By Mary Barbera, PhD, RN, BCBA-D
Have you ever been in a lecture where the material is way too easy or completely over your head? If you get in these situations what do you do? I bet you might doodle, play with your hair, or scroll through your Facebook newsfeed on your phone. This is the equivalent of a child with autism engaging in self-stimulatory behavior (otherwise known as “stimming”).
We all stim. In fact our solitary leisure activities (such as shooting a basketball into a hoop for a few minutes, playing the violin, or watching reality TV) are actually stimming. These self-stimulatory behaviors keep the neurons in our brain firing while we are not meaningfully engaged with others or working on a task where we need to concentrate.
Since children with autism usually have poor language, social, and leisure skills, some kids with autism engage in stim behavior for hours each day and these stim behaviors are often very disruptive across a variety of settings.
Stimming can take very different forms. Some kids might engage in stimming by rocking their bodies, flapping their fingers or by making loud vocalizations while kids with higher language abilities might script lines from movies, build the same lego structures over and over, or watch the same YouTube clips for hours.
Some stims, such as head banging or eye poking, can be dangerous or even life-threatening. I started with a 2-year-old client several years ago that banged his head repetitively on hard surfaces for 3 or more hours per day which caused an open wound on his head. With proper ABA/VB intervention and with regular supervision and oversight by me as the BCBA, we were able to get this young boy’s head banging down to under 5 minutes a day and his head wound eventually healed.
Want my Six Steps to Reduce Minor Self-Stim Behavior in Children with Autism cheatsheet? Click here.
As both a BCBA-D and a mom of a son with autism, you might be surprised to learn that unless a stim behavior is dangerous, like the 2-year-old client’s head banging described above, I almost never work on decreasing minor stim behavior directly. Instead of focusing on decreasing the stimming (rocking, moaning, scripting, etc.), I work on improving language and learning skills and eventually replacing very odd and immature stim behaviors with more socially appropriate leisure activities.
The key to stopping a stim behavior is recognizing that you cannot, in fact, simply STOP a behavior. Any behavior that is to be reduced must be replaced by an equally valuable or functional behavior.
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By Mary Barbera, PhD, RN, BCBA-D
I did a survey a few years ago and asked both autism parents and professionals about their #1 Autism ABA struggle and the top response was dealing with challenging behaviors.
I often get questions like this: What should I do if my child or client displays problem behavior (screams/argues/bites/kicks/flops to the ground) when a demand is placed (take a bath/do homework/go to bed)?
The answer to the question is similar regardless of the functioning level of the child, the type of problem behavior or the demand. Whenever problem behaviors occur, I believe the demands are usually too high, the reinforcement is too low and/or we don’t have adequate control of the reinforcement.
Before we can treat problem behavior, we need to accurately define what the behavior of concern looks like. Many people throw out vague words to describe problem behaviors displayed by their children or clients with autism. They might say Billy was “very off” today, “he was anxious” and/or “had a complete meltdown.” Even the word “tantrum,” which many professionals (including me) use routinely, doesn’t describe what exactly the behavior looks like.
In order to help parents or non-ABA professionals describe problem behavior more accurately, when a parent or professional says “he was anxious,” I ask, “What did that look like, was he pacing, tapping his fingers, taking short/shallow breaths?” Likewise, if they say, “He had a tantrum,” I would ask what that looked like. Did the child fall to the floor, kick adults, hit the sides of his head with his fists? While I can’t count anxiety or tantrums easily, I can count more specific behaviors.
Once you better define the behavior and decide which behaviors you are going to target first, I would recommend you take some data (how many times the behavior occurs per hour or per day).
Next I would look at activities when the problem behavior almost always occurs (when it is time to take a bath) and when the behaviors of concern never occur (while your child is playing on the computer).
You then should look at ways to “re-pair” activity that is resulting in problem behaviors such as the bathing routine. Some pairing techniques for bath time might be to get foam for the tub or bath paint/toys for instance and try to sandwich harder activities with fun activities (first bath then computer). A heavy focus on pairing and manding as well as an 8 to 1 ratio for positive to negative comments is usually helpful too. In fact, the key to controlling problem behavior in general is to spend 95% of your time preventing problem behaviors, not reacting to them.
If problem behaviors persist or are severe you will need a Board Certified Behavior Analyst (BCBA) or a related professional to help you since applying the principles of Applied Behavior Analysis is extremely complex and treating severe problem behaviors is outside of the scope of this short blog.
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I completed a Functional Behavior Assessment (FBA) recently on 9-year-old boy I’ll call Sam. His mother decided to home school Sam because she was worried that the public school her son attended might call the police if his behaviors continued to escalate.
Sam was diagnosed with high-functioning autism just after the age of three. He was included in general education classes since his IQ was in the normal range. Sam spoke in full sentences and could reportedly read at grade level. Sam’s outbursts, however, were very disturbing to the teachers and other students. While at school, Sam was sent to the principal’s office on multiple occasions and was suspended once when he knocked over a desk.
While an FBA is conducted to analyze the function of problem behaviors, I believe that a big part of an FBA should be dedicated to examining the child’s language and academic skills. In Sam’s case, his language deficits were very apparent to me as I completed a VB-MAPP assessment, even though he was a puzzle to school district personnel.
Sam displayed defective mands throughout the assessment since almost all of his requests revolved around escaping work. He asked his mom, “Can we be done?” and “Is it almost time for a break?” 30 times during a 20-minute work session. During the full day evaluation, Sam also only asked a few general questions starting with words such as “what,” “can” and “does.” I didn’t hear any complex mands for information with “why,” “how,” or “which” questions.
While Sam’s tacts were relatively strong, things fell apart for Sam when he was asked questions and needed to respond intraverbally. When I asked Sam to tell me some animals, foods, colors, and pieces of clothing or asked him simple “what” and “where” type questions, he was fairly accurate. However, when I asked him to tell me some things that are usually red, he looked around the room (looking for something to tact). I then asked him to close his eyes and tell me some things that are usually red and he demonstrated problem behavior. He screamed “Don’t tell me to close my eyes!” Similar problem behaviors were seen when how and why questions were asked.
The VB-MAPP assessment showed major skill deficits in manding for information and in the intraverbal repertoires. Sam’s problem behavior was primarily related to a history of escape from work involving high intraverbal demands. A few of the interventions recommended included the introduction of a token economy system, teaching Sam how to mand for information and using tact to intraverbal transfers to teach him to more effectively answer complex “wh” questions. An SRA program called Language for Thinking as well as a BCBA for six hours per month to oversee programming were also recommended and implemented.
If a student is displaying problem behaviors that are disruptive to his learning or the learning of others, the “problem behavior” box should be checked off on one of the first pages of the IEP. If this box is checked, a FBA needs to be conducted, preferably by a Board Certified Behavior Analyst (BCBA). A Behavior Intervention Plan should also be written and, once staff are trained on the plan (by the person who wrote it), it should be followed closely. Ongoing analysis and support for staff is also needed.
I believe that assessing the verbal and non-verbal operants as well as all academic areas should be a part of every FBA. Professionals who conduct FBA’s, as well as other professionals and parents who are working with students with significant problem behaviors need to understand the difference between mands, tacts, and intraverbals and the importance of assessing the verbal and non-verbal operants. A focus on the skill strengths and deficits (and not just on the problem behavior) will help each student with autism reach their full potential.
I go over this and so much more in my Autism ABA Help Course, so take a look and see if it could be right for you!
I often get questions like this: My child displays problem behavior (screams/argues/ bites/kicks/flops to the ground ) when a demand is placed (it is time to take a bath/do homework/go to bed). The answer to the question is similar no matter what the problem behavior or demand.
Whenever problem behaviors occur, I believe the demands are usually too high and/or the reinforcement is too low.
The first thing I would recommend is to take data (how many times the behavior occurs per hour or per day and take some ABC data too, if possible). Next I would look at activities when the problem behavior almost always occurs (when it is time to take a bath) and when it never occurs (while your child is playing on the computer).
You then should look at ways to “re-pair” the bathing routine (get foam for the tub or bath paint/toys for instance) and try to sandwich harder activities with fun activities (first bath then computer). A heavy focus on pairing and manding as well as an 8 to 1 ratio for positive to negative comments is usually helpful too.
Continuing to take data while you intervene is necessary to make sure the behaviors are decreasing. If problem behaviors are severe you may need a Board Certified Behavior Analyst (BCBA) or someone with lots of experience with problem behaviors to help you. My book (The Verbal Behavior Approach) –specifically chapters 2, 4, and 5 explain these ideas more fully. I also go over all this and more in my Autism ABA Help Course, so take a look!
I recently received a question related to my last blog on the importance of looking at medical issues before treating problem behavior. The question was, “How do you teach children with autism and severe language impairments to indicate they are in pain and to tell you where the pain is coming from?” I remember asking a very similar question to Lori Frost (co-creator of the Picture Exchange Communication System – PECS) years ago when I attended an introductory PECS workshop. Lori’s response was to make sure you label and preferably have your child label (with speech, PECS, or sign) when he has something visible that is obviously hurting him. In other words, when your child has a skinned knee or when he gets a bee sting, make a big deal out of labeling the pain for him. This is an important step with the goal that eventually your child will be able tell you he has internal pain which you can’t see such as a head ache or belly pain.
For a non-vocal or minimally vocal child, you might try — Boo Boo (with a Band-Aid picture card or the words) on my ___________ or my ___________ hurts and have your child fill in the body part by speaking or choosing a picture of a body part from an array. Even if your child is speaking, he or she might need added visual supports to learn this concept. To teach the labeling of pain, I would also recommend you try to put a real Band-Aid on a large picture of a boy (on various body parts) and have your child fill in the blank –boo boo on the boy’s ___________ or the boy’s ___________ hurts. You could also use the same idea to teach this concept with a simple talking device and/ or with sign language. I have found that receptive body parts and tacting body parts are usually prerequisite skills for labeling pain so I would also recommend working on these programs when your child is not in pain.
I believe the ability to label pain is an important skill which can and should be taught. For more information including details about my book, The Verbal Behavior Approach: How to Teach Children with Autism and Related Disorders.
As both a Registered Nurse and a Board Certified Behavior Analyst (BCBA), I find myself frequently reminding people that some behaviors are caused by medical issues and cannot effectively be treated behaviorally.
Here is a little review of the four main functions of problem behavior. Two functions are Socially Mediated which means that other people have been involved in the past that have reinforced the behaviors. The other two functions are Automatic which means that no other person needs to be involved. The child or adult engages in problem behavior because the behaviors are automatically reinforcing. Here are the four main functions broken down further:
1) Socially Mediated Positive Reinforcement (Attention/Access to Tangibles). In the past when the child engaged in problem behaviors, things were ADDED such as attention and tangibles.
2) Socially Mediated Negative Reinforcement (Escape from Demands). In the past when the child engaged in problem behaviors demands were REMOVED (or delayed or made easier).
3) Automatic Positive Reinforcement (Self Stimulation). The child engages in problem behavior because in the past when they have engaged in this behavior pleasure/reinforcement has been ADDED.
4) Automatic Negative Reinforcement (Pain Attenuation). The child engages in problem behavior because in the past when they have engaged in the behavior, pain was REMOVED (or lessened).
In Chapter 2 of my book, The Verbal Behavior Approach, I cover the first three functions in pretty much detail but I don’t explain Automatic Negative Reinforcement too well except to mention that children with problem behaviors which come on suddenly or which you suspect might be medical should see a physician. In many cases, however, it is difficult for you or any physician to determine if a problem behavior is caused by a medical problem, especially in children with autism who cannot fully communicate about pain or discomfort.
I had an experience with my own son in the past which I decided to write about to illustrate the importance of looking at medical issues when evaluating a child for the first time or when an established client experiences problem behaviors which start abruptly or increase without a clear explanation.
Lucas, who was 13 at the time and has moderate autism, showed an increase in self injurious behavior (SIB) over the past few months. While in the past he would occasionally bite his knuckle at school, the rate and intensity of his knuckle bites went up significantly (from approximately one knuckle bite a day at school to 10 knuckle bites occurring both at home and school). This increase occurred in the past two months and at times, in addition to the knuckle bites, Lucas would sometimes hit his head and cry.
Lucas’ teacher and aid at school kept careful ABC data and the behaviors usually appeared to be related to access to tangibles and/or escape. But the demands were not higher than usual and sometimes he would engage in problem behavior without a clear antecedent. The professionals who worked with Lucas for years were all concerned that his behaviors were worse than ever. I was concerned too and noticed that sometimes at home when he engaged in problem behaviors, he cried real tears (and engaged in SIB) while on reinforcement. At these times when I asked him what was wrong, he would almost always say “eyes” but I didn’t know if he was saying eyes because he was crying or if he was truly in pain.
I finally took him to the pediatrician who agreed to do a battery of blood tests and a CAT scan of his head and sinuses. Because we knew Lucas wouldn’t tolerate a CAT scan without sedation, the doctor had to arrange a CAT scan with anesthesia. The MD and I agreed that is everything came back normal; we would chalk up Lucas’ problem behaviors to puberty and treat it behaviorally.
While the blood work and CAT scan of the head were within normal limits, Lucas’ sinus CAT scan showed “sinus disease” which responded well to antibiotics and allergy medicine. I’m happy to report that Lucas’ problem behaviors went back to baseline and we worked hard to implement behavior procedures to get rid of his SIB altogether.
If you want more information about the techniques I described above and so much more, take a look at my Autism ABA Help Course.