The Basics of Behavioral Support
When an individual with autism is engaging in problematic behavior, such as self-injurious biting, name-calling or lashing out, what can parents, teachers and other support team members do to help? Creating a Behavior Support Plan (BSP) can help families who are feeling defeated by difficult behaviors. With the help of professionals, parents and support teams can craft and implement behavior support plans that respect the individual's dignity, promote consistency and enable the individual to choose different behaviors.
For some parents and caregivers, this piece will serve as a review of Behavior Support Plan principles that they have encountered previously. However, addressing the principles of behavioral support in an adult context is an important, often-overlooked step; strategies must be age-appropriate and the individual with autism may well be actively involved in the creation and implementation of their own BSP. These plans are not limited to children, as they play a significant role in the success of adults on the autism spectrum. For parents and caregivers who are unfamiliar with the principles of BSPs, this article will serve as a primer.
What is a Behavior Support Plan?
Behavior Support Plans are created for individuals when certain aspects of the individual's behavior become problematic. When certain behaviors consistently prevent individuals with autism—with or without intellectual disabilities—from desirable outcomes (learning, growing, maintaining personal safety and connecting well with others), BSPs can help the individual's team to respond wisely. BSPs are not solely for adults on the autism spectrum; they are meant for any individual whose behaviors consistently interfere with their ability to lead a fulfilling life. For example, informal BSPs may be employed for issues such as anger management, emotional eating, and compulsions of various kinds.
At its core, a BSP is a system set up to enable significant members of an individual's life to change their inconsistent, emotion-based response to problem behaviors to ones of forethought and consistency, in hopes that their new responses may, in time, alter the individual's problem behavior. In this way, BSPs are also an important bridge toward healthy relationships. At their best, BSPs represent a pre-meditated effort to respect and care for an individual. As Charles Clark, an individual who lives in a residential placement in Virginia, says of his informal behavior support plan, “It's my Love Plan. It's how my family members show me love.”
It's important to distinguish between a formal BSP and an informal BSP. Informal BSPs can be created by family members, teachers, or caregivers who understand the basic principles of behavior management. Formal BSPs, however, are governed by a stricter framework. Formal BSPs are typically written by psychologists, therapists or behavior analysts, and are implemented by an individual's support staff. Furthermore, formal BSPs are required in certain circumstances. For example, in the District of Columbia, an individual with intellectual disabilities who is taking psychotropic medications and receiving residential services through a Medicaid Waiver must have a formal BSP in place, and it must be reviewed annually. Regulations such as this are in place to prevent abuse of psychotropic drugs, and to ensure that behavioral strategies and supports are being utilized to address problem behaviors.
The Function of Behaviors
One of the foundations of thinking about supporting an individual with autism behaviorally is to understand the idea that each behavior has a purpose, or a function. Some behaviors, for example, may be intended to access a desired item or to avoid something unpleasant. Other behaviors may be attempts at gaining attention. Others are inherently pleasing to the individual. Knowing the function of a problematic behavior guides the creation and use of a BSP. (The function of a behavior is not the same thing as its origin. In other words, the origin of a behavior may be a problem with sensory integration or trauma such as bullying, but the function of the behavior may be to escape a current situation.) To this end, a professional may conduct a Functional Behavior Assessment (FBA)—a data-based analysis of the behavior—to help understand how to proceed in changing it.
The ABCs of Behavior Support
How does the support team gather data and document instances of problem behavior? A simple tool such as an “ABC” sheet (Antecedent, Behavior, Consequence) is often used by support professionals to log instances of problem behavior, and report on the essential elements of the event.
To complete the first section of the form, parents, staff and other support team members log the antecedents—that is, the things that came before—to the behavior. They ask themselves questions such as: What was going on before the behavior occurred? What was happening in the surrounding environment? What events or actions directly preceded the behavior? Was there a change from the usual routine? Had the person recently been ill? Were they hungry? They ask questions to determine what the individual's external and internal environment was like before the behavior in question occurred.
An example of a behavioral antecedent might be an obvious event, or trigger, such as a fire alarm, flashing light or other disturbance. Did something occur that caused sensory discomfort or overload? Or did a change in routine or plans impact behavior? The setting event to a problem behavior might be something that seems innocuous to an observer; for example, the behavior may be triggered by having one staff member assist them instead of another. Different individuals have different physical and psychological triggers, and what unsettles one person may not affect another.
As Richard Boesch, a clinical psychologist and supervisor for a DC-based behavioral support team says,“There are certain people who, because their threshold for stimulation is so low, may get set off by a fairly 'normal' level of sensory input. However, there are also people who have really high sensory thresholds, and their challenging behavior may be due to needing greater levels of [sensory] input.” In describing this second type of individual, Boesch uses the example of an individual with autism who needed to go outside and swing throughout the school day, because the rocking motion of the swinging provided them with the sensory input and stimulation they needed to remain calm.
Documenting antecedents is a vital part of preventing problem behaviors, because it allows support staff and parents to understand aspects of causation and to see the beginnings of a behavior. A specific individual's problem behavior may have a myriad of triggers, or there may be just one. In addition, the antecedents may be external and visible, or may result from an internal process, such as a biochemical imbalance or a psychological struggle. Whatever the probable antecedent, data collection can help the support team get a better idea of what is actually taking place. Once the antecedents have been identified, the support team can begin setting up systems to prevent further instances of problem behavior. “Really beginning to understand the setting events, the triggers that lead to behavior, is where most of the effort needs to be focused,” observes Boesch.
Once the antecedents have been examined, the support team must look at the behavior itself. What, exactly, is the individual doing that is problematic? On the ABC sheet, staff and parents describe the behavior in objective terms. What took place? What did the individual do or say that was problematic? It is necessary to describe the behavior objectively, writing, for example, “The individual threw a book,” instead of, “The individual was angry.” The first is a statement of observation; the second is an inference based on observation. The degree of difference between the two may seem slight, but it is significant; statements of observation can help educators, staff and parents to examine the problematic behavior based on data rather than suppositions about the feelings of the person with autism.
Finally, the ABC sheet asks the staff member or parent to examine the consequences of the behavior. They need to ask: What happened after, or because, the behavior took place? Was the individual ignored? Did they receive a great deal of attention, positive or negative? Did the behavior cause them to gain something desirable? Note that the term “consequence” does not refer to a punishment. It refers to the results of the behavior, whatever they may be. As with antecedents, this is an important section because it can help clue the individual's support team into why the individual exhibits their particular problem behavior. For example, does an individual's swearing always result in the attention of teachers and students? If so, the problem behavior (swearing) is resulting in a consequence that the individual finds pleasurable. In behavioral terms, the behavior is being “maintained” by attention as “reinforcement.”
Crafting a BSP
When creating a BSP, it's important to remember the basic principle governing behavioral supports: No one can force or coerce any true, lasting change in another person's behavior. One can, however, respond in such a way as to promote a different behavior. Additionally, when parents and educators begin a BSP, expectations for rapid positive change often arise. However, behaviors formed over long periods of time do not disappear overnight.
As a person with autism approaches adulthood, BSPs that were implemented during childhood may no longer function well. Additionally, families and support teams may now be able to actively involve the ASD adult in the formation and implementation of the support plan. If the person with autism is able to be a participant in creating and implementing the BSP, it is often very helpful for parents and caregivers to enlist the support of a professional. Allowing adults to work alongside professionals to form their own plans gives them a sense of ownership and fosters greater independence. The process often allows adults to develop a greater sense of self-awareness. The professional may be able to help the person with autism understand what’s triggering and maintaining the problematic behavior and may gain insight into what responses from others are most helpful. Unlike BSPs that are put in place for children (who are often unaware of the BSP's existence), BSPs that are put in place for adults have greater potential to be a collaborative effort. For instance, adults with ASD may be able to read and review their plans regularly, document their own behaviors, or assist support team members in filling out ABC sheets. Tasks like these help individuals to remember the purpose of the plan, and be accountable for its implementation. These collaborative plans are often most successful, as many adults on the autism spectrum can offer their support team valuable insights into their particular needs.
Implementing a BSP
The initial stages of a BSP may be the most difficult for the individual and their support team alike. Based on the analysis of the function of a problematic behavior, the BSP will outline what should happen when the behavior occurs. A good BSP will focus not only on decreasing problematic behaviors, but on increasing alternate acceptable ones. Removing whatever has been maintaining the problematic behavior can actually initially result in an escalation of that very behavior. For example, when parents, teachers and support personnel begin to ignore a behavior that was maintained by attention, individuals may actually increase the frequency and intensity of problem behavior, hoping to evoke the desired response once again. (This is often referred to as an “extinction burst.”) Providing an alternate, acceptable behavior often increases the probability that the individual will abandon their previous problem behavior. According to Boesch, “If you're just trying to extinguish a behavior by removing reinforcement, [the individual] will try harder. If you're providing an alternate behavior, you might not see the same surge.”
Accurately assessing the function of the problem behavior will also impact the progress of the BSP. Alternate behaviors are hard to provide without understanding the function of the one that needs to be decreased. For example, if the support team believes that the individual's behavior is attention-seeking, when it is actually a behavior designed to avoid something unpleasant, providing an alternate attention-seeking behavior will not be helpful. What should parents and support teams do if the function of an individual's problem behavior is not discernable? Boesch states, “It may take time to sort out what additional things are going on that are contributing. Try not to be frustrated, maintain consistency, and see what you can glean from situations where the behavior does occur.”
In simple terms, responses to behaviors—problematic or otherwise—come in two basic forms: reinforcing and punishing. Reinforcing responses are those which increase behaviors, while punishing responses decrease behaviors. Everyone has their own unique constellation of “reinforcers” and “punishers.” It is important that families and support teams work with professionals to understand what the individual with autism finds reinforcing. These are the things that will drive the BSP’s plan for behavior change.
When creating and implementing a BSP, consistency of response is key. When support teams meet to create BSPs, psychologists and team leaders emphasize the need for uniformity, with good reason: If an individual's behavior is rewarded in one setting and ignored in another, the problem behavior may actually become more entrenched. This phenomenon is due to the fact that the strongest type of reinforcement is “random intermittent reinforcement”—that is, occasional, unpredictable reward. To understand this, think about playing a slot machine. If every time a player inserted a coin and pulled the arm the machine spit out $5, the player would get quickly bored and stop playing. But if on some occasions the machine gives nothing, but on other occasions the player wins a jackpot, the player is more likely to continue to play. Boesch notes, “It just takes one person to keep a behavior going [via their intermittent reinforcement]. That being said, it's almost impossible to block this entirely, and so it's important to cultivate the alternate behavior. Make another behavior more valuable, more reinforced.” For this reason, it is important for support teams to maintain consistency, offer alternate behaviors, and create realistic plans, with reinforcement plans that can be maintained over time and across people and environments.
Further Support Principles Specific to Autism
The principles of behavioral support remain consistent across varying levels of intellectual and emotional intelligence. However, a few principles are helpful for offering behavioral support to individuals with autism specifically.
First, individuals with autism often have challenges in the area of interpreting emotional content. As such, making inferences about another person's feelings based upon facial expressions and gestures is a constant challenge. In order to offer behavioral supports for individuals with autism, particularly individuals who struggle with violent or self-injurious behavior, it is vital for support staff and family members to remain as calm as possible. When they do so, they not only give themselves a better chance of responding rationally, but they also ease the struggles of the individual that they are assisting. For an individual with autism, trying to interpret another person's heightened emotional state, while simultaneously maintaining calm behavior in a situation they find overwhelming, is extremely demanding, if not impossible.
Next, when supporting an individual with autism, it is imperative that sensory issues be taken into account in the BSP. Sensory issues are often triggers, and as such, individuals need ways in which to calm their bodies and minds. For example, the opportunity to calm down by utilizing a quiet room or a makeshift “squeeze machine” may prove invaluable for an individual with an overstimulated sensory system. By the same token, providing opportunities for individuals to receive higher levels of sensory input can be equally beneficial, as in the previous example of an individual who needed the rocking motion that swings provided to remain calm and focused.
Finally, behavioral support plans are designed with the individual in mind, but they can also help support team members. Individuals with autism may need to engage in behaviors that society does not consider “normal,” and this need can be difficult for some loved ones to accept. As such, a BSP allows team members to focus on their responses to specific behaviors. This renewed focus can alleviate the team member's anxiety, and reduce their desire to control (or "fix") the individual with autism's behavior. In this way, Behavior Support Plans can indeed become “Love Plans,” empowering support staff and family members to nurture relationships by responding calmly and consistently to an individual's problem behaviors.