Behaviour that Challenges

The following advice is adapted from NICE Guideline CG170: Autism in under 19s: support and management [http://www.nice.org.uk/guidance/cg170]

 

Assessment of Behaviour

When assessing behaviour that challenges, the practitioner should take the following potential causes into account:

  • impairments in communication that may result in difficulty understanding situations or in expressing needs and wishes
  • coexisting physical disorders
  • coexisting mental health problems
  • 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

 

Planning Care

A care plan should be developed and if any of the following have been identified, the care plan should state how they will be addressed.

  • 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

If this care plan is unsuccessful in addressing the behaviour, carry out a multidisciplinary review, taking into account the following:

  • 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

If mental health, physical health, behavioural and environmental causes of the behaviour that challenges have been ruled out, psychosocial interventions should be the first line of treatment.

Complete a functional assessment of the behaviour. This should include the following.

  • 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 intervention should be informed by the functional assessment, and 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

NB At the time of publication of NICE guidelines (August 2013), no antipsychotic medication had a UK marketing authorisation for use in children for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.


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