The Importance of Ruling Out Medical Issues Before Treating Problem Behaviors

As both a Registered Nurse and a Board Certified Behavior Analyst (BCBA), I find myself frequently reminding people that some behaviors are caused by medical issues and cannot effectively be treated behaviorally.

Here is a little review of the four main functions of problem behavior. Two functions are Socially Mediated which means that other people have been involved in the past that have reinforced the behaviors. The other two functions are Automatic which means that no other person needs to be involved. The child or adult engages in problem behavior because the behaviors are automatically reinforcing. Here are the four main functions broken down further:

1) Socially Mediated Positive Reinforcement (Attention/Access to Tangibles). In the past when the child engaged in problem behaviors, things were ADDED such as attention and tangibles.

2) Socially Mediated Negative Reinforcement (Escape from Demands). In the past when the child engaged in problem behaviors demands were REMOVED (or delayed or made easier).

3) Automatic Positive Reinforcement (Self Stimulation). The child engages in problem behavior because in the past when they have engaged in this behavior pleasure/reinforcement has been ADDED.

4) Automatic Negative Reinforcement (Pain Attenuation). The child engages in problem behavior because in the past when they have engaged in the behavior, pain was REMOVED (or lessened).

In Chapter 2 of my book (The Verbal Behavior Approach), I cover the first three functions in pretty much detail but I don’t explain Automatic Negative Reinforcement too well except to mention that children with problem behaviors which come on suddenly or which you suspect might be medical should see a physician. In many cases, however, it is difficult for you or any physician to determine if a problem behavior is caused by a medical problem, especially in children with autism who cannot fully communicate about pain or discomfort.

I had an experience with my own son in the past few weeks since I wrote my last blog which I decided to write about to illustrate the importance of looking at medical issues when evaluating a child for the first time or when an established client experiences problem behaviors which start abruptly or increase without a clear explanation.

Lucas, who is 13 and has moderate autism, showed an increase in self injurious behavior (SIB) over the past few months. While in the past he would occasionally bite his knuckle at school, the rate and intensity of his knuckle bites went up significantly (from approximately one knuckle bite a day at school to 10 knuckle bites occurring both at home and school). This increase occurred in the past two months and at times, in addition to the knuckle bites, Lucas would sometimes hit his head and cry.

Lucas’ teacher and aid at school kept careful ABC data and the behaviors usually appeared to be related to access to tangibles and/or escape. But the demands were not higher than usual and sometimes he would engage in problem behavior without a clear antecedent. The professionals who worked with Lucas for years were all concerned that his behaviors were worse than ever. I was concerned too and noticed that sometimes at home when he engaged in problem behaviors, he cried real tears (and engaged in SIB) while on reinforcement. At these times when I asked him what was wrong, he would almost always say “eyes” but I didn’t know if he was saying eyes because he was crying or if he was truly in pain.

I finally took him to the pediatrician who agreed to do a battery of blood tests and a CAT scan of his head and sinuses. Because we knew Lucas wouldn’t tolerate a CAT scan without sedation, the doctor had to arrange a CAT scan with anesthesia. The MD and I agreed that is everything came back normal; we would chalk up Lucas’ problem behaviors to puberty and treat it behaviorally.

While the blood work and CAT scan of the head were within normal limits, Lucas’ sinus CAT scan showed “sinus disease” which has responded well to antibiotics and allergy medicine. I’m happy to report that Lucas’ problem behaviors are now back to baseline and we will work hard to implement behavior procedures to get rid of his SIB altogether.

For more information about reducing problem behaviors in children with autism, please read Chapter 2 of my book (http://www.verbalbehaviorapproach.com/), listen to a radio show on reducing problem behavior (http://old.autismone.org/radio/?archive=5729) and/or read my previous blogs.