecedents and setting events both precede problem behavior, setting events do not trigger problem behavior by themselves. Rather, setting events can increase the likelihood that an antecedent will trigger problem behavior, either by putting the person in a state that makes the behavior more likely, or cuing the individual that an outcome they desire is available. Research has shown that setting events can include environmental conditions, social influences, or physiological factors. Examples of common environmental setting events for individuals with ASD include disrupting a person’s routine, and/or being in a situation that he or she is unable to predict upcoming events. Social setting events may include being left alone for a period of time or fighting with a family member or roommate. Illness, pain, sleep deprivation, hunger and medication changes are just a few examples of internal factors that increase the likelihood of problem behaviors.

In some cases, the occurrence of a disorder, specific disability, or psychiatric illness may be considered a setting event for the occurrence of problem behavior. This is significant because psychotropic medications have the potential to alter an individual’s response to environmental stimuli. For instance, researchers have recommended that selection of psychotropic medications include consideration of specific pharmacological treatment effects on an individual’s response to environmental stimuli maintaining both adaptive and problematic behavior (Thompson & Symons, 1999; Schall & Hackenberg, 1994). This highlights an important concern regarding the relationship between functional assessment of behavior, function based behavioral intervention, and drug treatment.

These factors highlight a variety of concerns related to the impact of what would be considered setting events, on the development and implementation of effective behavior support plans for individuals with ASD. Several examples highlight this concern. First, many individuals with ASD have an unusual need or craving for specific types of sensory stimulation. Understanding the unique pattern of sensory needs and their relationship to problematic behaviors is an important factor in developing effective intervention and support strategies. The focus on setting events provides a means of making adaptations to proactively meet sensory stimulation needs part of a support plan designed to prevent the problematic behaviors.

A related consideration is the frequent co-occurrence ASD and anxiety disorders (White et al., 2009). The experience of anxiety, its impact on adaptive functioning, and the potential justification for diagnosis of a co-occurring disorder often are overshadowed by the symptoms and problematic behaviors that accompany an ASD. Appropriate identification of anxiety, and determination of the role this plays as a predisposing factor for problematic behavior, is an important factor in developing appropriate and effective supports. Specifying feelings of anxiety as a setting event would justify the inclusion of calming activities or relaxation exercises as a precursor intervention designed to prevent the problem behavior. Recognition of an anxiety disorder as a setting event would indicate that clinical intervention and treatment of that disorder should be identified as a prevention strategy for those problem behaviors. This kind of assessment of behavior and development of a Functional Behavioral Assessment hypothesis afford the opportunity both to recognize and address important factors that often are neglected in developing behavior plans, along with establishing a framework that facilitates the integration of behavior intervention and support planning with clinical intervention.

In addition to identifying environmental variables that precede and follow problem behavior, the functional assessment gathers information about an individual’s communication, social skills, and other aspects of adaptive functioning and circumstances. This information can be used to design interventions to teach the individual new skills effectively competing with a problem behavior. For instance, an individual may engage in disruptive behavior at school or work in order to avoid persisting on a difficult task. The functional assessment process may indicate that the individual does not know how to ask for assistance or how to complete the task. In other cases, an individual may have strong social and communication skills that are not being used in settings where problem behaviors are occurring. Information related to an individual’s social and communication skills will provide the foundation for selection and teaching of new, adaptive skills that may function to replace problem behaviors or reduce the motivation to perform them.

The clinician or behavior specialist who desires to work with individuals with ASD and who may be dually diagnosed should become familiar with the clinical literature regarding mental illnesses and their treatment. An understanding of psychiatric diagnoses and pharmacological treatments is extremely important in providing the most comprehensive and effective intervention and support. In the mental health literature, it has been noted that one of the most critical areas of support for families is information about mental illness, the impact it may have on behavior, and how these conditions can be treated. Valuable resources for obtaining such information can be found through the National Association for Dual Diagnosis, with a listing of resources on NADD’s website (www.thenadd.org). Care providers also need to know how the mental illness will likely affect the behavior of the person. In conclusion, we wish to highlight the need for consideration of the very nature of ASDs as a potential setting event for problem behavior. We encourage the creation of comprehensive functional assessments that consider both ASDs and potential anxiety disorders among persons with ASDs. Effective treatment of challenging behaviors requires thinking across various ways in which we as a field have looked at understanding problem behaviors.

 

Philip Smith, PhD, is Assistant Professor of Pediatrics and Project Manager of Community Positive Behavior Supports and Daniel J. Baker, PhD, NADD-CC, is Associate Professor of Pediatrics, both at The Boggs Center on Developmental Disabilities at Rutgers Robert Wood Johnson Medical School. For more information, please visit www.rwjms.rutgers.edu/boggscenter.

References

Carr, E. G.. (1994). Emerging Themes in the Functional Analysis of Problem Behavior. Journal of Applied Behavior Analysis 27, 393–399.

Schall, D. W., & Hackenberg, T. (1994). Toward a functional analysis of drug treatment for behavior problems of people with developmental disabilities. American Journal on Mental Retardation, 99, 123-134.

Thompson, T., & Symons, F. J. (1999). Neurobehavioral mechanisms of drug action. In N. A. Wieseler, R. H. Hanson, & G. Siperstein (Eds.), Challenging behavior of persons with mental health disorders and severe developmental disabilities (pp. 125-150). Washington, DC: American Association of Mental Retardation.

Wacker, D. P., Steege, M. W., Northup, J., Sasso, G., Berg, W., Reimers, T., Cooper, L., Cigrand, K., & Donn, L. (1990). A component analysis of functional communication training across three topographies of severe behavior problems. Journal of Applied Behavior Analysis, 23, 417-429.

White, S.W., Oswald, D., Ollendick, T., & Scahill, L. (2009). Anxiety in children and adolescents with autism spectrum disorders, Clinical Psychology Review, 29, Issue 3, 216–229.

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