Severe problem behavior at home: what the professionals look for first (audio overview)

A free audio overview for families, derived from Special Learning's course "Severe Problem Behavior" (presented by Jennifer LaLuzerne and Amanda Yeager). It is a synthetic voice, not a person, summarizing one session of the course; it is not the session itself.

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Episode notes

• Free tools and guides, no account needed: special-learning.com/free-resources
• The ABCs of Autism guide, free and written for families: store.special-learning.com/free-abcs-of-autism.html
• The full session, and the rest of the series, is in Special Learning's Video CE Library, written for professionals: special-learning.com/for-behavior-analysts

Transcript

This is a free audio overview from Special Learning. It's a synthetic voice, not a person, and it's summarizing one session of a training course. It isn't the session itself.

The session is called "Severe Problem Behavior." It's taught by Jennifer LaLuzerne and Amanda Yeager, who directed a clinic for adolescents with autism and wrote and supervised the behavior plans there. It was recorded for professionals. This overview is for the families living with what it describes, because they are the largest audience for it and the least often spoken to directly.

A word before anything else. The session covers behavior that hurts people. Aggression, self-injury, eating things that aren't food, and others. If that is your house, nothing here is a plan for your child. It's a description of how the people who do this work think, so the conversations you have with them make more sense.

The session begins with what severe problem behavior is: behavior that's dangerous to the person or to the people around them, or that causes extreme distress to the family. And it's honest about how common it is. In one study the presenters cite, about two thirds of children and adolescents with autism had shown aggression toward a caregiver. In another, roughly a third of the children had some form of self-injury. If you've felt alone with this, the numbers say you aren't.

Then comes the part of the session that families should hear even though it's hard. The presenters describe a study that followed forty-nine adults with developmental disabilities who had severe self-injury, and looked at them again eighteen years later. Most were receiving more services, and most were on more medication. And for more than eight in ten of them, the self-injury had not changed in form, frequency, or severity. The families reported smaller lives, with less access to the community and to other people. The presenters call this very concerning, and it's the reason the session exists. These behaviors don't usually fade on their own. They have to be worked on, deliberately, and the work is what the rest of the session is about.

The session then turns to how a behavior plan gets written, and the first idea is the one everything else rests on. Before anyone tries to stop a behavior, they need to understand what it does for the child. The session calls this the function. The same behavior, the same hitting or head banging, can be a way of getting out of something, a way of getting attention, a way of getting an object, or something the body does for its own sake. Two children can look identical and need opposite plans. The presenters say that writing a plan without this understanding is likely to be inefficient, ineffective, or even harmful, because the plan can accidentally feed the very behavior it's meant to reduce.

There's a formal way of finding the function that involves deliberately setting up situations to see when the behavior appears. The session is careful about it. It's a professional procedure, it's used as a last resort when the behavior is dangerous, and it has to be adjusted for safety. The presenters add a detail that matters for families whose child wears protective gear. In the studies they describe, the padding or helmet changed how often the behavior happened, which meant it could hide the function. So the gear kept the child safe and also made the picture harder to read. Both are true, and a good team plans for both, including how the gear will eventually be reduced.

The second idea is a rule the presenters state more than once. If you're reducing a behavior, you must teach something in its place. The behavior was doing a job. Take it away without giving the child another way to do that job and either the struggle continues or a new behavior appears, possibly a more dangerous one. The replacement has to do the same work, it has to be easier than the problem behavior at first, and other people have to be able to recognize it. Tapping a shoulder instead of pinching. A card or a sign or a word for "break" instead of dropping to the floor. The session's name for teaching this is functional communication training, and it calls it one of the most common and effective approaches there is.

Much of the middle of the session is about prevention, and this is the part a family can recognize from daily life. Making sure the child can communicate, whatever the method. A schedule the child can see, so a hard task doesn't arrive as a surprise and so the good part of the day is visible too. Breaks before frustration peaks, not after. A few easy asks before a hard one. Choices, even small ones, which the presenters say can work on their own and cost nothing. Tasks that are neither too hard nor so easy they're boring, because both can set things off. A timer, so the end of screen time is announced by a clock rather than by a person. And attention given freely for ordinary good behavior, not only in response to the bad.

The session also explains what happens when a behavior stops working. If hitting has gotten a child what he wanted for five years and one day it doesn't, the presenters say, he may hit harder or longer while he figures out that the rule has changed. They call this an extinction burst, and they say two things about it. It's the thing professionals warn parents about most. And the research they cite found it happened less often than people expect, and less often still when the child was being taught a replacement at the same time. That's the reason plans come as packages rather than single moves.

Then the session goes through specific behaviors, and a few points are worth carrying. For soiling, the first step the presenters name is a thorough medical check by a doctor, before any behavioral work. For eating non-food items, the session is blunt that the risk of serious harm may be higher than for other forms of self-injury, and that the older approaches once used are no longer the standard. For hair pulling and for rumination, the message is the same as everywhere else in the session: find out what the behavior is doing, because the answer decides the plan.

The session includes something rarer in a training course. Case studies from the presenters' own clinic where the plan didn't fully work, and they say so. A boy whose aggression got worse under a plan, with medication changes and other conditions in the mix. A teenager whose behavior fell during a medication change, where the presenters ask openly whether it was the plan, the medicine, or the fact that he was very tired, and say plainly that a tired child is not the quality of life they want. Another young person for whom a procedure that worked had to be stopped when the rules changed, and the behavior came back. The presenters don't hide any of this. For a parent who has watched a plan fail, that honesty is worth something.

One more thing the session raises, briefly, and this overview will match its brevity. Suicidal thoughts in adolescents and adults with autism are under-recognized, in part because a person may not be able to say what they're thinking. The presenters' point is only that families and professionals should keep watching, and take any talk of death seriously. That is a conversation for the professionals around your child, not for this recording.

Two things the session includes that this overview leaves out. The details of how staff are trained on the restrictive parts of a plan, and the specific procedures used in the case studies. Both belong to the people carrying them out under supervision, not to a summary.

The session closes on a sentence its own presenters repeat throughout: they can't say it enough that the plan has to fit the function. The words for these things differ between countries and services. What doesn't differ is that a behavior that hurts your child is doing something for your child, and the way out starts with finding out what.

This is general information for families, not clinical advice, and not a treatment recommendation for any individual child. If your child or anyone else is in immediate danger, contact your local emergency services.

If you want something to use today rather than something to buy, Special Learning's free tools and guides are at special-learning.com/free-resources, no account needed.

The full session, and the rest of the series, is in Special Learning's Video CE Library; the link is in the episode notes.

This has been a free audio overview from Special Learning.