Verbal Behavior Approach: How to Teach Children with Autism and       Related Disorders [Mary Lynch Barbera]

Saturday, March 20, 2010

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 (, listen to a radio show on reducing problem behavior ( and/or read my previous blogs.


  1. Mary,
    Thank you for your post. Way back in the Jurassic I learned from someone that in the event of uncharacteristic or "out of the blue" changes, esp. negative changes - look to illness, injury or even physiologic need (hungry, thirsty, missed sleep) first (unless there was clearly some kind of instructional change or closely tied contingency that can be tested right way) and eliminate that as a possibility. So far that's tended to play out for us.

    I am very glad that you were able to find out what was wrong for Lucas, and moreover to get him medical care to help him feel better. Warm regards.

  2. Mary,
    Thanks again for such pertinent and essential information. This week I would like my class of certified teachers that are also studying special education to take a look at your blog and post a comment. Thank you (and Lucas) for being our guide.
    Prof Pete Post

  3. Nonverbal children have a difficult time communicating any needs they may have. Add to that fact when they don't feel quite right, can be challenging to parents and physicians. Some of these children can have symptons that are not typical and causes which are not easily recognized. If these medical issues are not treated, the child will not be able to participate in the classroom to the best of his/her ability. Parents know their child best. If they feel something is "not quite right" with their child, a phone call to his teacher and a trip to the doctor's office is important to rule out any medical conditions the child may have. I like the idea from the article, "Biomedical Factors in Autism" from the website: where the author suggests bringing in a videotape of the child's behavior to help with the diagnosis. The doctor can view the child in the comforts of his own home.
    As parents we have all made trips to the pediatrician to rule out any medical issues that might be going on with our children. By treating any medical conditions that may be causing the child to act out will help to improve his performance in school and overall quality of life.
    Kim A.

  4. Thanks Mary for the information regarding your son. I am a student of Professor Pete and as a future Special Education educator I feel it is important to gain as much information as possible on the many topics that we disuss in class. Unfortunately, in the districts that I have worked in, too many teachers don't go far enough in documenting student's behaviors. After reading your blog, I realize that many behaviors that I have seen student's display and teachers overlook should have been monitored more closely. Like Regina, I am happy that you were able to find out what was really bothering Lucas and sharing the importance of remembering to rule out medical issues prior to treating a behavior problem...Good luck and God bless you both!

  5. Mary,
    This is great information not only for parents but educators as well. I believe that you are exactly right in prescribing to the theory of ruling out medical problems for some behaviors that seem out of the norm even for special needs children. Our 10 year old son has explosive disorder. We have had him seen by a child psychologist but not a pediatrician. I believe that we should have him seen by a medical professional because his behavior is not getting any better.

    Thank you,
    Michael S.

  6. Mary,
    I am a student of Professor Post. I found your information very crucial - about ruling out medical issues when children with behavior problems. I agree with Crystal that many of the schools I have worked for don't document enough in regards to behavior. Many times teachers throw the behavior, emotional label out without further inquiry. It takes a lot for you as a parent to seek out other options that no one has presented to you. I am glad you pursued medical options with Lucas and I hope others like Michael will get the help they need for their child and look into other options like medical issues.

    Thank you,

    Sandy O.

  7. Mary,
    I am also a student of Professor Post, the information you presented was wonderful, and I have found from my experience that working with students with special needs that are nonverbal can be frustrating for an individual when they are used to verbally relaying and receiving information. Over the years, working as a one-on-one paraprofessional with non-verbal students it was pertinent that we learned a way to communicate with one another. We learned from one another how to communicate with each other. The way we communicated was through hand gestures, body language, and visual eye contact; a person’s eyes can say so much and even with my nephew who has difficulty expressing/explaining himself due to his special needs. Both children used their behaviors to express the pain/feelings when they could not use words. It was difficult at first to figure out what they were trying to say or wanted but it seems when someone is just not feeling right or are in pain they show this through their different behaviors. I am sure if we look at ourselves, we could see some of these behaviors in us when we are not up to par. It is important to remember that behavior may not just be a behavioral issue but a bigger underlining issue, a medical issue that needs to be addressed. Documenting behaviors and changes in those behaviors can become a valuable asset like they were to your son.
    Thank you,
    Karen F.

  8. Mary--Thank you for sharing about your experience with your son. He is so fortunate to have such an observant mom and teachers. I can't imagine your relief to find an answer to what was going on. I am a relatively new teacher (also a student of Pete Post) and have had times when my student's behaviors just aren't making sense. While working in a lower income school district with many single parents I believe time and money often stopped them from investigating the medical side to their child's behavior. In these cases we often had to deal more with the behavior because we could not find what may be triggering or preceding the child's behavior. This was often very frustrating. Thanks again for the wonderful reminder to not overlook the possibility of an underlying medical issue.

    Julianne VW

  9. Mary,
    Thank you for sharing information about your son. I am a student of Pete Post and also a 6 year teacher. I currently left the field of teaching and became a developmental therapist, working with children birth to three. I have learned as a therapist how crucial it is for parent's to pursue medical advice/diagnosis/supports. As Julianne stated above, I often too believe that money is often a reason to stop investigating the innner workings of their children. I just don't think that you can put a price on the life and successfulness of your child. Thanks again for the information.
    Janna F.

  10. Hi I am a student of Professor Post and it is a good thing that you took your son to the doctor before jumping to conclusions. When we are dealing with children of all natures sometimes we tend to jump to conclusions. I feel that it is of the utmost importance that we try to get to the root of the problem as teachers and parents. Thanks for bringing to light your story as a teaching tool for all of us!
    Mike K

  11. Mary, Thanks for sharing your story, I teach in an alternative program within my school district. Most times I am finding we just go along with what has been said in the past about the students. Pushing the envelope as an educator is dificult, but often times I believe it is necessary. There are times I wonder what is the root of each of my student's problems. I think it is necessary to take children to get a medical opinion before preceeding in any other fashion.

    T.J. L.

  12. Mary, Thank you for giving us that helpful situational advice. I am a student of professor post and I believe that in too many instances, children are just labeled as having behavioral problems without being properly examined by all possible channels, i.e. (psychologists, physicians, social workers, teachers, parents, etc.) These examinations are especially important when you are dealing with a student who has trouble communicating,such as a students with autism or communication disorder, because even if they know what is wrong with them, they cannot tell you. A agree with fellow bloggers that money plays a huge part in students not receiving proper examinations. It can be a very expensive process for a school district or family to complete without achieveing any results. But as your blog has shown, this process is very necessary and can increase the quality of life and learning time for the student and their family. (Not to mention their teachers!) Thank you again for bringing this very necessary topic to light.
    Steve S.

  13. This article is extremely thought provoking when it comes to the behaviors of special needs students. Over the past years I have worked with many students who often have unexplained behaviors that are very challenging. Trying to communicate with students about these behaviors even when they have adequate communication skills is difficult let alone a student who cannot explain what he/she is feeling. It often seems easy to think a student has total control over what they are doing, and the situation can simply be remedied with a reminder or reprimand. The fact is that often there is so much more that plays in to why the behavior has appeared and whether it is socially mediated or automatic it is going to take some degree of investigation to get to the bottom of and remedy the issue. The scary part is that often it could very well be an underlying medical issue that the child does not understand. I am glad to hear you were able to find a remedy and some obviously much needed relief for your son. Thank you for this interesting first hand perspective on this topic.
    Tom O.

  14. Thank you so much for sharing your personal experience with all of us. I understand a diagnosis so much better when it is related to a real life situation. Your son is very fortunate to have caring teachers and parents that realized something was not right. In the wrong hands at school he may have been reprimanded time and time again for things that were out of his control. It is great that you noticed the signs from your son especially while crying and him continuously mentioning his eyes. Without this diagnosis you may have spent a great deal of time coming up with new ways to curb behavior. Thank you for the advice to always seek medical attention first as a precaution.
    Kim Capretz

  15. Mary,
    Thank you for your article. How frustrating it must have been for you and your son to not be able to effectively communicate his not feeling well. He was fortunate to be surrounded by adults who knew enough to take the time to figure out what caused his sudden change in behavior. It is easy for adults to quickly chalk up bad behavior to nothing more than just that, bad behavior. Thank you for reminding us to take the time to pay attention and look for answers to problems that may not always be so obvious. Thank you, again.
    Jackie C.S.

  16. Mary,
    Thank you for reminding us that a child's bad behavior isn't always willful. I agree with Tom's comments that often adults tend to think that proper discipline will correct the problem. Teachers especially need to be aware that difficult behavior can have medical reasons. I know students who were previously labeled as being a "slug" and a "weirdo". After making careful observations and speaking with their parents, these children have been diagnosed with ADD and autism respectively. Instead of being ridiculed and punished, they can now discover how best to learn and live with their disabilities.
    Kathy K.

  17. I am a student of Professor Post's class, and I think that many adults tend to forget that children lack the experience, knowledge, and means to effectively communicate their health concerns. A high school teacher, I have noticed that there is a significant gap in the students' medical knowledge about common problems that are likely to effect them. Some pupils are leery about mentioning their issues because they feel it will place unwanted financial strain on their families. It's important to urge students to voice their worries before problems exacerbate. Teachers and parents have a responsibility to montior children's well-being and take measures to uncover the source of behavioral problems.
    Laura M.

  18. I find that because nonverbal children cannot communicate their needs and desires very well often times people assume the cause of the behavior. I have had close experience with nonverbal children as two of my nephews have autism. They have a hard time communicating when something is wrong and often times an illness. Brandon's teacher assumed he was acting out on a count of not wanting to do the work in school but it turns out that he was running a 103.5 fever and was extremely miserable and wanted the attention. I think that teachers and professionals need to pay more attention to their students and their usual and typical behavior and make note that if this is not normal for the student then to rule out what it could be before assuming!! I appreciate your blog and the information you shared about Lucas. Thanks for allowing this to be a guide for us! I look forward to more posts from you!
    Kristen W

  19. Mary,
    I work in an alternative special ed school and I really enjoyed reading your blog. I know many children who have terribly violent behaviors and their parents are not cooperative with the school in helping their child calm their behaviors. I know most children with special needs really hate going to the doctor but it is possible to take them. It must be hard having a child who is nonverbal that is expericing pain with no way to really express him. I applaud you for your efforts and hope you help others who are struggling with how to help their children.
    Megan C

  20. I am a person who believes that medicine is a great and wonderful thing. Sometimes we are too quick to look for the fast fix of problematic behaviors. Medicine is not always the key. I appreciate your posting because you are showing the other side, when medicine is needed due to a health problem not a behavioral problem, and it may not even be considered. In your case, if your son had not been given a CAT scan, you and the school staff may have still been searching for ways to improve his behavior. Children with Autism cannot always express to us what they want or what is wrong in the usual way. We must listen very closely to what they are saying and try to figure it out.
    Karen A.