When your child's behavior hurts someone: what the professionals look for first.

A free article for families, derived from Special Learning's course "Severe Problem Behavior," presented by Jennifer LaLuzerne and Amanda Yeager.

If your child hits, bites, bangs their head, or eats things that aren't food, you already know what "severe" means. You may also know how few people talk to families about it directly.

This session was recorded for professionals. Its presenters directed a clinic for adolescents with autism and wrote and supervised the behavior plans there. We're writing it up for you, because families living with this are the largest audience for it and the least often spoken to.

Nothing here is a plan for your child. It's a description of how the people who do this work think, so your conversations with them make more sense.

Safety comes first, every time. If anyone could get hurt, keep everyone safe first and get help from your child's team or emergency services.

You're not the only one

The session defines severe problem behavior as behavior that's "dangerous to the individual or his family," or that causes "an extreme amount of distress" to the person and the people who love them.

It's also honest about how common this is. In one study the presenters cited when this was recorded, "sixty-eight percent of children and adolescents with autism showed aggression towards a caregiver." In another, almost a third of the children had some form of self-injury. If you've felt alone with this, you aren't.

Why it has to be worked on

The next part is hard to hear, and it's the reason the session exists.

The presenters also describe an earlier study that followed 49 adults with severe self-injury and looked at them again 18 years later. More of them were getting services. "Eighty percent" were on medication. And yet "eighty four percent of the sample was still engaged in problem behaviors at the same extent that they had been eighteen years prior." Families also reported smaller lives, with less access to the community and to other people.

"This was very concerning," the presenters say. These behaviors don't usually fade on their own. They have to be worked on, on purpose, and the rest of the session is about how.

First, find out what the behavior is doing

Everything in a good plan rests on one idea. Before anyone tries to stop a behavior, they need to understand what it does for your child. The same hitting or head banging can be a way to get out of something, a way to get attention, a way to get an object, or something the body does for its own sake. Two children can look the same and need opposite plans.

A plan written without that understanding, the presenters say, "is likely to be inefficient, ineffective or even harmful because you might be inadvertently reinforcing those behaviors."

There's a formal test that sets up situations on purpose to see when the behavior appears. The session is careful about it. It's a professional procedure, used as "a last resort method" when behavior is dangerous, and adjusted for safety. It isn't something to try at home.

If your child wears protective gear, the presenters make a point worth knowing. In the studies they describe, the gear could change how often the behavior happened, which made its purpose harder to see. The gear keeps your child safe, and it can also hide the picture. A good team plans for both, including how the gear will eventually be reduced.

Always teach something in its place

The presenters repeat this rule. "If you fail to put a replacement behavior in place ... a new behavior may crop up that could be equally dangerous or more dangerous."

The behavior was doing a job. If it's taken away without another way to do that job, the struggle continues. So the new skill has to:

• Do the same job. In their words, it needs to be "functionally equivalent."
• Be easier than the old behavior, "at least in the initial stages."
• Be something other people will notice. Think about "the likelihood that others will recognize and respond."

Tapping a shoulder instead of pinching. A card, a sign or a word that means break, instead of dropping to the floor. Teaching this is called functional communication training, which the presenters call "one of the most common and effective interventions for treating severe problem behavior."

Stopping it before it starts

Much of the session is about prevention, and you'll recognize most of it from home:

• Your child can always communicate, whatever way they do it.
• A schedule they can see, so a hard task isn't a surprise and 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. "It doesn't cost anything," the presenters say, and it can reduce challenging behavior on its own.
• Tasks that fit. Too hard and too easy can both set things off.
• A timer, so a clock announces the end of screen time, not a person.
• Attention for the good moments, not only the hard ones: "making sure that you're catching them being good."

When it gets worse before it gets better

The session explains what happens when a behavior stops working. If hitting has worked for years and suddenly doesn't, a child "may try to do it bigger and better than I've ever done it before." This is called an extinction burst.

The presenters say two things about it. It's "something we caution everybody about." And the research shows it "doesn't happen quite as often as ... we might say," especially when a child is being taught a replacement at the same time. That's why good plans come as a package, not a single step.

If you're asked to use any of this at home, use it only the way your team has shown you. If your child seems upset, in pain or overwhelmed, help them first. And if anyone could get hurt, keep everyone safe first and get help from your team or emergency services.

A few specific behaviors

• Soiling. The first step the session names is "a thorough medical check for your child" by a doctor, before any behavioral work.
• Eating things that aren't food. The presenters say the "risk of death" with this behavior "may be higher than other forms of self-injurious behaviors." Older approaches once used for it are no longer the standard. This one belongs with your child's doctor and team now.
• Bringing food back up. Start with a medical check, because this can have a physical cause. Then find out what the behavior is doing.
• Hair pulling. The message is the same as everywhere else in the session: find out what the behavior is doing, because the answer decides the plan.

When a plan doesn't work

The session does something rare. The presenters show their own cases where the plan didn't fully work, and they say so. For one boy, "the graph is not very impressive." For another, behavior fell during a medication change, and they ask openly whether it was the plan or "the fact that he was very tired." And they say plainly that a tired child is "certainly not a quality of life that we want."

If you've watched a plan fail, that honesty is worth something. A failed plan isn't the end. It's information.

Keep watching, and take it seriously

The session raises one more thing briefly, and so will we. Thoughts of suicide in autistic teens and adults are "likely to be under reported," partly because a person may not be able to say what they're thinking. If your child talks about death, the presenters call it "definitely a warning sign." Tell their doctor or team.

If your child talks about not wanting to be here, or you're worried about their immediate safety, you don't have to carry it by yourself. In the U.S., you can call or text 988 any time. If someone is in immediate danger, call 911. Outside the U.S., call your local emergency number.

Questions to take to the meeting

• What do you think this behavior is doing for my child?
• What will my child be taught to do instead, and is it easier than the behavior?
• What's the plan for keeping everyone safe, including at home?
• If my child wears protective gear, how will we know what the behavior is for, and how will the gear be reduced?
• What should I expect if things get worse before they get better?
• Has my child had a medical check for anything that could be causing pain?

If you are reading this outside the United States

The session was recorded in the United States, and some of the rules and services it mentions are local. Where you live, the professionals and the help available may be different.

What doesn't differ is the idea at the center of the session. The presenters say it throughout: it's "critical to identify the maintaining variables." A behavior that hurts your child is doing something for your child, and the way out starts with finding out what.

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This article is drawn from a recorded Special Learning course. It is general information for families, not clinical advice, and not a treatment recommendation for any individual. It does not describe the rules of any particular school district or country. If your child or anyone else is in immediate danger, contact your local emergency services.

Special Learning is a BACB Authorized Continuing Education (ACE) Provider (OP-14-2437). Authorization as an ACE Provider does not imply endorsement or approval of the ACE event content by the BACB.