Physical challenging behaviour includes biting, pinching, slapping, spitting and hair pulling.
There may be medical, sensory, behavioural or communication-related reasons why a person on the autism spectrum does these things.
Physical pain, discomfort or medical issue
The person may feel unwell, tired, hungry, thirsty or uncomfortable. Biting may be due to pain in the mouth, teeth or jaw. Spitting may be related to a difficulty with swallowing or to producing too much saliva. Aggression may be due to adolescent hormonal changes.
Some biting behaviour may be a continuation of infant mouthing behaviour, or a later occurrence of the mouthing phase.
Seeking sensory input
Chewing and biting provide sensory input to the proprioceptive system, which regulates what different parts of the body are doing at different times. The person may enjoy the way saliva feels.
The person may be using this behaviour to communicate that something is causing distress and to get it to stop. They may have no other functional way of communicating their needs, wants and feelings.
Frustration or distress
Life can be exceptionally overwhelming at times for people with autism, and the behaviour may be an expression of sheer frustration or distress in response to a range of different stressors. This can include difficult demands, meeting new people, experiencing unpleasant sensory stimuli, a change in routine, switching activities or having to wait for something – some people have difficulty with the concept of time and sequencing.
The person may have learned that the behaviour can be a very powerful way of controlling the environment. A behaviour which was initially a response to physical pain or frustration could eventually become a way of avoiding a demand or ending an undesired situation (eg turning the television off, interrupting an argument taking place nearby). The person may have learned that they enjoy the reaction or interaction they get as a result of the behaviour.
Think about the function of the behaviour
Complete a behaviour diary, which records what is occurring before, during and after the behaviour, or a functional analysis questionnaire. Make notes on the environment, including who was there, any change in the environment and how the person was feeling.
Rule out medical and dental causes
Visit the GP or dentist and seek a referral to a specialist if needed. Bring along notes about when the behaviour happens (ie what time of day and in which situations), how often it happens, when it first started, and how long it lasts.
Provide sensory opportunities
Find alternative activities, or provide a bum bag of alternative objects, that provide a similar sensory experience to that provided by the challenging behaviour, and build these into the daily routine. For a person who bites, you could provide chewy tubes, gum, carrots, raw pasta or sultanas. For a person who pinches, you could provide play-dough. For a person who hits, you could do a clapping song/rhyme. For a person who pulls hair, tie long hair back and find something to replicate the pulling sensation, eg ‘row your boat’ game, tug of war, climbing up a rope.
Introduce communication tools
Support the person to use other ways of communicating their wants, needs and physical pain or discomfort, eg by using a visual stress scale, PECS (Picture Exchange Communication System), pictures of body parts, symbols for symptoms, or pain scales, pain charts or apps.
Use social stories to explain why it’s not appropriate to bite/spit/hit, and describe alternatives.
Some people use communication boards to indicate how they are feeling. This could be a blackboard or a Velcro board with key emotional words or emotional faces. Every time the person engages in challenging behaviour, encourage them to use this form of communication instead.
Some people may find it easier to communicate by text or email.
Remove physical and sensory discomforts
Provide relief for physical discomfort, eg pain killers. Remove unpleasant sensory input, eg use ear defenders to block out noise, use sunglasses to reduce light, and reduce strong smells, replacing them with smells that the person prefers.
Prepare for change
Prepare the person for any changes in routine or for meeting new people. You could use visual supports, showing photos of new people and places, introducing them in small stages. A child or adolescent with autism may find physiological changes associated with puberty difficult to cope with, and you may need to prepare them for this.
Structure transition times
The previous activity may have been something the person greatly enjoys, or it may be that once focused on an activity, they find it difficult to adjust to something else. You could:
- use a visual timetable showing the day’s activities, or a now-and-next board
- use a timer to indicate when an activity is finished
- encourage the person to put the activity into a finished tray or to put the symbol for the activity into a finished box to signal that the activity is over
- use visual supports to show the steps leading up to each activity
- make the waiting time between activities as short as possible
- have a visual, concrete representation of how long the person needs to wait before the activity is going to begin - this might be an electronic timer, sand timer, or stickers on a clock face
- consider making enjoyable activities available during transition times - a transition box, containing a number of different activities, could keep the person focused during these times, making an unstructured timeframe much more structured.
People with Pathological Demand Avoidance may need a less directive and more flexible approach than others on the autism spectrum. Consider reducing the demands placed on the person at difficult times of the day.
When a particular person is targeted
If a particular family member or support worker seems to be the target for challenging behaviour, think about what might be triggering it. It might be that a perfume scent is overwhelming, or that the other person is associated with a distressing activity.
Maybe the person is upset when the support worker or family member spends time with other people. If so, you could try scheduling some time specifically for them to spend together and showing this on a visual timetable. Very strict boundaries need to be kept as to when this will happen and for how long. It may be useful to have a sand timer so that the person knows that the time is up when the sand runs out.
There may simply a personality clash between the person and a staff member. If this may be the case, consider whether this staff member could work with other people instead?
Provide support for managing emotions and relaxation
Look at anger/emotions management and create opportunities for relaxation. You can do this by, for example, looking at bubble lamps, smelling essential oils, listening to music, massages, or swinging on a swing.
Challenging behaviour can often be diffused by an activity that releases energy or pent-up anger or anxiety. This might be punching a punch bag, bouncing on a trampoline or running around the garden.
If the person has low self-esteem, highlight all of their achievements and strengths in an achievement book of photographs and certificates. Counselling or joining an autism-specific social group may also help.
Respond quickly and consistently
Respond quickly and consistently, eg for spitting, wipe away saliva immediately. Limit verbal comments, facial expressions and other displays of emotion, as these may inadvertently reinforce the behaviour. Try to speak calmly and clearly, in a neutral and steady tone of voice.
Tell the person what they need to do instead of the behaviour, eg "David, hands down". Use visual cues such as picture symbols to back up instructions. Redirect to another activity that is incompatible with the behaviour (eg an activity that requires both hands, or that occupies the mouth, such as sucking a sweet) and provide praise and reinforcement for the first occurrence of appropriate behaviour, eg "David, that's excellent playing with your train".
Reward appropriate behaviours
Provide frequent encouragement to the person for engaging in appropriate behaviour and for periods in which they did not engage in physical challenging behaviour. This will help the person to learn that other, more appropriate behaviours bring positive outcomes.
Rewards can take the form of verbal praise and attention, preferred activities, toys, tokens or sometimes small amounts of favourite foods or drinks. Ensure that you clearly name the behaviour that you are rewarding, eg "Jane, that's good waiting!" and ensure that rewards are provided immediately after the behaviour that you wish to encourage eg "You can spend 10 minutes on the computer now".
It should be noted that some people with autism do not enjoy social attention. In these circumstances, verbal praise can cause distress and actually stop the person engaging in the desired behaviour in the future.
If the physical challenging behaviour is presenting significant risks to the person or those around them or is resistant to intervention, try to get specialist help to deal with the behaviour. Arrange an appointment with the GP to discuss the issue and to request referral to a behavioural specialist if appropriate.
If you are reading this information from a print-out, you can visit the web page and find out more at www.autism.org.uk/challengingbehaviour