Question
I am a special education teacher. I have an autistic (high functioning) student that hits impulsively. We have tried behavior modification, social stories, sensory exercises, and music therapy. She will say what she did was wrong and we will role play the correct behavior. She still hits and is getting in a lot of trouble. There is no pattern or functional cause. I want to help her but am running out of ideas. Does you have any suggestions??
Answer
There is a great concern about the incidence of violent behavior among kids and teens with High-Functioning Autism (HFA) and Asperger's (AS). This complex and troubling issue needs to be carefully understood by parents, educators, and other grown-ups. HFA and AS kids as young as preschoolers can show violent behavior. Moms and dads and other adults who witness the behavior may be concerned; however, they often hope that the young child will "grow out of it." Violent behavior in a youngster at any age always needs to be taken seriously. It should not be quickly dismissed as "just a phase they're going through!"
Faced with a world in which they find it difficult to interact socially, communicate clearly, and control their own behavior, kids on the autism spectrum sometimes respond with aggressive behavior. Aggression - physical and verbal - is a common characteristic of the disorder, and can be directed toward inanimate objects, moms and dads and other family members, educators, peers, and even toward the youngster herself. An observant parent or teacher can take practical steps to soothe and redirect a violent youngster.
Range of Aggressive Behavior—
Violent behavior in kids and adolescents with the disorder can include a wide range of behaviors. Kids who exhibit aggressive behavior intend to deliberately hurt others. Aggression can manifest in a number of ways including:
- biting
- cruelty toward animals
- destroying public or personal property
- explosive temper tantrums
- fighting
- fire setting
- hitting
- kicking
- pushing
- spitting
- threats to hurt others (including homicidal thoughts)
- throwing objects
- use of weapons
Factors Which Increase Risk of Aggressive Behavior—
Numerous research studies have concluded that a complex interaction or combination of factors leads to an increased risk of violent behavior in HFA/AS kids and adolescents. These factors include:
- being the victim of physical abuse and/or sexual abuse
- brain damage from head injury
- combination of stressful family socioeconomic factors (poverty, severe deprivation, marital breakup, single parenting, unemployment, loss of support from extended family)
- emotional problems
- exposure to violence in media (TV, movies, etc.)
- exposure to violence in the home or community
- frustration
- genetic (family heredity) factors
- limited communication or problem solving skills
- low self esteem
- presence of firearms in home
- previous aggressive or violent behavior
- spending time with peers who are aggressive
- stress
- temperament
- use of drugs and/or alcohol
What are the "red flags" for aggressive behavior in kids?
Kids on the spectrum who have several risk factors and show the following behaviors should be carefully evaluated by a Child and Adolescent Psychiatrist:
- Becoming easily frustrated
- Extreme impulsiveness
- Extreme irritability
- Frequent loss of temper or meltdowns
- Intense anger
Moms and dads and educators should be careful not to minimize these behaviors in kids.
What can be done if a youngster shows aggressive behavior?
Whenever a mother/father or other adult is concerned, they should immediately arrange for a comprehensive evaluation by a qualified mental health professional. Early treatment by a professional can often help. The goals of treatment typically focus on helping the youngster to:
- accept consequences
- be responsible for his/her actions
- express anger and frustrations in appropriate ways
- learn how to control his/her anger
In addition, family conflicts, school problems, and community issues must be addressed.
Can anything prevent aggressive behavior in this population?
Research studies have shown that much violent behavior can be decreased or even prevented if the above risk factors are significantly reduced or eliminated. Most importantly, efforts should be directed at dramatically decreasing the exposure of kids and adolescents to violence in the home, community, and through the media. Clearly, violence leads to violence.
In addition, the following strategies can lessen or prevent violent behavior:
- Early intervention programs for violent youngsters
- Monitoring the child's viewing of violence on TV/videos/movies
- Prevention of child abuse (use of programs such as parent training, family support programs, etc.)
- Sex education and parenting programs for adolescents
Treatment—
To be effective, treatment approaches for aggressive children need to take these factors into account:
• ‘Me against the world’ attitude. Kids who become aggressive have often learned to see the world as a cold and hostile place. They develop a habit of thought that attributes hostile intentions to others. This attitude leaves them little choice but to fight virtually all the time. If, for example, another youngster bumps up against them in the hallway at school, they immediately take offense, certain that they were attacked. They cannot imagine that perhaps the bumping was just clumsiness on the other youngster's part or an attempt to tease that really wasn't hostile.
• Always the victim. Even while they are the aggressors, aggressive children almost always think of themselves as victims--of unfair educators, of other bullies, of prejudice--and believe that their aggressive acts are therefore totally justified.
• Distorted thinking. Aggressive kids come to believe that overpowering another child is a mark of strength and worth, and that violence is a legitimate way to resolve conflict. Popular media support this idea, with wrestlers who pound their opponents without mercy and so-called action heroes who slaughter foes by the truckload. For good or bad, the government unwittingly encourages the idea that "might makes right" when it engages in shows of strength celebrating the Army and police. Aggressive kids needn't look far for evidence that force is what really counts.
• Never safe. The violent youngster sees the world as an unsafe place in which there are only victims and victimizers, so he (unconsciously) chooses to be one of the latter. The power and delight he takes in hurting others, in combination with his already numbed emotions, can make for a lethal mixture.
• Self-esteem. For some kids, violence toward other kids may be a powerful source of self-esteem, particularly if they lack other confirmation of their human worth. In many cases, the problem is not lack of self-esteem as much as lack of self-esteem related to positive, peaceful accomplishments.
• The loss of empathy. Aggressive kids often don't even recognize (much less feel) the suffering of others. Empathy develops early in infancy. Most nine-month-old infants register concern if they see their moms and dads crying, for example. Kids who have been emotionally traumatized learn to protect themselves from further emotional damage by shutting off their own feelings along with any empathic feelings they might have for others.
Specific Strategies for Parents and Teachers—
• Acknowledge your child’s feelings while setting boundaries. Maintain eye contact with your youngster and find ways to help him verbalize his anger. Let him know that it’s okay to be angry but hurting others in not acceptable behavior. You can say, "I understand that you’re angry but I expect you to (state the boundary)."
• Acknowledge your role. When one youngster is acting out, the family will blame him for the family's dysfunction. Oftentimes, you will see a family that will present a disruptive youngster for treatment ... this is the sacrificial lamb for the family's toxicity. Parents need to examine their own behavior, and if need be, the entire family should seek counseling.
• Be selective about the types of television programs your kids watch. Don’t let them view shows that depict violence as humorous, or as a way to deal with problems.
• Clearly State Expectations. Power struggles will be reduced when the youngster knows what is expected of him.
• Don't get into a power struggle with a youngster. Sometimes aggressive kids know that if they struggle long enough with their parents (e.g., yelling, screaming, throwing temper tantrums in a crowded store, etc.), they will get their way. Be firm in disciplining your youngster and let them know that there boundaries that they have to observe.
• Evaluate Outside Influences. If aggressive behavior has developed suddenly or has gotten worse over time, then find out if the youngster has a food allergy. Other factors to consider are environmental conditions, change in medication or a change in the home or school setting. Some drugs cause aggression. Seasonal or food allergies can cause discomfort that the youngster can't describe, leading to extreme behavior.
• Every youngster has currency. Use it! There's not a youngster born that doesn't have currency, whether it's toys, clothes, games, or television. Access to this "currency" needs to be contingent upon proper behavior (e.g., if a youngster throws a temper tantrum in a crowded store, he should not be rewarded with a toy or a coloring book). He needs to (a) understand the consequences of his behavior, (b) be able to predict the consequences of his actions with 100% accuracy.
• Identify Triggers to Aggression. Sometimes violent outbursts are predictable. For example, does wearing a warm winter sweater cause him to become angry? Maybe the fabric feels uncomfortable against his skin, or the smell of the drier sheet is offensive to him. Examine every component of a situation that seems to trigger aggressive actions and making adjustments.
• If you know that your child is prone to frequent aggressive outbursts, always be prepared to avert trouble by sticking close by when he is playing with others.
• Maintain a unified front. Sometimes aggressive kids know that if they engage in "divide and conquer" tactics with their parents, they will be able to get their way. If you're together, if you're unified and if you're there for each other, then all of a sudden there's strength in numbers.
• Make sure that your kids have opportunities to expend excess energy by getting plenty of physical activity each day.
• Obtain a proper diagnosis from a psychologist. Many times, mothers/fathers are quick to make evaluations of their kid's unruly behavior, such as blaming aggressiveness on ADHD, attention deficit hyperactivity disorder. Parents need to revisit their evaluations, because a youngster's violence may be stemming from other issues. Don't make judgments until you get to the root of the problem.
• One of the best ways to teach your youngster nonviolence is to control your own temper. If you express your anger in quiet, peaceful ways, he’ll probably follow your example.
• Reduce Stress. Sometimes stress over not being able to verbalize frustration causes aggressive behavior. If a youngster is angry that he can't button his coat, but is unable to describe how he feels about lacking that skill, he could act out inappropriately. Examining the root problem and addressing it may help to curb angry behavior. Calm reactions on the part of the parent or teacher are important here.
• Remove kids from the stimulant that triggers violent outbursts.
• Seek a Doctor's Advice. Medication may be needed, especially if the youngster's behavior is hazardous to him or those around him. The U.S. Food and Drug Administration has not approved a medication specifically for HFA or AS. But some drugs used to treat other conditions have been shown to be useful in treating young people with an autism spectrum disorder. A health care professional can help you determine whether medication will be helpful for your aggressive youngster.
• Simplify the Environment. Arrange furniture in a sensible way for the youngster so that he can easily maneuver through rooms. If a youngster often tries to escape through a certain door, change the path of the room so that he is unlikely to go near that door. Keep surfaces clear, taking special care to place breakables and dangerous or messy items out of reach. Organize and structure the youngster's living space to minimize frustration. Again, labels can help the youngster understand where things belong and make him less likely to become overwhelmed or anxious. Restrict access to items that tend to cause power struggles.
• Since kids tend to repeat behaviors that are reinforced, it is important for you to provide them with consistent, positive attention for behaviors that are acceptable.
• Stop being intimidated by your youngster. Many moms and dads are afraid to discipline an unruly youngster for fear that their youngster will hate them for being an authority figure. Your youngster doesn't have to like you or even love you, but he does have to respect the parent-youngster relationship and realize that there will be consequences for negative actions. Recognize that you don't have to be your youngster's friend, but you do have to be his parent.
• Your surroundings can set the tone for calm or chaos. So minimize stress levels in the immediate environment.
Pharmacologic Treatment of Aggression—
Medications are frequently used in the management of aggression, and current psychopharmacologic treatment strategies involve treating aggression as part of each particular syndrome.
• Antidepressants— Antidepressants reduce fear, irritability, and anxiety, emotions that are in the same spectrum as agitation. Current findings point to decreases in negative mood and aggressive attacks, as well as positive changes in personality traits after antidepressant treatment.
• Antipsychotics— Antipsychotic medications are not recommended for people who do not have a psychotic or bipolar disorder. Lorazepam or another nonspecific sedating agent is preferred.
• Benzodiazepines— Lorazepam is a good choice to treat acute agitation or aggression, particularly when the cause is not clear. Benzodiazepines also have a risk for abuse, and therefore should not be used on a regular basis.
• Beta Blockers— Beta-adrenergic blockers, especially propranolol, have been used to treat aggressive behavior in a number of diagnoses, including autism.
• Mood Stabilizers— Mood stabilizers are primarily used for the treatment of bipolar disorder and as an adjunct treatment for schizophrenia. They are also used to treat aggression, although they are not prototypical for this purpose.
Before prescribing medication for aggression, the clinician should ensure that the child or adolescent has a medical evaluation to rule out contraindications to treatment and to determine whether the aggressive symptoms might improve without the use of drugs (e.g., cognitive-behavioral therapy). Psychiatric evaluation is also necessary to determine whether depression, anxiety, substance abuse, or other problems are present. Treatment of these conditions may also result in reduced symptoms of aggression.
==> Preventing Aggressive Behavior in Aspergers and HFA Children