- Managing an aggressive outburst from your child with autism spectrum disorder
- Managing self-injurious behaviour in your child with autism spectrum disorder
- Getting professional help
- Why is ASD Often Associated with Aggressive Behavior?
- Autism Can Involve Elevated Aggression Levels But The Sources Are Unclear
- Dealing With Aggression In Autistic Patients
- Understanding aggression in autism
- New Research on Children with ASD and Aggression
- Asking Questions about Autism and Aggression
- Shedding Light on Aggression and ASDs to Help Families
- Aggressive Behavior in Children with Autism
- Signs of Aggressive Behavior in Autistic Children
Managing an aggressive outburst from your child with autism spectrum disorder
You probably can’t prevent every outburst from your child with autism spectrum disorder (ASD). But you can try to manage the aggressive behaviour when it happens. Here are some tips.
The first and most important thing is to stay calm. Most aggressive outbursts or tantrums happen because your child has feelings building up and he can’t communicate them. By managing your own feelings and staying calm and quiet, you won’t add your emotions to the mix.
During an outburst your child will be feeling very stressed. It’s hard to process what someone else is saying when you’re feeling stressed, and this is especially true for children with ASD, who can have trouble understanding language.
It can help if you limit what you say to short phrases or even just a couple of words – for example, ‘Sit down’ rather than ‘Lachlan, come over here and sit down’.
You might need to move your child to a safer place, away from anything that could hurt her – for example, shelves that could fall over or glass objects. A quiet enclosed space outside might be an option. You might also need to get other people to move out of the way for safety.
Visual cues can also help in these situations – for example, you might have a picture of a quiet place in your home that your child can go to.
If you find you have to use physical restraint when your child has an aggressive outburst, speak with your child’s paediatrician or a behavioural therapist, ideally a Board Certified Behaviour Analyst®, about other options.
Physical restraint can be dangerous to both you and your child, and can often increase your child’s anxiety and make the situation worse. Positive behaviour support is always preferable to physical options.
Managing self-injurious behaviour in your child with autism spectrum disorder
Working out what your child with autism spectrum disorder (ASD) is trying to tell you with self-injurious behaviour can help you decide how to manage it.
For example, your child might find it hard to switch from one activity to another. He might bang his head on the floor when you tell him that it’s time to put away his train set before dinner. You could try warning him five minutes before you need him to pack away by showing him a photo of washing hands and sitting at the table for dinner. This will give him a warning, plus time to finish what he’s doing.
If your child has been doing a puzzle for 10 minutes and starts to pull her hair, she might be trying to let you know that she wants to do something else. Offering her a new activity might stop the hair-pulling.
Your child might hit himself because he wants you to look at him and talk to him. Going over to him and giving him attention will stop him hitting himself. The next step is teaching him to get your attention in another way – for example, by saying ‘Mum’ or coming to you and showing you a help card.
Your child might be feeling frustrated and need help. For example, your child has been playing with a doll but the leg comes off, so she starts to scream and scratch herself. If you help her fix the doll, it will stop her hurting herself. The next step is teaching your child to show her frustration in another way – for example, to say, sign or show a picture to tell you when she needs help.
A note about responding to self-injurious behaviour
Giving your child what he wants can strengthen the behaviour and make it more likely that your child will behave in the same way in a similar situation in the future.
A better long term strategy is to:
- prevent the behaviour by avoiding situations that trigger it
- teach your child to express his needs in a more positive way
- ignore self-injurious behaviour and reward your child when he expresses himself in a more positive way.
This can be hard to do without professional help to work out why your child is behaving aggressively or self-injuring.
Getting professional help
A Board Certified Behaviour Analyst® or other experienced professional can help you understand and manage your child’s aggressive or self-injurious behaviour. This might be particularly helpful if you’ve already tried other strategies without success.
For example, the professional might use functional analysis to work out why your child is behaving aggressively or is self-injuring. Then the professional might create a positive behaviour support plan that includes strategies to reduce the behaviour and teach new behaviour.
A mother in our group has written this excellent guide to coping with an aggressive child in order to help other parents who may be in a similar situation.
These are some tips that I have picked up along our journey. I am by no means an expert, but there are some things that I learnt the hard way and I’m hoping that by listing them here, I might be able to help other parents who are in our situation.
1: It isn’t your fault
This sounds obvious, but it is really hard to remember this when your child is shouting at and hurting you. It truly isn’t your fault; don’t waste energy beating yourself up over it and trying to work out what you may have done wrong. If you are reading this and trying to do something to help your child, then you are a fantastic parent and I really hope the following helps.
2: Behaviour is communication
It may be hard to believe at the moment, but children use behaviour as communication, they don’t usually wake up in the morning determined to make life hard. I found that once I understood this, I had a lot more patience with my son. One of the best ways that I have heard autistic behaviour described is the ‘Coke Bottle Effect’. Imagine your child is like a Coke bottle; every time that something causes them stress is like one shake of the bottle until eventually the bottle explodes.
For an autistic child the things that can cause them stress can be very insignificant to us and therefore we don’t fully appreciate the effect of these on the child. Some examples of this could be their teacher wearing stronger perfume than normal or a different type of bread used for their packed lunch.
3: Keep a diary
I was advised to buy a week to a page diary and write in it details of my son’s aggressive outbursts. This includes what triggered the outburst, how long it lasted, what caused it to end, and a rating – 10 being the worst ever and 1 being not very much aggression at all.
We very quickly started to see patterns. For example, Sundays are always a problem day for us, probably because he was getting stressed about school on Monday.
We also started to keep notes in the diary of other things that could affect his mood, such as sessions with his mentor, non-uniform days at school or other significant changes to the routine. It may seem that this is a lot of work, but I really do recommend it as understanding the patterns and triggers in the behaviour can help you to help your child deal with these emotions better.
4: Keep siblings safe
Again this is something that probably doesn’t need saying, but it is so important. The aggression from our kids is a form of domestic violence, and our role is to not only ensure that siblings are kept safe, they must also be protected from witnessing their parents being victims of this violence.
We were advised to create an emergency plan with a family member. My mum has spare pyjamas, a toothbrush, etc., at her house and we can ring her and she will come and get my youngest son and take him to hers for as long as is needed. We have also explained to him that if we tell him that he needs to go to his room for a bit, it is not a punishment, it is to keep him safe.
5: Be prepared to make lifestyle adjustments
A lot of my frustrations were because it was so hard to do things that a ‘normal’ family can do. One of our biggest problems was car journeys, as my son regularly got aggressive in the car.
Once we got into the habit of splitting the boys up so that one was in the front with the driver and the other was sat in the back with the other adult. We then had far fewer problems with car journeys. We have also had to adjust our sleeping arrangements so that the boys don’t have to share a bedroom.
6: Don’t be afraid to talk about the aggression
What you are experiencing is serious and you need to get help, but unfortunately help is really hard to get. If you have any professionals working with you, then talk to them about it. Show them the diary as this will give them an idea of how often you are experiencing this. I also made voice recordings on my phone, which proved really useful as well.
If you don’t have a social worker or paediatrician, then talk to the SENCO at your child’s school as they are able to make referrals. There will also be a school nurse linked to the school who you can ring. Once you have spoken to someone, keep on talking to them. Unfortunately you have to keep badgering to get help.
7: When it’s ended, it’s ended
Once the aggression has ended, the child needs to have chance to recover. They will not only be exhausted from the physical exertion but they will be mentally exhausted. Try not to bombard them with questions as this will be confusing and they may not remember very much about what has just happened.
Also try not to dish out consequences, this could increase the child’s frustration, particularly if they don’t know why they got angry in the first place and they don’t have the ability to control it. I found it much better to reward the times when I could see that my son started to get angry and then controlled it.
8: Remember the positives
It can sometimes be really hard to see past the aggression. I found it helped me to take photos of my son while he was happy doing everyday things like playing with Lego, going out for a walk etc. These were not photos for Facebook or sending to Grandma; these were photos for me to keep on my phone and look at when I felt really low, to remind me of the lovely son that was still there underneath the aggression.
Unfortunately, this is a tough journey and you have to work at finding the strategies that work for you and your child. However, you are not alone. There are many parents going through the same thing and it does help to remember that. Just don’t be afraid to talk about it and ask for help.
- Lives in the Balance – an American website with advice on how to support children with aggressive behaviour
- Notes from our Behaviour that Challenges workshop
- Violent & Challenging Behaviour: The Basics – information from Yvonne Newbold, who is working extensively in this area
Why is ASD Often Associated with Aggressive Behavior?
Izzy was diagnosed with autism spectrum disorder at the age of 3. Like many parents whose first child is autistic, Izzy’s parents missed many of the early signs—delayed speaking skills, lack of eye contact and interaction. When their pediatrician suggested a formal evaluation, they were resistant. But as the girl grew older, her tantrums and inability to communicate or make a meaningful interpersonal connection became too much to brush under the rug any longer.
At home and at her specialized daycare, Izzy’s caregivers learned to manage her outbursts. But when she started preschool at age 4, she entered a new and confusing world with larger classrooms and instructors who were not equipped to deal with her needs.
She started to throw books and hit teachers. A tantrum could end up with baskets of toys flying across the room. At recess, kids and playground aides had to be particularly wary because rocks were Izzy’s projectiles of choice.
Such aggressive behavior is well known to applied behavior analysts and other people who routinely work with kids with severe cases of ASD… but it’s the reasons behind this aggressive behavior and why it’s so frequently linked to autism that are not so easily understood.
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Autism Can Involve Elevated Aggression Levels But The Sources Are Unclear
Aggression is not itself a symptom of autism and not all ASD patients are aggressive. Studies vary on how prevalent aggression is in ASD cases. A 2010 survey found that 68 percent of children with ASD showed aggressions toward caregivers, while 49 percent were aggressive with non-caregivers. A 2014 study, however, found that somewhere in the neighborhood of 25% of children with autism will also show aggressive behavior, such as throwing objects, hitting people, or intentionally breaking things – numbers that are troubling for caregivers and advocates and a major concern for parents and teachers who have to look out for the safety of siblings and classmates.
The studies also indicate that symptoms of aggression often overlap in patients with extreme anxiety and attention deficit issues.
Aggression is most common in ASD patients with low IQ scores but only a moderate level of autism symptoms.
The underlying elements leading to aggressive behavior in ASD patients are not well understood. There may be some biological connections related to the differences in brain structure that are known to exist in autism cases. A 2017 study from Brigham Young University compared MRI scans between two groups of ASD patients and found that among the group that exhibited problematic levels of aggression, brain stem volumes were lower. This suggests a core, autonomic connection between the disorder and aggressive behaviors.
There are also a number of underlying elements common to the disease that can lead to anxiety and frustration, and the aggression that often follows. Social and communications difficulties are some of the core symptoms of ASD, and are often the source of the kind of intense frustration and anxiety that results in a meltdown. Worse, without the usual array of verbal and non-verbal communication skills that are available to neurotypical people to use to explain their thoughts and feelings articulately or otherwise work out problems, one type of behavior that is almost guaranteed to get a response is… you guessed it, aggression. When they are unable to communicate their thoughts and needs normally, autistic kids may learn early on that hitting or yelling is one way to get a message across.
Dealing With Aggression In Autistic Patients
Aggression is one of the more common behaviors in autistic individuals that ABAs are asked to address- if for no other reason than because these issues have the biggest potential for harm, to the autistic individual and to those around them. Because aggressive behaviors can be among the most disruptive, and even the most dangerous ways ASD expresses itself in patients, it rises to the top of the list as the number one priority for parents, teachers and ABAs.
Applied behavior analysis has become the treatment of choice for autism but it has also long been an option for treating aggression, both in ASD and neurotypical patients. A 1999 study shows that using variable and delayed reinforcement techniques to curb aggression and impulsive behavior were effective.
Recently, combined treatments that include both elements of ABA and medications have been found to be effective in treating patients with aggression issues.
But in Izzy’s case, ABA therapy by itself helped her and her family turn the corner. A telehealth pilot program that brought a skilled ABA into Izzy’s home via computer to provide treatment remotely helped her learn to develop coping skills that improved her self-control and minimized her aggressive outbursts. Izzy’s case is an example of a success story that owes its happy ending to ABA interventions coupled with on-going involvement from parents and teachers who worked to provide consistent feedback.
Understanding aggression in autism
Jennifer Richler; Katherine Gotham.
Two new studies explore the link between autism and aggression — a controversial connection that weighs heavily on individuals with the disorder and their families.
One study, published 1 September in Research in Autism Spectrum Disorders, found that one in four children with autism shows aggressive behavior, such as hitting others, destroying property or throwing temper tantrums. In this study, aggression was more common among children with mild autism symptoms and low intelligence quotients. Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention.
The second study, published 11 September in Autism, explored possible pathways to aggressive behavior in undergraduate students who do not have autism. It found that social anxiety and anger rumination — the tendency to dwell on negative, hostile feelings — predict verbal and physical aggression. People who tend to think or talk about the same things over and over again — a feature of autism dubbed cognitive perseveration — are more likely to dwell on negative feelings.
The studies are timely, given the media attention surrounding Kelli Stapleton, a Michigan mother who pleaded guilty to the attempted murder of her 14-year-old daughter, Issy, in September. Issy had autism and a history of aggression that was at times extreme. Coverage of the case generated considerable controversy, particularly among autism rights advocates, who felt some media reports painted the mother as a victim of her daughter’s aggression.
In reality, the case was much more complicated. Stapleton was abused as a child. At her trial, psychiatric experts suggested that she had a personality disorder that made her ill-suited to face the challenges of raising a child with autism and aggressive behavior.
Putting aside these particulars, the case provides an opportunity to consider aggression in autism. While extreme, the behaviors that Issy displayed are consistent with those seen in some people with autism: They lash out, often in moments of anger or frustration, often at caregivers and family members.
This is a major source of stress for families. Some parents worry about their safety and that of their other children. There is also misplaced concern among the general public, particularly in light of another high-profile case: that of Adam Lanza.
Lanza, who in 2012 shot and killed his mother, 20 elementary school children and 6 school staff members before killing himself, reportedly had a diagnosis of Asperger syndrome. As a result, much of the media attention surrounding the tragedy focused on a possible connection between autism and violence.
There is little empirical evidence for such a connection. In fact, aggression in children with autism tends to be impulsive, vastly different from the premeditated murders Lanza carried out.
Though some people with autism are aggressive to themselves and to their caregivers, we have no reason to think that autism leads to intentional violent behavior. However, given that individuals who dwell on anger may be more prone to aggressive behavior,it is worth considering whether the relationship between anxiety, anger rumination and aggression might also extend to violence in some individuals with autism.
It’s also important to consider that autism is not the only vehicle to social isolation and anger rumination. People with depression, schizoaffective disorder and social phobia also experience these phenomena. In fact, aggression has been more consistently linked to these types of psychiatric disorders than to autism.
Rather than focusing on whether autism and violence are connected, we believe that it is far more useful to look for ways to ease aggression in individuals with the disorder. These new studies suggest that alleviating problems with sleep, attention or anger rumination might be a first step.
Katherine Gotham is assistant professor of psychiatry at Vanderbilt University in Nashville, Tennessee. Jennifer Richler is a freelance science writer based in Bloomington, Indiana, who holds a Ph.D. in clinical psychology.
New Research on Children with ASD and Aggression
Information shared by families participating in the Simons Simplex Collection project helps researchers explore questions about aggression in children on the autism spectrum.
Aggressive behaviors in children with autism spectrum disorders (ASD) often cause a great deal of difficulty for families. Hitting, kicking, biting, throwing objects, and other behaviors common during a temper tantrum or meltdown can greatly increase parent stress.1 To make things worse, a vicious cycle can begin so that behavior problems increase stress and increased stress (together with fraying nerves and poorer parental responses to the behavior) result in even worse behavior problems.2
Disruptive behaviors also may interfere with interventions meant to help a child, and with a child’s ability to succeed at school. They may keep a child barred from a variety of community activities. (Children with aggressive behaviors may not be welcome in after-school, scouting, sports, or other programs.) Furthermore, fear of aggressive incidents may keep a family at home, increasing their sense of isolation and decreasing their quality of life.
However, little work had been done to study aggression in children with ASD. Now, a new study reveals that aggression is extremely common in children on the autism spectrum, but is not associated with the same factors usually linked to aggression in typical children.
Asking Questions about Autism and Aggression
Despite its importance in the lives of children with ASD and their families, aggression has rarely been investigated by autism researchers. That is why Drs. Stephen Kanne and Micah Mazurek of the Thompson Center for Autism and Neurodevelopmental Disorders at the University of Missouri recently set out to explore two vital questions:
- How often do children with autism spectrum disorders (ASD) exhibit aggressive behavior?
- What risk factors are associated with aggressive behavior in children with ASD?
Thanks to families that participated in the Simons Simplex Collection (SSC), providing information about their children’s development and behavior at 13 university-based autism centers across North America, Drs. Kanne and Mazurek had enough information to take an in-depth look at these questions in a way that had not been possible before.
Many studies have examined risk factors for aggression in children with no disabilities. Factors such as male gender, low IQ, low family income, low parental education, and harsh parenting techniques have all been associated with increased aggression or antisocial behavior in typical children.3,4,5,6 Most studies looking at aggression in people with ASD, on the other hand, have focused on just a few individual cases, not on risk factors for people with ASD as a group.
Drs. Kanne and Mazurek set out to change this, carefully evaluating aggressive behaviors in 1,380 children with ASD between the ages of 4 and 17.7 Because the children had participated in the Simons Simplex Collection, the researchers had a rich set of information to draw upon, including the results of gold-standard autism assessments such as the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview – Revised (ADI-R), the results of IQ tests, and measures of repetitive behaviors, receptive language, and emotional and behavioral functioning.
How many children with ASD had aggressive behaviors?
Among the entire group of 1,380 children with ASD, the researchers found that 56% were engaging in aggressive behaviors towards caregivers, while a smaller number (32%) engaged in these behaviors towards non-caregivers. Similarly, 68% of the children had previously behaved aggressively towards caregivers and 49% towards non-caregivers. These are extremely high rates, especially when compared with those for people who have intellectual disability (ID) but not autism. Aggressive behavior has been documented in only 7-11% of these individuals.8,9
This study therefore provides solid evidence that aggressive behaviors are a major challenge for families of children with ASD.
What risk factors are associated with aggressive behaviors for children with ASD?
The researchers wondered whether the same factors that are associated with aggression in typical children also would be associated with aggression in children with ASD. To find out, they divided the children into two groups: 489 children who had definitely displayed physical aggression such as hitting and biting and 549 children who had never or very rarely displayed aggression. Children in the middle, who had displayed only mild aggression, were dropped from the analysis so that the two other groups would be very distinct from one another.
The researchers were surprised to find that many of the risk factors associated with aggressive behaviors in typical children don’t apply at all to children with ASD. For example, being male is usually associated with a much higher risk of aggressive behavior, but this isn’t the case among children with ASD. Girls and boys with ASD are equally likely to be aggressive. In the same way, lower parental education, lower IQ, and lower language or communication ability are not associated with risk of aggressive behavior in this group of children with ASD, although they are in typical children. The only factor that seems to work the same way for children with ASD as it does for typical children is age: in both groups, the younger the child, the more likely he or she is to be aggressive. The children with ASD who are most likely to have aggressive behaviors, when compared with other children on the spectrum, are those with the following characteristics:
- More repetitive behaviors, especially self-injurious or ritualistic behaviors, or extreme resistance to change
- More severe autistic social impairment
- A higher family income
The information available did not permit the researchers to explore when and why children with ASD have aggressive outbursts. Their results do seem to dovetail with those of other researchers, however. For example, in 2005, researchers at the University of Kansas compared aggressive behaviors in 23 children with autism and 23 typically developing children and found the motivations behind the behavior are very different for the two groups. Typical children use aggression to achieve social goals, such as getting attention or avoiding adults’ demands. Children with autism – especially boys – become aggressive when adults interfere with a repetitive behavior, when someone tries to take away an item they need to continue a repetitive routine, or when they are trying to escape uncomfortable sensory input.10 The new (and much larger) study has again identified a link between repetitive behaviors and aggression.
One result is especially perplexing, and the researchers don’t know what to make of it. They had expected that families with more resources would have more access to interventions, and that their children would have fewer behavior issues. Why would higher family income be associated with a higher risk of aggression in children with ASD? “It is possible,” they wrote, “that families with higher incomes are better able to access interventions that challenge (and may be frustrating for) their child with ASD, and in turn may create situations that produce aggressive behaviors.”7 Another possibility is that people at different income levels may be more or less likely to report aggression. Perhaps those in lower income brackets are more sensitive to potential criticism of their parenting and blame for their child’s aggressive behavior, while higher income people are more immune to societal blame and so more freely report aggression in their children. Further research will be needed to see if this unexpected result holds up over time and, if so, how to explain it.
Shedding Light on Aggression and ASDs to Help Families
This new study provides confirmation that aggression is a major issue for caregivers of children on the autism spectrum, validating the experience of many and laying the groundwork for future research. It underscores the need for interventions to address aggression in children with ASD, and to support families coping with it.
Aggressive Behavior in Children with Autism
Aggression and temper tantrums seen in autism are common between ages of 2 and 5 and are the most challenging behavior situations for parents with autistic children. In the aggression accompanied by autism, the child may harm himself or people and items in his/her surroundings.
Children with autism who can not explain what they want by talking, can not express things that disturb them or can not say that they are hurt because of communication difficulties. Therefore they express these sensory sensitivities with aggression and temper tantrums. Sometimes even an insignificant situation can lead to repetitive behavior tantrums.
In autism spectrum disorder, starting handling with aggression and tantrums at child development ages is very important. As the child grows, aggression becomes more difficult to cope with, becomes a repetitive behavior and the physical damage of the child who gets stronger to the self or his/her environment can be greater. Even this situation shows how important paying attention to early diagnosis and treatment of autism spectrum are.
Signs of Aggressive Behavior in Autistic Children
With the birth of autistic children, their families start struggling with many problems. Behavioral impairment is one the biggest problems for families having children with autism. Sometimes mild, but often intense, behavioral impairments are observed such as self-harm, biting, scratching, hitting head, biting siblings or kicking.
First of all, it is necessary to find the cause of aggression and to remove the situation or thing that causes the child to become aggressive. If the cause of aggression is not known exactly, it could be some kind of pain. For example, if they have a teeth or abdominal pain and people with autism may not explain this situation with language skills so they can react with aggression.
Being afraid of toilet, not being able to speak, understand what is said, going out of routine or not being able to reach a thing they want are among the causes of aggression. It is very important that the children with autism is observed by parents and educators well and to find the cause of aggression with therapies and observations in the autism treatment. Aggression is seen in situations such as anxiety, fear, anger, insecurity, failure and suffering.
What to do?
The frequency and intensity of aggression and tantrums must be certainly coped with because it affects the learning quality of the children with autism negatively. The causes of aggression and tantrum must be found and treated. In case of aggression or tantrum, the autistic children should not be intimidated. It should not be forgotten that this is a way of expressing a situation that the autistic people are disturbed. With good observation, it is possible to determine what the children’s expects. When trying to change problematic behaviors, they should not be rushed, they should be changed without losing confidence. It should also not be forgotten that one reason for aggression is trying to attract the attention of the parents.
These problems can be removed by creating a list of aggression cases. Instead of entering a crowded place with autistic children who reacts excessively to voices or noise, routine work such as shopping can be made by one of the family members alone.It should be known that a lot of things can be changed with a balanced and consistent behavioral training. Support from an expert should be obtained and it must be remembered that parental support is very important.