As individuals with autism age out of the educational system, families are faced with a number of challenges. Maladaptive behavior, in particular, can be a significant stressor for families of adults with Autism Spectrum Disorder (ASD). While estimates of the prevalence of problem behavior vary considerably, it tends to be more common in individuals with ASD relative to other disorders. Common topographies of problem behavior include aggression, self-injurious behavior, property destruction, ritualistic behavior, disruption, and inappropriate vocalization, as a few examples. While procedures for assessment and treatment for these kinds of problem behavior are well-established in the behavioral literature, the adult population presents unique challenges for families and care providers.
Functional Assessment of Problem Behavior
Functional assessment is an important first step in the effective treatment of maladaptive behavior. Functional assessment represents a collection of procedures used to determine the environmental factors that cause and maintain maladaptive behavior. Functional assessments may include indirect assessment procedures (e.g., questionnaires and structured interviews), descriptive assessment (e.g., collecting observational data related to the antecedents and consequences of maladaptive behavior), and functional analysis (e.g., hypothesis testing and the manipulation of environmental variables).
Over the last several decades, a robust literature validating the effectiveness of functional assessment has emerged. The literature has shown that these assessment procedures are effective for identifying the function of maladaptive behavior and that treatments based on these procedures are more effective than treatments that are selected arbitrarily (Pelios, Morren, Tesch & Axelrod, 1999). While the literature validating the effectiveness of these procedures is clear, assessing the maladaptive behavior of adults with autism presents unique challenges as compared to assessment with younger populations. Some of these challenges are highlighted below.
Legislation – Perhaps one of the most significant barriers for older individuals with autism is the fact that legislation mandating the use of functional assessments only extends to individuals up to age 21. As a result, adults diagnosed with autism are not entitled to the same behavioral supports as their younger counterparts. Consequently, adults diagnosed with autism have fewer opportunities to have sound functional assessments conducted, which can lead to poorer outcomes over time.
Cost of services – Providing services for adults with autism spectrum disorders represents a substantial economic expense for families and government agencies (Cimera and Cohan, 2009; Ganz, 2006; Järbrink, McCrone, Fombonne, Zanden, & Knapp, 2007). It has been estimated that it costs approximately $3.2 million dollars to financially support an autistic person over their lifetime (Ganz, 2006). With limited funds available, assessment and treatment practices are more likely to use less thorough models of assessment and treatment which require less time, money and other resources.
Lack of qualified staff – Another significant challenge is the lack of available trained staff with experience working with adults with ASD. Many staff members tasked with assessment and treatment plan development lack the necessary training to do so effectively (Sigafoos, Roberts, Couzens, & Caycho, 1992; Wood, Luiselli, & Harchik, 2007). This gap in the availability of well-trained professionals can lead to poorly designed assessment and treatment.
Severity of the maladaptive behavior – Another barrier to effective assessment and treatment is the severity of the behavior being treated in adults. Adults with autism often engage in challenging behavior that is considerably more intense in comparison to that of the behavior of their younger counterparts. The risk of injury may deter staff members from running sound functional assessments despite the empirical support for their use.
Concern with running traditional functional analyses – While traditional functional analysis represents the most accurate way to determine the function of the behavior, it is also the most intrusive and time-intensive assessment method. Furthermore, there is a concern that this kind of assessment involves the evocation of maladaptive behavior, which increases risk to the learner and the staff who are conducting the assessments.
Complexity of challenging behavior in adults – Intervening with challenging behavior in adult populations with autism tends to be more labor-intensive and difficult, in that it tends to be more complex. Maladaptive behavior that has occurred over the course of many years may be controlled by many different factors and have multiple forms, which can increase the difficulty and the duration of the assessment and intervention process.
These concerns often lead to the use of less intrusive, yet less empirically sound modes of assessment. The use of less supported methods of assessment increases the likelihood of errors occurring in the assessment process, which in turn, compromises the subsequent effectiveness of interventions and worsens outcomes for the adult ASD population.
Assessment Solutions
In light of these challenges, there have been a number of less intrusive assessment variations that may be of particular use for older learners exhibiting challenging behavior. These procedural variations include: AB models of functional analysis, trial-based functional analysis, and the functional analysis of precursor behavior.
AB models of functional analysis – AB models of functional analysis involve manipulating the settings or antecedents for problem behavior and observing the effect on the occurrence of the behavior. For example, a practitioner may expose a student to low levels of attention (e.g., acting distracted) or presenting difficult demands (e.g., a math worksheet) and then observe the effects on problem behavior. These manipulations may provide valuable information about what triggers and maintains problem behavior. For instance, if an individual engages in problem behavior when presented with demands, but does not engage in the absence of demands, it suggests that escape may be the function of the behavior. The outcome data recorded from this type of assessment is comparable to traditional functional analyses and has been shown to be empirically sound (Freeman, Anderson, & Scotti, 2000; Anderson & Long, 2002).
Trial-based models of functional analysis – Trial-based models of functional analysis involve running extremely brief sessions (e.g., 1-2 minutes) and only reinforcing the first instance of the maladaptive behavior. This method of assessment has garnered empirical supported and has been shown to correspond well with traditional functional analysis (Bloom, Iwata, Fritz, Roscoe, & Carreau, 2013; LaRue, Lenard, Weiss, Bamond, Palmieri, Kelley, 2010). In addtiion, this assessment method reduces the overall occurrence of maladaptive behavior, thus mitigating concerns about evoking and reinforcing maladaptive behavior.
Functional analysis of precursor behavior – Precursor models of assessment generally involve conducting a functional analysis for a less severe problem behavior that reliably precedes the more severe challenging behavior. For example, if inappropriate vocalizations were to occur immediately prior to aggression, conducting a functional analysis of the vocalization may yield information about the function of the aggression without actually evoking it. Precursor models of assessment have garnered empirical support for their use (e.g., Smith & Churchill, 2002) and may be particularly useful for limiting the occurrence of problem behavior during the assessment process.
Intervention Strategies for Adults with Autism Spectrum Disorders
Broadly speaking, best-practice interventions can occur at one (or more) of three points along the ABC sequence of problem behavior described above: doing something to the environment before the behavior happens, training an alternative behavior to replace the maladaptive behavior, or changing what happens after the behavior has just occurred. It bears repeating that the implementation of all of these strategies either require or are greatly enhanced by an accurate understanding of the function of the maladaptive behavior in question, which may be determined through functional assessment techniques. The bottom line is that better assessments permit better treatments.
Antecedent-based strategies – Techniques that modify the environment prior to the occurrence of a behavior in order to prevent that behavior from occurring are known as antecedent-based strategies. These techniques may include providing access to preferred items/activities or breaks from task demands on a schedule, independent of the occurrence of the maladaptive behavior in order to reduce an individual’s motivation to engage in problem behavior. This procedure, referred to as noncontingent reinforcement (NCR), has been shown to be effective in reducing problem behavior in individuals with autism (Vollmer, Iwata, Zarcone, Smith, & Mazaleski, 1993), and may be effectively combined with other behavioral interventions.
Antecedent-based strategies are a particularly important tool in the treatment of problem behavior in adults with ASD. As noted previously, older individuals with ASD may be capable of extremely dangerous and harmful actions as compared to the capabilities of children. As the saying goes, an ounce of prevention is worth a pound of cure. However, the use of strategies like NCR require the presence of an adequate number of well-trained staff to ensure that the schedule is followed correctly and consistently.
Functional Communication Training (FCT) – FCT is an intervention strategy that involves teaching an individual to use an adaptive response to take the place of problem behavior (Carr & Durand, 1985). FCT consists of providing the individual with a means of accessing preferred items and activities in an easy and effective way (e.g., using a touch card, sign language, or an augmentative communication device). The unique appeal of FCT is that it leads to the acquisition of a new functional skill. This means that the benefits that are observed following FCT are more likely to result in enduring change, and may prevent the emergence of future maladaptive behavior. One special consideration in the use of FCT is that the behavior under treatment may have a long history of reinforcement, and therefore may persist even after the new alternative response has been trained.
Consequence-based strategies – The last category of interventions are those which alter the outcomes produced by the behavior in a way that make the behavior less likely to happen again in the future. Consequence-based strategies may include breaking the relationship between a behavior and the outcome that has previously been associated with it, known as extinction, and may also include adding or removing something from the individual’s environment which makes the problem behavior less likely to occur in the future, referred to as punishment.
It is important to note that, in many cases, these interventions may be combined in a way that improves their effectiveness for addressing problem behavior. For example, when attempting to treat problem behavior through the training of a new adaptive communicative request with FCT, it can be advantageous to have problem behavior contact extinction. This effectively creates a scenario where the new response “works” and the old one does not, which can increase the speed at which the desired behavioral change occurs.
When intervening with adults with ASD in particular, the risks of implementing extinction may be prohibitive. Under these circumstances, practitioners need to emphasize the use of preventative procedures and FCT to address challenging behavior. Identifying strategies for decreasing maladaptive behavior without the use of extinction represents an important area in need of research.
In conclusion, as rates of autism diagnosis continue to rise, more and more adults on the spectrum will be in need of effective assessment and treatment procedures. Despite the fact that the majority of the related literature reflects the needs of children with autism, some helpful insights regarding working with the adult population have emerged. Assessment strategies, such as AB analyses, trial-based functional analyses (FA), and precursor FAs, represent empirically-sound assessment procedures that may limit the risks associated with challenging behavior in older populations. Relatively little research has investigated treatment issues as specific to individuals with ASD. Preventative strategies, replacement skills (FCT) and extinction all remain key components in designing effective interventions for this population. In cases in which extinction is not a viable option, practitioners must increase emphasis on other preventative treatment components to keep people safe.
There exists a troubling gap in state of assessment and intervention for older individuals with ASD. Failure to identify viable solutions for this population can lead to poor outcomes, including more intrusive interventions, more restrictive placements, and an increased likelihood of psychotropic medication use. The assessment and treatment approaches outlined above provide an important starting point in the development of a comprehensive model of care for this rapidly growing population.
Ethan Eisdorfer, MA, and Mikala Hanson, BA, are doctoral candidates at the Graduate School of Applied and Professional Psychology (GSAPP) at Rutgers University and Robert H. LaRue, PhD, BCBA-D, is Director of Behavioral and Research Services at the Douglass Developmental Disabilities Center at Rutgers, The State University of New Jersey. For more information, please contact Robert LaRue, PhD, BCBA-D, at (848) 932-4500 or larue@scarletmail.rutgers.edu.
References
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