Autism and challenging behaviour

The view from Sweden - Bo Hejlskov Elvén details a method for helping staff members to work with challenging behaviour in people with Autism.

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  • Challenging behaviour is defined as behaviour staff do not know how to manage.
  • We need to apply a quality control model of manage, evaluate, change in order to prevent further challenging behaviour.
  • Methods of behaviour management are found in the Low Arousal Approach tradition.
  • Evaluation methods must be focused on what staff can actually change.
  • Change methods are found in different traditions, but should be autism specific, focusing on prevention by changes of method and physical environment rather than on changing the behaviour of the autistic person.

I started working in the autism field a couple of years after my graduation as a clinical neuropsychologist. It wasn’t on purpose. I was doing assessments in youth forensic care, and was often asked how to manage challenging behaviour in young offenders. My psychologist schooling did not prepare me for that question, so I started looking at what others had said on the matter. I ended up reading a lot on the Low Arousal Approach, and recommending it in youth forensic care. After about a year I was approached from the autism field. I knew very little about autism at the time, but very much on human rights and the management of challenging behaviour in a human rights framework.

What first amazed me was the amount of challenging behaviour. Where the youngsters in your forensic care would act out quite rarely, often around once a month, autistic people sometimes acted out on a daily basis. Where the care in youth forensic facilities was focused on training and therapeutic interventions, autism care was often focused on behaviour management and the prevention of challenging behaviour. The frequency and severity of challenging behaviour in the autism field exceeded what I was working with in the youth forensic facilities in a way I had not previously understood. But I soon found that there were also common factors.

Challenging behaviour: a definition

What I soon found was that when staff contact me regarding challenging behaviour, there is one thing that has nothing to do with the diagnosis of the person with the behaviour or the sector where staff work: Challenging behaviour seems to be behaviour that staff do not know how to manage. The behaviour that staff think is challenging in schools (like using bad language towards teachers) vary a lot from behaviour staff think is challenging in autism (like biting staff trying to brush one’s teeth). This means that it is difficult to describe challenging behaviours across diagnostic boundaries, but it makes it a lot easier to work with. This definition means that in order to get rid of challenging behaviour all we need to do is figure out how to manage it. Which places the responsibility on staff instead of on the person with the behaviour.

This is a good thing. Mainly because it is a lot easier to change staff behaviour than the behaviour of autistic people in care. But it also means that if staff members are hit by an autistic person we must attribute the hit to staff method: The member of staff acted in a way that resulted in a hit. This is essential in order to increase staff competence. Only if staff members accept responsibility for the situation we can prevent it happening again. Staff members need to figure out what went wrong and what to change so the situation will be different the next time around.

In managing and preventing challenging behaviour, we need to work from a simple quality control model: Manage, Evaluate, Change.

Manage

Of course we need good managing methods in order to keep the danger of someone getting hurt at a low level. We need reactive methods like Studio III to manage even the most violent situation that might arise. But we also need good proactive methods in order to defuse crisis situations before they reach a level where reactive methods are needed.

Since the 1960s, research has pointed towards expressed emotion as a negative factor. Staff need to keep calm in order to manage and defuse situations before they escalate too far. This means that there is a number of actions staff need to either avoid or increase:

  • Avoid dominating eye contact. Autistic people often avoid eye contact because of the increase in affect intensity that can result from eye contact. A normal eye contact is three seconds at a time, and should of course be used when it comes naturally. But in crisis situations we should avoid it.
  • Keep your voice down and without jaw tension. By speaking calmly we can decrease the level of stress and affect intensity in autistic people.
  • Keep your distance. This means that we try to keep a yard or two between staff and the person they support, and even walk backwards a step or two after placing a demand. We should also try in difficult situations to keep our side toward the person instead of our front, both to avoid being affected by the person’s level of stress and affect, and to not escalate the affect intensity of the autistic person.
  • Divert. Get the person to direct his or her attention away from the increasing affect intensity by getting him or her to think of something else. Use a cup of tea if you must, but humour, questions, singing or a fast change of staff in the situation are also great diversions.

Of course we also need proper reactive methods for managing even dangerous situations. I recommend Studio III as it prevents danger for both staff and the person with the behaviour.

Evaluate

After a crisis situation, we need to evaluate what went wrong in the situation. I use what we call fixed questions in order to direct staff towards what they can change to prevent a similar situation in the future. The fixed questions are such as:

  • What lead to the crisis situation? Nothing happens out of the blue, find precursors to the crisis that we can change.
  • Did we use the proper proactive methods? Did we defuse the situation by using low arousal methods and diversions as described above?
  • Do crisis situations often happen in the same place, time of day or situation? Can we change any of those in order to prevent it happening again?
  • How is the perceptual environment? Do we have the space needed, do we have autism friendly light and sound (no echoes, sound insulation between rooms, good LED light instead of flickering light fixtures)?
  • Which stress factors in the person’s life can we decrease?

Change

Most challenging behaviour can be prevented. In autism we often recommend autism-specific methods such as TEACCH and AAK, but PBS is also widely used as is a person-centred framework and autism-friendly physical environments. These are change methods in my view. They are about prevention of challenging behaviour, not management of the behaviour.

I believe however, that change methods cannot stand alone. They need to be combined with good management and evaluation tools. Every time we have managed a challenging behaviour situation we need to consider what we need to change. And we need to consider both the physical environment, staff behaviour, level of structure and communication assistance. It is essential to understand that what needs to be changed is not the autistic person but what staff can change. In that way we become effective and actually decrease challenging behaviour substantially.

Using a quality control model like the manage, evaluate, change model keeps us on our toes and our services in shape. And inserts a sense of being able to make a difference into staff. This not only decreases challenging behaviour, it also help services keep staff longer and without burnout.

Bo Hejlskov-ElvenBo Hejlskov Elvén is a clinical psychologist based in Sweden. He has written a number of books on managing challenging behaviour across diagnostic boundaries.

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