Ruling Out Autism Medical Problems…Easier Said than Done!

As you probably know, I’m both a mom to an adult son with autism as well as a BCBA.  But what you may not know is that I’m also a Registered Nurse. I often remind people that medical issues can cause some behaviors in children and adults with autism. And you cannot treat medical issues behaviorally. That’s why today I’m talking all about autism medical problems and how you can best help your child or client.

Four Main Functions of Behavior

Here is a little review of the four main functions of behavior. Most Behavior Analysts (including me) really focus on 3 of them. Because when a child has a problem behavior, it’s usually for three reasons. The first reason is that the child wants something and you say no or to wait. The second reason is the child doesn’t want to complete a task such as eating food that they don’t like. And the third reason a child might exhibit problem behaviors is for automatic reinforcement. So they may rock, make noises, or even bang their head when they are not actively engaged.

In Chapter 2 of my book, The Verbal Behavior Approach, I cover the first three functions in a lot of detail, but I don’t explain the fourth function, automatic negative reinforcement, too well. What I do mention is that children with problem behaviors that come on suddenly should be evaluated by a physician.

In many cases, however, it is difficult to determine if a problem behavior is caused by a medical issue. Especially in children and adolescents with autism who cannot fully communicate about pain or discomfort. I did a podcast that goes a bit more into the details of problem behaviors related to pain and the four functions of behavior.

I’m going to tell you 2 stories about Lucas to illustrate the importance of looking at medical issues. You can do this when evaluating a child for the first time. You should also do this when an established client abruptly experiences problem behaviors without a clear explanation.

Autism Medical Problems

Lucas started having motor tics when he was 6. They came on suddenly and over the course of a few days, they were occurring 500 times/day. He also had open wounds on his legs which appeared out of the blue.  I googled “acute onset tics” and found a condition called Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (PANDAS) which is now known as PANS since many cases of this autoimmune disorder are associated with bacterial infections other than Strep. Once he started on an antibiotic, Lucas’ tics went from 500/day back to 0. So we had evidence that these tics were caused by a medical problem. And without medication, all the behavioral treatment in the world most likely would not have helped.

When Lucas was 13, he showed an increase in self-injurious behavior (SIB) over a few months time. While in the past he would occasionally bite his knuckle at school, it went up significantly. From approximately one knuckle bite a day at school to 10 knuckle bites occurring both at home and school. In addition to knuckle bites, Lucas started to sometimes hit his head and cry.

Assessing Medical Problems

Lucas’ teacher and aid at school kept careful ABC data. And the repetitive 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. 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.

Automatic Negative Reinforcement

I knew as a BCBA that these behaviors – like his tics years earlier – were not effectively treated behaviorally. So we took him to the pediatrician to do a battery of blood tests and a CAT scan of his head and sinuses. Lucas’ sinus CAT scan showed sinus disease. It responded well to antibiotics and allergy medicine.

I spoke with Dr. Brian Iwata, an internationally recognized behavioral expert, on treating severe problem behaviors using autism research. He said no controlled studies have ever been published on problem behaviors with an automatic negative reinforcement function. Yet many BCBAs and parents assume the doctor has ruled out that the behaviors are related to medical issues. Therefore they go full steam ahead trying to reduce these problem behaviors using ABA principles alone.

I believe that it is nearly impossible to rule out all autism medical problems that may be causing or contributing to problem behaviors. Especially in children and adults with moderate to severe autism who also have major language delays, an intellectual disability, attention deficit, or sleep problems.

What can you do with this information about autism medical problems:

  1. Think about medical issues that could be at play when assessing a new child. Or if an existing client shows an abrupt increase in problem behaviors.  Many medical professionals now believe autism is an autoimmune disease. So researching PANDAS/PANS at www.Pandasnetwork.org or by going to the centers for disease control online may be a good starting point.
  2. Keep and share data between home and school so parents can share behavioral data with the child’s physician.
  3. If you are a BCBA or researcher, consider studying behaviors related to medical issues, including risk factors and risks of autism.

Please leave me a comment below and share this post! If you want to learn even more about autism medical problems, check out my podcast episode on ruling out medical conditions. Watch next week’s blog on how to teach children with autism to tell you when they are in pain. You can also join my free workshop by going to www.marybarbera.com/workshop.