NICE Clinical Guidance on Behaviour that Challenges in Children and Young People on the Autism Spectrum

The following is an extract from "Autism spectrum disorder in under 19s: support and management" (2013). London: NICE.

Anticipating and preventing behaviour that challenges Assess factors that may increase the risk of behaviour that challenges in routine assessment and care planning in children and young people with autism, including:

  • impairments in communication that may result in difficulty understanding situations or in expressing needs and wishes
  • coexisting physical disorders, such as pain or gastrointestinal disorders
  • coexisting mental health problems such as anxiety or depression and other neurodevelopmental conditions such as ADHD
  • the physical environment, such as lighting and noise levels
  • the social environment, including home, school and leisure activities
  • changes to routines or personal circumstances
  • developmental change, including puberty
  • exploitation or abuse by others
  • inadvertent reinforcement of behaviour that challenges
  • the absence of predictability and structure. Develop a care plan with the child or young person and their families or carers that outlines the steps needed to address the factors that may provoke behaviour that challenges, including:

  • treatment, for example, for coexisting physical, mental health and behavioural problems
  • support, for example, for families or carers
  • necessary adjustments, for example, by increasing structure and minimising unpredictability.

Assessment and initial intervention for behaviour that challenges If a child or young person's behaviour becomes challenging, reassess factors identified in the care plan and assess for any new factors that could provoke the behaviour. Offer the following to address factors that may trigger or maintain behaviour that challenges:

  • treatment for physical disorders, or coexisting mental health and behavioural problems
  • interventions aimed at changing the environment, such as:
  • providing advice to families and carers
  • making adjustments or adaptations to the physical surroundings (see recommendation If behaviour remains challenging despite attempts to address the underlying possible causes, consult senior colleagues and undertake a multidisciplinary review. At the multidisciplinary review, take into account the following when choosing an intervention for behaviour that challenges:

  • the nature, severity and impact of the behaviour
  • the child or young person's physical and communication needs and capabilities
  • the environment
  • the support and training that families, carers or staff may need to implement the intervention effectively
  • the preferences of the child or young person and the family or carers
  • the child or young person's experience of, and response to, previous interventions.

Psychosocial interventions for behaviour that challenges If no coexisting mental health or behavioural problem, physical disorder or environmental problem has been identified as triggering or maintaining the behaviour that challenges, offer the child or young person a psychosocial intervention (informed by a functional assessment of behaviour) as a first-line treatment. The functional assessment should identify:

  • factors that appear to trigger the behaviour
  • patterns of behaviour
  • the needs that the child or young person is attempting to meet by performing the behaviour
  • the consequences of the behaviour (that is, the reinforcement received as a result of the behaviour). Psychosocial interventions for behaviour that challenges should include:

  • clearly identified target behaviour
  • a focus on outcomes that are linked to quality of life
  • assessment and modification of environmental factors that may contribute to initiating or maintaining the behaviour
  • a clearly defined intervention strategy that takes into account the developmental level and coexisting problems of the child or young person
  • a specified timescale to meet intervention goals (to promote modification of intervention strategies that do not lead to change within a specified time)
  • a systematic measure of the target behaviour taken before and after the intervention to ascertain whether the agreed outcomes are being met
  • consistent application in all areas of the child or young person's environment (for example, at home and at school)
  • agreement among parents, carers and professionals in all settings about how to implement the intervention.

Pharmacological interventions for behaviour that challenges Consider antipsychotic medication for managing behaviour that challenges in children and young people with autism when psychosocial or other interventions are insufficient or could not be delivered because of the severity of the behaviour. Antipsychotic medication should be initially prescribed and monitored by a paediatrician or psychiatrist who should:

  • identify the target behaviour
  • decide on an appropriate measure to monitor effectiveness, including frequency and severity of the behaviour and a measure of global impact
  • review the effectiveness and any side effects of the medication after 3-4 weeks
  • stop treatment if there is no indication of a clinically important response at 6 weeks. If antipsychotic medication is prescribed:

  • start with a low dose
  • use the minimum effective dose needed
  • regularly review the benefits of the antipsychotic medication and any adverse events. When choosing antipsychotic medication, take into account side effects, acquisition costs, the child or young person's preference (or that of their parent or carer where appropriate) and response to previous treatment with an antipsychotic. When prescribing is transferred to primary or community care, the specialist should give clear guidance to the practitioner who will be responsible for continued prescribing about:

  • the selection of target behaviours
  • monitoring of beneficial and side effects
  • the potential for minimally effective dosing
  • the proposed duration of treatment
  • plans for stopping treatment.

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23 Aug 2021