Here is a little review of the four main functions of behavior. Most Behavior Analysts (including me) really focus on 3 of them. Because when a child has a problem behavior, it’s usually for three reasons. The first reason is that the child wants something and you say no or to wait. The second reason is the child doesn’t want to complete a task such as eating food that they don’t like. And the third reason a child might exhibit problem behaviors is for automatic reinforcement. So they may rock, make noises, or even bang their head when they are not actively engaged.
Lucas started having motor tics when he was 6. They came on suddenly and over the course of a few days, they were occurring 500 times/day. He also had open wounds on his legs which appeared out of the blue. I googled “acute onset tics” and found a condition called Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (PANDAS) which is now known as PANS since many cases of this autoimmune disorder are associated with bacterial infections other than Strep. Once he started on an antibiotic, Lucas’ tics went from 500/day back to 0. So we had evidence that these tics were caused by a medical problem. And without medication, all the behavioral treatment in the world most likely would not have helped.
Lucas’ teacher and aid at school kept careful ABC data. And the repetitive 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. 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 knew as a BCBA that these behaviors – like his tics years earlier – were not effectively treated behaviorally. So we took him to the pediatrician to do a battery of blood tests and a CAT scan of his head and sinuses. Lucas’ sinus CAT scan showed sinus disease. It responded well to antibiotics and allergy medicine.
I spoke with Dr. Brian Iwata, an internationally recognized behavioral expert, on treating severe problem behaviors using autism research. He said no controlled studies have ever been published on problem behaviors with an automatic negative reinforcement function. Yet many BCBAs and parents assume the doctor has ruled out that the behaviors are related to medical issues. Therefore they go full steam ahead trying to reduce these problem behaviors using ABA principles alone.
