A professor in the Division of Applied Research and Educational Support at the University of South Florida, Glen Dunlap, Ph.D. works on research, training, and demonstration projects in the areas of positive behavior support, early intervention, and family support. Currently a member of OAR’s Scientific Council, he has been involved with individuals with disabilities for more than 30 years. He helped establish the West Virginia Autism Training Center and Florida’s Center for Autism and Related Disabilities. Dr. Dunlap has directed numerous research and training projects, authored more than 170 articles and book chapters and co-edited four books, and served on 15 editorial boards.
Autism spectrum disorders (ASD) are a collection of developmental disabilities in which there is a great range of severity. Some children with ASD have severe intellectual disabilities, have no conventional communication skills, and require full-time supervision. On the other end of the continuum, there are children with ASD who have challenges with social connectedness but function well within (or above) the typical range in academic and functional life competencies.
Regardless of their level of functioning, children with ASD are at serious risk for the development of problem behaviors. Risk is manifested as difficulties in understanding and managing the social environment, challenges in getting needs met, and problems in communicating physiological and interpersonal discomfort. Such difficulties and frustrations are readily expressed in the form of problem behaviors such as prolonged and violent tantrums, property destruction, excessive stereotypic behaviors, aggression, and self-injury. These problem repertoires can be shaped (inadvertently) into intensive and chronic patterns of behavior that are increasingly resistant to intervention as children grow older without effective alternatives having been established.
The presence of serious problem behaviors is arguably the most significant impediment to learning and healthy social-emotional development for children with ASD. Problem behaviors are common reasons for excluding children from general education settings and other inclusionary opportunities, and they constitute a primary reason for limiting community participation, social interaction, and direct instructional interactions. Parents are understandably reluctant to include their children with ASD in community outings if their children are likely to engage in conspicuous problem behavior. Problem behaviors are also major sources of parent stress, as well as stress for teachers and other caregivers. As children proceed through their pre-school years and enter childhood and adolescence, the effects of serious problem behaviors can accumulate so that it can be extremely difficult to envision a life that is not constrained by highly restrictive living arrangements and very few opportunities for developing relationships or meaningful skills related to social interaction, community participation, or independent functioning. For these reasons, the vital importance of early detection, assessment, and remediation of problem behaviors has been increasingly appreciated. And a great deal of applied research on ASD has focused on problem behaviors (Horner, Carr, Strain, Todd, & Reed, 2002).
The vast majority of efforts in the literature to resolve problem behaviors have been initiated after the behaviors have already become frequent occurrences with serious implications. That is, most efforts to resolve problem behaviors are not initiated until the problem is fully developed and, presumably, highly resistant to remediation. Little research has focused on prevention of problem behaviors or on intervention at early stages in problem behaviors’ development. This is understandable for many reasons (including the methodological difficulties associated with prevention research), but it is also inefficient and, arguably, less effective than an approach that emphasizes early strategies of prevention.
An alternative approach centers around the thesis that problem behaviors of children with ASD can be addressed more satisfactorily if dedicated prevention efforts are undertaken before problem behaviors emerge, and on a continuum of prevention and intervention strategies geared to the degree of risk and chronicity-severity of the problem behavior. This article promotes a three-tiered prevention model as a framework for a hierarchy of strategies differing in their intensity and the resources needed for their implementation, and balanced against the status of the problem behavior(s) exhibited by the child with ASD.
A Model of Prevention
The prevention model being advanced for children with ASD is based on the three-tiered model of prevention that has been increasingly common in many arenas of social services including public health and education (e.g., Fox, Dunlap, Hemmeter, Joseph, & Strain, 2003; Sugai et al., 2000; Walker et al., 1996). The model begins by defining a target behavior in need of prevention, such as smoking cigarettes or destructive/disruptive behaviors. Strategies intended to prevent the occurrence or further development of the target behavior are then categorized along a hierarchy related to the proportion of the population for whom the strategy would be pertinent, the intensity of the strategy, and in terms of the stage of the target behavior’s development.
Level 1 strategies are intended for the entire population of interest (e.g., all children with ASD). The strategies are geared to an early stage of prevention and are relatively inexpensive and easy to implement. This level is referred to as primary prevention, involving universal applications. For instance, for smoking prevention, universal strategies might include public service announcements on television; for school-wide discipline, universal strategies might include posters promoting awareness of expected behavior, simple instruction for the entire student body, and a system of acknowledgement for students who follow school rules. Universal strategies for children with ASD would be implemented for all children, as young as possible, who are diagnosed or described as having ASD.
Level 2 is referred to as secondary prevention, and is intended for individuals for whom Level 1 is insufficient and who are clearly at risk for, or who are already demonstrating, early indications of the target behavior. Level 2 strategies for smoking prevention might focus on teenagers and include, as one example, lectures and films in secondary schools depicting the health dangers of smoking. For school-wide discipline, Level 2 might include social skills groups or special reinforcement contingencies for targeted groups of students identified as being at particular risk for school behavior problems.
For children with ASD, Level 2 might include specific procedures designed to teach appropriate problem solving and to divert children from using problem behavior. Level 2 strategies are more focused than Level 1, involve a smaller proportion of the population, and are less intensive and costly than Level 3 strategies. Still, for children with ASD, due to their substantial risk factors, it is likely that a relatively large segment of the population will require and benefit from Level 2 strategies.
Level 3 is for individuals who are already displaying the target behavior and require relatively intensive and individualized interventions. This level is referred to as tertiary prevention, with individualized, intensive intervention procedures. For smokers, strategies might include individualized counseling or therapy, nicotine patches or gum, and other techniques (e.g., self-management) demonstrated to be effective in such circumstances. For school-wide discipline, Level 3 could include functional assessment of the target behavior followed by individualized, behavioral interventions that might incorporate, for chronic cases, wraparound procedures involving families and community agencies.
For children with ASD, Level 3 involves individualized assessment and assessment-based interventions that are relatively well-represented in the current literature on positive behavior support and applied behavior analysis. These strategies are markedly more expensive in terms of resources and time required than Levels 1 or 2.
It is important to clarify that Level 3 for children with ASD is not just one level of intensity. It is actually a set of procedures on a continuum of intensity that is based on the extent to which the child’s problem behaviors are severe, long-lasting, and demonstrably resistant to change. That is, if a child is beginning to display tantrums at school, but the tantrums are limited to one or two classes and have not been exhibited at home or in the community, then the procedures need not be time consuming or especially effortful (though they may still require individualized assessment and an individualized intervention plan). Similarly, if the child is only 2 or 3 years old with problem behaviors that have functions that are easily understood, then they might call for a relatively straightforward and efficient process of intervention development and implementation. On the other hand, if a child has demonstrated severe problem behaviors for several years, and the problems have persisted in many environments despite multiple efforts of remediation, then the Level 3 process is likely to require a considerable investment of time and resources to be effective.
A Brief Synopsis of Strategies
Level 1 Strategies: Level 1, or primary prevention, strategies are intended for all children with an ASD diagnosis, and should be implemented as soon as the diagnosis is suspected. Two major objectives of Level 1 strategies are to: (1) provide a comprehensible, stimulating and non-irritating environment for the child, and (2) teach the child, from a very early age, that interacting with the social environment is a pleasurable and satisfying enterprise.
General strategies that are part of Level 1 include:
- Developing strong, positive relationships between parents (and other family members and caregivers) and the child. The intent is to teach the child that parents and caregivers are stable, secure, and safe figures that provide nurturance, comfort, pleasure, and guidance. Developing attachments is a challenge for children with ASD, so special efforts are required, even when signs of a child’s interest are not apparent.
- Providing a safe, comprehensible, stimulating, and responsive environment. As children with ASD often have difficulty navigating their surroundings, it is useful to be sure that clear physical cues are consistently available to help the child locate desired items and to make appropriate requests. A correlate of this strategy is that a child with ASD should be exposed to a variety of community and social contexts, while being supported by assistance and positive guidance to insure that these experiences are enjoyable and successful for the child.
- Ensuring that the child’s physical health is sound, that somatic complaints are understood and addressed, and that the child consumes food and beverages that are nutritious. A child’s physiological well-being is an important factor in preventing the emergence of problem behaviors.
- Providing intentional instruction to help the child acquire functional communication skills needed to effectively and conventionally control aspects of the child’s interactions with his environment.
Level 2 Strategies: Level 2 strategies involve specific procedures designed to enhance a child with ASD’s social competencies and, indirectly, help prevent the development or display of problem behaviors. Level 2 is for children with ASD for whom Level 1 is insufficient and who have risk factors that indicate a need for more deliberate strategies. Such risk factors include obvious delays in language development, notable avoidance of social interactions, and a failure to acquire functional skills. These criteria suggest that a large proportion of children with ASD may require Level 2 supports, though the actual proportions are unknown and must await the completion of considerable research.
The ASD literature offers many examples of Level 2 strategies, including elements of specialized programs (National Research Council, 2001). An excellent example is provided by Strain and Schwartz (in press) who describe a strategy referred to as “appropriate engagement intervention,” in which the procedural focus is on increasing children’s appropriate engagement with classroom materials and activities. Although not designed explicitly as an intervention for problem behaviors, increases in engagement tend to covary negatively with occurrences of problem behavior and, thus, the engagement intervention serves well as a strategy for preventing problems without an intensive behavior intervention plan.
Another set of strategies is found in “Pivotal Response Treatment (PRT)” (Koegel & Koegel, 2006). Included within PRT are numerous variables that are useful for increasing the motivation and engagement of children with ASD, and such variables serve not only to enhance children’s academic, communicative, and social development, they also serve to prevent problem behaviors. Such procedures involve less effort and intensity than Level 3 strategies, yet they can be extremely useful for encouraging pro-social development and preventing the development of problems.
Level 3 Strategies: Level 3 is comprised of procedures that are most readily associated with interventions for problem behaviors because these are the strategies that are deployed after problem behaviors have developed to the point that they present obstacles to education and healthy social-emotional development, and present threats to the physical and emotional safety of the child with ASD, his peers, or others in the vicinity. At one time, the predominant approach for such problem behaviors was based almost entirely on contingency management, in which interventions consisted of manipulations of rewards and punishers.
While contingency management is still important, Level 3 strategies have broadened considerably over the past two decades and now include a focus on rearrangements of the antecedent environment and instruction on functional alternatives to the problem behaviors. Level 3 strategies now place a strong emphasis on education rather than suppression. In addition, Level 3 interventions are generally preceded by a process of functional assessment, designed to identify intervention components that address the individualized functions of the particular child’s problem behaviors. The overall process of assessment and intervention is based on applied behavior analysis and commonly referred to as positive behavior support (Dunlap & Carr, 2007; Sailor, Dunlap, Sugai, & Horner, in press).
The process for implementing individualized Level 3 strategies generally consists of five steps:
- Establishing a team and gaining a unified understanding of the child and an agreement on the short and long-term goals of intervention
- Conducting a functional assessment of problem behavior
- Developing an individualized intervention plan
- Implementing the intervention plan
- Evaluating the effects of the intervention
This process of positive behavior support (PBS) has been demonstrated in numerous studies, literature reviews, and syntheses to be effective in building desirable skills and reducing or eliminating problem behaviors (Carr et al., 1999; Dunlap & Carr, 2007). As testimony to its effectiveness, the methods and outcomes of PBS have been described in numerous Web sites, articles, manuals, and books, and the vast majority of these resources offer information and guidance that is evidence-based, credible, and useful.
The purpose of this article was to describe a multi-tiered approach to the problem behaviors of children with ASD. The emphasis of the framework, at all levels, is on prevention. Children with ASD present such a large number and complexity of risk factors that complete prevention of problem behaviors is not always realistic, at least for some children. However, it is expected that careful attention to the strategies at the primary and secondary tiers of the model (Levels 1 and 2 of intervention) will effectively prevent the development of problem behaviors for some children and at least mitigate the need for highly intensive Level 3 interventions for the remainder.
Research is clearly needed to validate the efficacy of the model and to refine the strategies that are especially useful, especially at Levels 1 and 2. However, there is every reason to believe that the model can be a very beneficial approach for addressing the critical concerns associated with problem behavior and children with ASD.
Carr, E. G., Horner, R. H., Turnbull, A. P., Marquis, J., Magito-Mclaughlin, D., McAtee, M. L., Smith, C. E., Anderson-Ryan, K., Ruef, M. B., & Doolabh, A. (1999). Positive Behavior Support for People with Developmental Disabilities: A research synthesis. Washington, DC: American Association on Mental Retardation.
Dunlap, G., & Carr, E.G. (2007). Positive behavior support and developmental disabilities: A summary and analysis of research. In S.L. Odom, R.H. Horner, M. Snell, & J. Blacher (Eds),Handbook of Developmental Disabilities (pp. 469-482). New York: Guilford Publications.
Fox, L., Dunlap, G., Hemmeter, M. L., Joseph, G. E., and Strain, P. S. (2003). The teaching pyramid: A model for supporting social competence and preventing challenging behavior in young children. Young Children, 58, 48-52.
Horner, R.H., Carr, E.G., Strain, P.S., Todd, A.W., & Reed, H.K. (2002). Problem behavior interventions for young children with autism: A research synthesis. Journal of Autism and Developmental Disorders, 32, 423-446.
Kincaid, D. & Fox, L. (2002). Person-centered planning and positive behavior support. In S. Holburn & P. M. Vietze (Eds.), Person-Centered Planning. Research, Practice, and Future Directions (pp. 29-50). Baltimore: Paul H. Brookes.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal Response Treatments for Autism: Communication, Social, and Academic Development. Baltimore, MD: Brookes Publishing Company.
National Research Council (2001). Educating Children with Autism. Committee on Educational Interventions for Children with Autism. Catherine Lord and James P. McGee (eds). Division of Social Sciences and Education. Washington DC: National Academcy Press.
O’Neill, R.E., Horner, R.H., Albin, R.W., Storey, K., Sprague, J.R., & Newton, J.S. (1997).Functional Assessment of Problem Behavior: A Practical Assessment Guide. Pacific Grove, CA: Brooks/Cole.
Sailor, W., Dunlap, G., Sugai, G., & Horner (Eds). Handbook of Positive Behavior Support. New York: Springer.
Strain, P., & Schwartz, I. (in press). Positive behavior support and early intervention for young children with autism: Case studies on the efficacy of proactive treatment of problem behavior. In W. Sailor, G. Dunlap, G. Sugai, & R.H. Horner (Eds). Handbook of Positive Behavior Support. New York: Springer.
Sugai, G., Horner, R.H., Dunlap, G., Hieneman, M., Lewis, T.J., Nelson, C.M., Scott, T., Liaupsin, C., Sailor, W., Turnbull, A.P., Turnbull, H.R. III, Wickham, D., Ruef, M., & Wilcox, B. (2000). Applying positive behavior support and functional behavioral assessment in schools.Journal of Positive Behavior Interventions, 2, 131-143.
Walker, H. M., Horner, R.H., Sugai, G., Bullis, M., Sprague, J.R., Bricker, D. et al. (1996). Integrated approaches to preventing antisocial behavior patterns among school-age children and youth. Journal of Emotional and Behavioral Disorders, 4, 194-209.