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What's Really Behind Challenging Behavior in Autism?

Marina Sarris
Interactive Autism Network at Kennedy Krieger Institute
Date Published: 
November 14, 2017

As parents know, behavior and speech are intertwined. "Use your words," we tell toddlers when they misbehave. Solve your problems by talking it out, not fighting, we say when they get older.

Autism often limits someone's ability to speak or communicate in other ways, causing frustration. So it's assumed by families and professionals alike that speech problems fuel the challenging behaviors often found in youth with autism: hitting oneself or others, tantrums, throwing things, running away, screaming, or being disruptive.

But a new study of youth with autism in psychiatric hospitals calls that "prevailing assumption" into some question. Researchers found that the ability to speak was not a major factor in severe behaviors in those children, teens and young adults. Instead, the biggest influence was the person's ability to cope and adapt.1

A Surprising Result

Many times people responded positively to improved communication skills, but for some kids, it wasn't reducing problem behaviors as much as I would have liked.

Those findings are surprising, allowed the study's lead author, speech-language pathologist Diane L. Williams PhD. In her field, "there were very strong feelings that communication equals behavior, and if we increase a person's communication skills, that will decrease his behavioral problems," said Dr. Williams, who leads the Communication Sciences and Disorders department at Pennsylvania State University.

Yet, from her own experience with patients, she knew that learning to speak did not eliminate behavioral problems in everyone with autism. "Many times people responded positively to improved communication skills, but for some kids, it wasn't reducing problem behaviors as much as I would have liked."

Her study involved 346 youth ages 4 to 20 in the Autism Inpatient Collection (AIC), a study of inpatients at special psychiatry units at six hospitals in the United States. They all had behavioral or emotional problems that were serious enough to require a hospital stay. But they varied greatly on other measures, such as levels of speech and intelligence. Roughly half of the youth in the study had little or no speech, and half spoke fluently. Two out of five youth had intellectual disability, with most of those youth also having limited speech.1

In their analysis, the researchers took the youth's ages and nonverbal intelligence scores into account because those factors could influence problem behaviors. Despite their verbal differences, both groups – those who could speak in sentences and those who had few words – had similar levels of irritability and autistic behaviors, such as hand flapping and rocking. The youth who could speak fluently, surprisingly, had more externalizing behavior, that is, aggression and angry outbursts.1

"A lot of people think one of the reasons some kids act out so much is because they can't communicate," said child psychiatrist Matthew Siegel, a principal investigator with the Autism Inpatient Collection who worked on this study. "That might be true, but in terms of acting out in the form of aggression, that's not what we found."

Paying Attention to Aggression in Autism

photo of chalk pieces, some broken, to illustrate information about autism and aggression"Aggression," Dr. Siegel said, "is a big deal." Indeed. In another study, two-thirds of families reported that their child with autism had shown aggression toward caregivers, and half reported aggression toward non-caregivers. Those findings came from the Simons Simplex Collection (SSC), a study of families who each had one child with autism.2 The SSC study, like the one involving autism inpatients, did not find a link between aggression and having lower language or communication abilities. It did find a greater risk of aggression in children who were younger and who had more ritualistic behaviors, a greater resistance to change, and more self-injury.

"We need to pay attention to aggression. We know that aggression is the biggest cause of stress in parents," said Dr. Siegel, who directs the Developmental Disorders Program at Spring Harbor Hospital in Maine.

In interviews with IAN, some parents have said they worry that aggression and self-injury could prevent their son or daughter from staying safe, keeping a job, or living independently or with others in adulthood.

The autism inpatient study did not find a clear path from verbal skills to problem behavior, and its authors note that the results may not apply to youth with fewer behavior challenges. But some parents and professionals, as well as other research studies,3-5 say there is a connection between lower verbal skills and challenging behavior.

Learning to Communicate Can Bring Changes

photo of girl with speech therapistOne teacher recently told IAN, through a Facebook message, "Most students in my class are nonverbal, but I have seen enormous behavioral strides made once these students are able to communicate their needs. Behavior always has a function, and if the student isn't able to communicate with words, they need to express themselves in some way. Some learn that challenging behaviors help them have their needs met early on, and this sticks with them," he said.

Dr. Jennifer Zarcone, a senior behavior analyst at Kennedy Krieger Institute, said she has noticed a link between limited speech and behavioral problems. She works with inpatients on the Institute's Neurobehavioral Unit, which specializes in treating self-injury and severe behaviors in youth with autism and developmental disorders. "I'm more likely to see kids with more communication difficulties who are having more problem behaviors," she said. To help address that, speech-language pathologists help patients learn to communicate with picture exchange systems, mobile devices, and assistive technology, she said.

Dr. Zarcone said she understands why the AIC study found that youth with lower adapting/coping skills had more severe behavioral problems. "That makes sense that coping scores are associated with more behavior problems. Children who can't cope with the frustration of being told 'no,' for example, would have more behavioral problems," she said.

To gauge coping skills, the researchers looked at certain scores from the Vineland Adaptive Behavior Scales, which tests how someone functions in everyday life. Among other adaptive skills, it measures coping abilities, such as whether a person follows rules, returns borrowed items, abides by time limits, controls emotions when upset, and apologizes.6

Exploring a Link between Speech and Coping Skills

She helped him put into words what he was feeling.

photo of autism researcher Diane L. Williams PhD, speech-language pathologistIs there a connection between verbal abilities and coping skills that could explain why some see verbal and behavioral improvements going hand-in-hand?

Perhaps it is because some interventions that increase communication also may improve a person's coping skills, and that may explain why behavior can improve as language does, speculated Dr. Williams' research team. "The reason increasing communication skills can have a positive effect on behavior may be because the child's repertoire of coping skills has increased," their research article said. For example, an intervention that teaches a student how to communicate with others and regulate his emotions also may be broadening his ability to cope with day-to-day frustrations. Those coping skills, in turn, could lead to calmer behavior.

One example of a language-based intervention that could help with coping is the Social Story™, a tool developed by teacher Carol Gray in 1990. A Social Story is a personalized and illustrated story that teaches someone what to expect from, and how to respond to, a new or difficult situation. A Social Story can provide the language that a child needs to understand a situation and adapt his behavior to it, Dr. Williams said. (See below for more information on Social Stories.) The National Standards Project has rated story-based programs, including Social Stories, as an "established intervention" for children, teens, and young adults with autism. That means there is enough research evidence to say these stories work.7

Some parents intuitively use language in a way that helps their children understand and regulate their behavior, Dr. Williams said. One time she happened to be waiting for an elevator with a mother and her 8-year-old son with autism. "The boy started to run around and touch things, and his mother said to him, 'It's hard to wait for the elevator. The elevator will be here soon, and when it comes, you're going to push all the buttons.' And he stopped running. She never said, 'Settle down.' She never said, 'Stop doing that.' She helped him put into words what he was feeling. I was fascinated by this interaction. The mom explained to me, 'I'm his mediator. He can't put his feelings into words.' By her doing it, that helped him regulate himself."

In addition to targeting communication skills, Dr. Williams and Dr. Siegel said, interventions may also need to teach strategies that help people with autism regulate their emotions. "We might want to focus on improving adapting and coping strategies to address problem behavior," Dr. Siegel said.

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Photo credits: 1) iStock, 2) Daniel Watson, Unsplash, 3) iStock, 4) Diane L. Williams, PhD, CCC-SLP

References: 
  1. Williams, D. L., Siegel, M., Mazefsky, C. A., & Autism and Developmental Disorders Inpatient Research Collaborative (ADDIRC). (2017). Problem behaviors in autism spectrum disorder: Association with verbal ability and adapting/coping skills. Journal of Autism and Developmental Disorders, doi:10.1007/s10803-017-3179-0. Abstract.
  2. Kanne, S. M., & Mazurek, M. O. (2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disorders, 41(7), 926-937. doi:10.1007/s10803-010-1118-4. Abstract.
  3. Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (2007). Atypical behaviors in children with autism and children with a history of language impairment. Research in Developmental Disabilities, 28(2), 145-162. doi:10.1016/j.ridd.2006.02.003. Abstract.
  4. Baghdadli, A., Pascal, C., Grisi, S., & Aussilloux, C. (2003). Risk factors for self-injurious behaviours among 222 young children with autistic disorders. Journal of Intellectual Disability Research: JIDR, 47(Pt 8), 622-627. doi:507 [pii] Abstract.
  5. Ando, H., & Yoshimura, I. (1979). Speech skill levels and prevalence of maladaptive behaviors in autistic and mentally retarded children: A statistical study. Child Psychiatry and Human Development, 10(2), 85-90. Abtract.
  6. Pearson Clinical Psychology.Vineland adaptive behavior scales, second edition. Retrieved from https://www.pearsonclinical.com/psychology/products/100000668/vineland-adaptive-behavior-scales-second-edition-vineland-ii-vineland-ii.html?nGroupInfoID=aVineland#tab-details
  7. National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: National Autism Center.