Hi, I’m Dr. Mary Barbera. As some of you know I’m both a mom to an adult son with autism as well as a board certified behavior analyst, but what you may not know is that I’m also a registered nurse and I find myself frequently reminding people that some behaviors exhibited by children and adults with autism are caused by medical issues and cannot effectively be treated behaviorally. Here’s a little review of the four main functions of behavior, and most behavior analysts including myself, really focus on three of them. When a child has a problem behavior, it’s usually for these three reasons: the first reason is that the child wants something or wants attention and you either deny him what he wants or you tell them to wait. The second reason that a child might display problem behavior is that the child doesn’t want to complete a task, a difficult demand such as eating food that they don’t like or taking a bath and the third reason the child might exhibit some problem behavior is for automatic reinforcement. So they may rock or make noises or script when they’re not actively engaged. In Chapter two of my book, “The Verbal Behavior Approach,” I cover the first three functions in pretty much detail, but I don’t explain the fourth function which is automatic negative reinforcement. I don’t explain it too well except to mention that children with problem behaviors, especially when they come on suddenly or when you expect that the problem behaviors might be medically related you should have the child see a physician. In many cases, however it is difficult, if not impossible, for you or any physician to determine if a problem behavior is caused by a medical problem, especially in children with autism who cannot fully communicate about pain or discomfort. I have lots of experience with my own son, as well as many of my clients in the past. So I’m going to tell you two stories about Lucas’s medical issues to illustrate the importance of looking at medical issues when evaluating a child for the first time, or when an established client, or your own child experiences problem behaviors which start abruptly or increase without a clear explanation. When Lucas was six years old, he started having motor tics. I remember they came on suddenly, you know all of a sudden he would start twitching his shoulder and the next day he would add the sound “knit net” and then he might add motor movements of his arm. It was really bad, and like I said this all came on so suddenly and I clicked and counted and the tics were occurring 500 times a day over multiple days. At the same time, he also had open wounds on his legs and I didn’t know what that was about and I didn’t know if it was related. So I googled acute onset tics and found a condition which he was later diagnosed with called Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep or PANDAs, which is now known as Pan’s since many cases of this autoimmune disorder are associated with bacterial infections other than strep. So once Lukas was started on an antibiotic, his tics which were 500 a day, went back to zero. So we did have proof that these ticks were probably caused by some medical problem and without medication all of the behavioral treatment in the world probably would not have helped. When Lukas turned 13, he showed an increase in self injurious behavior, or SIB for short, and these SIB incidences occurred and increased rapidly over a few months time. While before that, he would occasionally bite his knuckle at school, the rate and intensity of knuckle bites when he was 13 went up significantly from approximately one knuckle a day at school to ten knuckle bites occurring both at home and at school. And in addition to knuckle bites, Lucas also started to hit his head with his hand or fist and cry. Lucas’s teacher and aide at school kept careful ABC data under the direction of a behavior analyst and the behaviors usually appear to be related either to access to tangibles and/or escape but the demands were not higher than usual and sometimes Lucas would engage in problem behavior without any clear antecedent. The professionals who worked with Lucas for many years were all concerned that his behaviors were worse than ever. I was really concerned too and notice that sometimes at home when he engaged in SIB, he cried real tears and even sometimes he engaged in SIB while he was getting 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. I knew as a BCBA that these behaviors were most likely related to something medical, just like his tics years earlier were not effectively being treated behaviorally. So we took him to a pediatrician who agreed to do a battery of blood tests and a CAT scan of his head and sinuses. While the blood work and CAT scan of his head were within normal limits, Lucas’s sinus CAT scan showed sinus disease which responded well to antibiotics and allergy medicine. Lucas also went on to get allergy shots which have helped his headaches and sinus issues a lot too. Recently in August of 2016, I spoke with Dr. Brian Iwata, an internationally recognized expert – probably the expert in treating severe problem behavior – after he did a presentation at an autism conference. When we spoke after this conference lecture, on automatic behaviors he told me that he knew of no controlled studies that had ever been published on behaviors with an automatic negative reinforcement function. Yet many BCBA is and parents, operate under the premise that the doctor has “ruled out” that the behaviors are related to medical issues, therefore they go full steam ahead trying to reduce problem behaviors using ABA principles alone. I believe that it’s nearly impossible to rule out all medical issues that may be causing or contributing to problem behaviors and children and adults with moderate or severe autism who also have major language delays. So what can you do with this information? Number one: think about medical issues that could be at play when assessing a new child, or if an existing client or your child, shows that abrupt increase in problem behaviors. Number two: keep and share data between home and school so parents can share behavioral data with the child’s physician, and number three if you are BCBA or a researcher, please consider studying behaviors related to medical issues. If you’re watching this video anywhere other than marybarbera.com, I hope that you hop on over there leave me a comment and share this post. Also watch next week’s blog where I’ll discussed how I teach children with autism how to tell you when they are in pain. Thanks a lot and have a great week.