ABA Insights: It’s Not Always Behavioral! Ruling Out Medical Causes to Challenging Behavior

When working as a BCBA (board certified behavior analyst) with individuals diagnosed with autism/autistic individuals, clients often present with challenging behavior. Data show that children with neurodevelopmental disabilities, such as autism, present with an increased risk of engaging in challenging behavior. The risk of an individual engaging in challenging behavior often increases if a child presents with an intellectual disability and/or decreased communication and other adaptive skills (Kennedy and Richman, 2019). Common challenging behaviors a BCBA may encounter include tantrums, aggression, self-injurious behaviors, and property destruction.

The BACB Ethics Code calls BCBAs to consider the medical needs of their clients throughout treatment. Code 2.12 states the following, “Behavior analysts ensure, to the best of their ability, that medical needs are assessed and addressed if there is any reasonable likelihood that a referred behavior is influenced by medical or biological variables. They document referrals made to a medical professional and follow up with the client after making the referral.” The previous quote indicates that a BCBA must ensure that they are being parsimonious in determining why a challenging behavior is occurring; this meaning that a challenging behavior may now always occur to gain access to a tangible, to escape a demand, to gain attention, or to provide automatic reinforcement. Instead, always seek to ensure that a client’s basic physical and medical needs have been addressed (BACB, 2020).

Many clients that a BCBA works with may present with deficits in communication, which is one of the diagnostic criteria that leads to someone being diagnosed with autism. Due to this deficit, an individual diagnosed with autism may struggle to not only communicate their wants and needs, but also to express potential feelings of discomfort or pain (CDC, 2022). People with neurodevelopmental disabilities (NDD) have a higher prevalence of health conditions such as gastrointestinal conditions, headaches, allergies, sleep problems, etc. In addition, people who engage in challenging behavior have higher rates of health conditions. Because an individual with a neurodevelopmental disorder may also have communication deficits, these medical conditions often go undetected (Kennedy and Richman, 2019).

For example, individuals who have constipation conditions often experience pain related to this. If a person has constipation in addition to NDD, this may lead to challenging behaviors as a result of the pain. If this person were to go without medical treatment due to lack of being able to express the pain, this person could undergo behavioral treatment and continue to be in pain for years to come. Additionally, undiagnosed health conditions may lead to reducing a person’s life expectancy as well as the development of secondary health diagnoses. One study showed that a boy engaged in self-injurious behavior (SIB) to reduce ambient noise when he was experiencing otitis media symptoms were present, but SIB did not occur when these symptoms have subsided. Additionally, research has shown that food refusal in children with feeding disorders if often correlated with oral-motor deficits as well as gastroesophageal reflux (May and Kennedy, 2010).

With health conditions occurring frequently in the autism community, the question for a BCBA is, how do I know when to refer a client for a medical evaluation? One way is through looking at the data in challenging behavior. If data are variable in the rates of challenging behavior, a BCBA could consider monitor health symptoms, such as bowel movements and sleep patterns. Consider also looking at the

antecedents of a behavior more closely. Is the behavior happening following mealtimes? Is the behavior happening when exposed to loud sounds or bright lights? Is the client hitting themselves on the ear or jaw? Is it allergy season? (May and Kennedy, 2010).

One study looked at the rates of aggression in a man who frequently experienced low hours of sleep. The data from this study show that the man engaged in aggression more frequently when demands were placed if he slept less than 5 hours. On days where the man slept more than 5 hours, aggression occurred infrequently (May and Kennedy, 2010). Gather data on many factors about clients: their food intake, their sleep patterns, their bowel movement patterns, allergy patterns, ear infections, etc. Consider taking this data and engaging care coordination with physicians to ensure a client’s medical needs are being met. Ask questions such as, “We notice on days where he is not sleeping for more than 6 hours, we see higher rates of challenging behavior. Could we potentially look into a sleep study?”, “We notice on days when they are constipated and passing gas often, we see higher rates of aggression. Could we look into getting a referral to a gastrointestinal specialist?”, etc.

There are many more examples in behavior analytic and health literature that show the effectiveness of treating health conditions that could be listed in this blogpost. Behavior analysts have a large duty to advocate for their clients and to ensure that they are ruling out potential medical and biological causes to behavior. Additionally, BCBAs must collaborate with other care providers constantly. When a BCBA has a client who presents with challenging behavior, they should always remain parsimonious and remember, it’s not always behavioral.

References

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. https://bacb.com/wp-content/ethics-code-for-behavior-analysts/

Centers for Disease Control and Prevention. (2022, April 6). Diagnostic criteria. Centers for Disease Control and Prevention. Retrieved April 21, 2022, from https://www.cdc.gov/ncbddd/autism/hcp-dsm.html

Kennedy, Craig and Richman, David (2019). Preventing Challenging Behaviors in People with Neurodevelopmental Disabilities, Current Developmental Disorders Reports, 6.

May, Michael and Kennedy, Craig (2010). Health and Problem Behavior Among People with Intellectual Disabilities, Behavior Analysis in Practice, 3(2).