Interventions entions for challenging behaviour in adults with autism bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: http://pathways.nice.org.uk/pathways/autism-spectrum-disorder Pathway last updated: 23 September 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved
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1 Adult with autism and challenging behaviour No additional information 2 Before initiating other interventions for challenging behaviour Address any identified factors that may trigger or maintain challenging behaviour (see assessment of challenging behaviour in identification and assessment) before initiating other interventions. Such factors should be addressed by offering: the appropriate care for physical disorders (for example, gastrointestinal problems or chronic pain) (see the NICE pathway on gastrointestinal conditions) treatment for any coexisting mental disorders, including psychological and pharmacological interventions (for example, anxiolytic, antidepressant or antipsychotic medication), informed by existing NICE guidance interventions aimed at changing the physical or social environment (for example, who the person lives with) when problems are identified, such as: advice to the family, partner or carer(s) changes or accommodations to the physical environment (see the physical environment in general principles of care). For adults who have a learning disability and autism, and whose behaviour challenges see the NICE Pathway on challenging behaviour and learning disabilities. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 7. Assessing possible triggers for behaviour that challenges 3 Identifying the correct intervention for challenging behaviour Offer a psychosocial intervention for the challenging behaviour first if no coexisting mental or physical disorder, or problem related to the physical or social environment, has been identified as triggering or maintaining challenging behaviour. Page 3 of 10
When deciding on the nature and content of a psychosocial intervention to address challenging behaviour, use a functional analysis. The functional analysis should facilitate the targeting of interventions that address the function(s) of problem behaviour(s) by: providing information, from a range of environments, on: factors that appear to trigger the behaviour the consequences of the behaviour (that is, the reinforcement received as a result of their behaviour 1 ) identifying trends in behaviour occurrence, factors that may be evoking that behaviour, and the needs that the person is attempting to meet by performing the behaviour. In addition to the functional analysis, base the choice of intervention(s) on: the nature and severity of the behaviour the person's physical needs and capabilities the physical and social environment the capacity of staff and families, partners or carers to provide support the preferences of the person with autism and, where appropriate, their family, partner or carer(s) past history of care and support. 4 Psychosocial interventions Psychosocial interventions for challenging behaviour should be based on behavioural principles and informed by a functional analysis of behaviour. Psychosocial interventions for challenging behaviour should include: clearly identified target behaviour(s) a focus on outcomes that are linked to quality of life assessment and modification of environmental factors that may contribute to initiating or maintaining the behaviour a clearly defined intervention strategy a clear schedule of reinforcement, and capacity to offer reinforcement promptly and contingently on demonstration of the desired behaviour a specified timescale to meet intervention goals (to promote modification of intervention strategies that do not lead to change within a specified time) a systematic measure of the target behaviour(s) taken before and after the intervention to ascertain whether the agreed outcomes are being met. Page 4 of 10
Quality standards The following quality statement is relevant to this part of the interactive flowchart. 8. Interventions for behaviour that challenges 5 Combined interventions Consider antipsychotic medication 1 in conjunction with a psychosocial intervention for challenging behaviour when there has been no or limited response to psychosocial or other interventions (such as environmental adaptations). Antipsychotic medication should be prescribed by a specialist and quality of life outcomes monitored carefully. Review the effects of the medication after 3 4 weeks and discontinue it if there is no indication of a clinically important response at 6 weeks. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 8. Interventions for behaviour that challenges 6 Pharmacological interventions Consider antipsychotic medication 2 for challenging behaviour on its own when psychosocial or other interventions could not be delivered because of the severity of the challenging behaviour. Antipsychotic medication should be prescribed by a specialist and quality of life outcomes monitored carefully. Review the effects of the medication after 3 4 weeks and discontinue it if there is no indication of a clinically important response at 6 weeks. Do not routinely use anticonvulsants for the management of challenging behaviour in adults with autism. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 8. Interventions for behaviour that challenges 1 Reinforcement may be by the person with autism or those working with or caring for them. Page 5 of 10
1 At the time of publication (June 2012), no antipsychotic medication had a UK marketing authorisation for this indication in adults with autism. Informed consent should be obtained and documented. 2 At the time of publication (June 2012), no antipsychotic medication had a UK marketing authorisation for this indication in adults with autism. Informed consent should be obtained and documented. Page 6 of 10
Glossary ADHD Attention deficit hyperactivity disorder Behavioural principles Ideas, such as reinforcement and function of behaviour, that underlie behavioural therapies and underpin many interventions teaching adaptive skills for community living for people with autism, including those with challenging behaviour. CAMHS Child and adolescent mental health services. Care pathways Systems designed to improve the overall quality of healthcare by standardising the care process and promoting organised efficient service user care based on best evidence to optimise service user outcomes. CBT Cognitive behavioural therapy. Challenging behaviour A term used to describe behaviour that is a result of the interaction between individual and environmental factors, and includes stereotypic behaviour (such as rocking or hand flapping), anger, aggression, self-injury, and disruptive or destructive behaviour. Such behaviour is seen as challenging when it affects the person's or other people's quality of life and or jeopardises their safety. Chelation A procedure that involves using one or more substances (chelating agents) to remove materials that are toxic, including heavy metals such as mercury, from the body. Page 7 of 10
CPA Care programme approach. DCD Developmental coordination disorder DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th edition Easy read An accessible format for written communication designed for people with a learning disability. It uses simple jargon-free language, short sentences and illustrations. Facilitated communication A therapeutic intervention whereby a facilitator supports the hand or arm of a person with autism while using a keyboard or other devices with the aim of helping the person to develop pointing skills and to communicate. Functional analysis A method for understanding the causes and consequences of behaviour and its relationship to particular stimuli, and the function of the behaviour. The function of a particular behaviour can be analysed by typically identifying (1) the precursor or trigger of the behaviour, (2) the behaviour itself, and (3) the consequence of the behaviour. Hyper- and/or hypo-sensory sensitivities Being over-sensitive (hyper-sensitive) or under-sensitive (hypo-sensitive) to sound, light, colour, smell or taste, which can cause anxiety or even pain in a person with autism. Informant A family member, partner, carer or other third party known to the person with autism who is able to provide information about the person's symptoms and behaviour so that professionals can Page 8 of 10
have a fuller picture of the person's developmental history. Some assessment tools for autism require information from informants. ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Revision Learning disability Lower intellectual ability (usually defined as an IQ of less than 70) that leads to problems in learning, developing new skills, communication and carrying out daily activities. Learning disability severities are defined by the following IQ scores: mild = 50 69, moderate = 35 49 and severe = 20 34. A person with a mild to moderate learning disability may only need support in certain areas. However, a person with a moderate to severe learning disability may have no speech or limited communication, a significantly reduced ability to learn new skills and require support with daily activities such as dressing and eating. Learning disabilities are different from 'learning difficulties', like dyslexia, which do not affect intellect. Learning disability is sometimes also called 'intellectual disability'. Modelling A technique used in behavioural therapy that utilises video and other media. The service user observes target behaviour on the video or computer screen, and repeats it. ODD Oppositional defiant disorder OCD Obsessive compulsive disorder Reinforcement A technique used in behavioural therapy to teach 'rules' of social engagement through providing prompts for behaviour. Page 9 of 10
Sources Autism spectrum disorder in adults: diagnosis and management (2012) NICE guideline CG142 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence 2016. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT www.nice.org.uk nice@nice.org.uk 0845 003 7781 Page 10 of 10