NICE Guidance on Challenging Behaviour by Adults on the Autism Spectrum

The following extracts are from Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. (2012). London: National Institute for Health and Clinical Excellence.

Interventions for Challenging Behaviour

9.4.1.1 Before initiating other interventions for challenging behaviour, address any identified factors that may trigger or maintain the behaviour (see recommendation 9.2.1.20) by offering:

the appropriate care for physical disorders (for example, gastrointestinal problems or chronic pain)
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 recommendation 9.1.1.8).

9.4.1.2 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.

9.4.1.3 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)
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.

9.4.1.4 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.

Psychosocial interventions for challenging behaviour

9.4.1.5 Psychosocial interventions for challenging behaviour should be based on behavioural principles and informed by a functional analysis of behaviour (see recommendation 9.4.1.3).

9.4.1.6 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.

Combined interventions for challenging behaviour

9.4.1.7 Consider antipsychotic medication 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. Informed consent should be obtained and documented 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.

Pharmacological interventions for challenging behaviour

9.4.1.8 Consider antipsychotic medication 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.

9.4.1.9 Do not routinely use anticonvulsants for the management of challenging behaviour in adults with autism.

Related Publications

National Institute for Health and Clinical Excellence (2012) Autism in adults: diagnosis and management. London: National Institute for Health and Clinical Excellence Read Full (New Window)

Quick link:: https://informationautism.org/nice-guidance-adults-challenging-behaviour

Updated: 23 Aug 2021

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