Behaviours of Concern and Autism

Current Research

Current Research Studies and Reviews

We have identified 30 research reviews of behaviours of concern in autistic people published in peer-reviewed journals.  

Some of the reviews looked only at studies which included autistic people; others looked at studies which included people with a range of conditions including autism and learning disabilities.

• Some of the reviews looked only at individuals from a specific age range -such as primary school children, adolescents or adults. Other reviews looked at individuals from across the age range.
• Some of the reviews looked at interventions designed to reduce behaviours of concern. Other reviews looked at related issues, such as the assessment and prevalence of behaviours of concern.
• Some of the reviews looked only at studies of particular types of intervention (such as behavioural interventions). Other reviews looked at a wide range of different interventions.
• The most commonly assessed interventions were behavioural interventions, medications, and augmentative and alternative communication.

Results of Interventions

Some of the reviews reported some benefits from specific types of intervention. For example,

• Doehring et al. (2014) reported that many relatively simple behavioural interventions could be used to decrease severe problem behaviors among children and adolescents with autism spectrum disorder and/or intellectual disability.
• Hutchins and Prelock (2014) reported that interventions, such as functional communication training, interpretive strategies, the Picture Exchange Communication System, augmentative and alternative communication, and pivotal response training, can support increased communication and decrease challenging behaviour.
• Matson and Dempsey (2007) reported that ‘medication does have a significant role to play in persons with ASD, particularly with respect to older adolescents and adults with severe challenging behaviors and/or comorbid psychopathology but that only if these problems are chronic, severe and unresponsive to psychological and educationally based treatments.’
• Kaat and Lecavalier (2013) reported that parent training has been the primary mode of psychosocial treatment for behaviours of concern in autistic people and has some support for its efficacy.
• McNellis and Harris (2014) reported that ‘...  newer models of residential treatment that combine specialized comprehensive services, evidence-based interventions, intensive family support and training, and treatment overlap with community providers can offer an effective and efficient treatment option.’

Some of the reviews reported that there was currently mixed or insufficient evidence to support the use of some interventions. For example,

• Stigler (2014) reported ‘Research focused on the treatment of severe irritability has primarily involved the atypical antipsychotics, including risperidone and aripiprazole. Anticonvulsants have also been investigated for targeting serious behavioral disturbance; however findings have been mixed. Advances in the pharmacotherapy of irritability in ASD continue to inform practice. Research is needed to develop safer and more effective drug treatments for serious behavioral disturbance in this population.’                                                                                                                     

Many of the reviews reported that undertaking a functional analysis of the behaviours of concern before undertaking an intervention was more likely to lead to successful results.For example

• Horner et al (2002) reported that the one consistent finding has been that interventions developed from functional assessment information appear more likely to result in significant behaviour reduction. 

Some of the reviews reported that some interventions were more effective for some individuals than for others. Other studies reported there were no differences. For example

Walker and Snell (2013) reported that ‘AAC interventions were more effective with younger children than with adults [with various disabilities].’

• Heyvaert et al. (2014) reported ‘The group of participant characteristics included in our study(i.e., age, gender, criteria used for diagnosing autism, intellectual disability level, and level of verbal communication ability)did not significantly influence the overall efficacy of the behavioral interventions.’

Some of the reviews reported that interventions were equally effective regardless or the type of challenging behaviour.For example

• Heyvaert et al. (2014) reported that ‘we can conclude that the behavioural treatments were equally effective regardless of the type of problem behavior that was targeted.’

Some of the reviews reported that some types of intervention could be potentially hazardous or difficult to implement. For example

• Coury (2011) reported that risperidone and aripiprazole ‘cause significant adverse effects including marked weight gain, sedation, and risk of extrapyramidal symptoms. Strength of evidence around adverse events is high for both risperidone and aripiprazole. When considered in aggregate, risperidone and aripiprazole are efficacious [for challenging behaviours] but are associated with significant adverse effects that limit their use to patients with severe impairment or risk of injury.’
• Doehring et al (2014) reported that some behavioural interventions reveal a risk for injury and a need for specialized assessment and placement, careful tracking, and high-quality treatment that few agencies could likely replicate without increases in training and support.

Other findings

Hutchins and Prelock (2014) reported that, ‘whichever strategy is employed, a genuine attitude of respect for the individual and his/her perspective needs to be adopted. There are misunderstandings between people and what we call challenging behaviors can make perfect sense when viewed by the person with autism. In short, an attitude of respect and non-judgment helps move us toward understanding the reasons behind maladaptive behaviors so that we may address them effectively and with the most careful consideration.’

Status of Current Research Studies and Reviews

There are limitations in most of the research reviews we have identified to date and in most of the studies included in those reviews.

Some of the reviews were undertaken some time ago. For example, Aman (2004), Horner et al (2002), McClintock et al (2002), and Mirenda (1997) were all undertaken more than 10 years ago which means that they do not include the most recent research.

Some of the reviews were limited to people on the autism spectrum of a specific age. For example, Sawyer et al (2014) looked only at adults on the autism spectrum whereas Horner et al (2002) looked only at children on the autism spectrum aged 8 years or younger.

Some of the interventions were limited to people on the autism spectrum with additional conditions. For example, Hutchins and Prelock (2014) looked only at people on the autism spectrum with a learning disability whereas Kaat and Lecavalier (2013) looked only at children and adolescents on the autism spectrum with disruptive behaviour disorders.

Many of the reviews were limited to specific types of intervention.For example,

• Heyvaert et al. (2014), Machalicek et al (2007), Hoer et al (2002) and Montgomery et al (2014) looked only at behavioural interventions
• Duran and Merges (2004), Hutchins and Prelock (2014) and Mirenda (1997) looked only at forms of augmentative and alternative communication
• Aman (2004), Coury (2011), Matson and Dempsey (2007) and Sawyer et al (2014) looked only at medications
• Klinger et al (2013) looked only at caregiver- mediated approaches while McNellis and Harris (2014) looked only at residential treatments.

Most of the reviews included very small numbers of studies and/or participants on the autism spectrum. For example  

• Horner et al (2002) included only nine studies
• Sawyer et al (2014) included only seven studies
• Mirenda (1997) included only eight participants on the autism spectrum.

Most of the reviews identified only low quality studies or did not report on the quality of the studies.For example  

• Heyvaert et al. (2014) reported only on single-subject research papers
• McNellis and Harris (2014) reported only on case studies
• Mirenda (1997) did not report on the quality of the studies, although it is likely that they were all single-subject research papers.

Some of the reviews (Griffith et al, 2013 and Griffith and Hastings, 2014) were a synthesis of qualitative research and did not attempt to provide a quantitative analysis of interventions.

Some of the reviews were written by authors involved in the development or use of specific types of intervention. For example, Marc Durand (one of the co-authors of a review on functional communication training) developed functional communication training with Edward Carr.

Updated

21 Sep 2022