Challenging behaviour in children with autism spectrum disorder

Some children with autism spectrum disorder (ASD) will exhibit challenging behaviours, sometimes referred to as behaviours of concern or behaviours that challenge.

Challenging behaviour can be defined as any behaviour that:

• is a barrier to a person participating in, and contributing to their community (including both active and passive behaviours)
• undermines, directly or indirectly, a person’s rights, dignity or quality of life, and
• poses a risk to the health and safety of a person and those they live and work with.

Challenging behaviour can take a variety of forms, and be either:

• externalised—involving damage to objects or aggression directed towards people or causing self-harm
• internalised—resulting in the person being withdrawn, inattentive and unresponsive, or not engaging in activities that they might otherwise be expected to do.

Challenging behaviour in a child with autism spectrum disorder occurs on a spectrum of severity, ranging from noncompliance and self-stimulatory behaviours (eg rocking or engaging in certain rituals) to more severe behaviours (eg extreme aggression, hurting themselves) that require immediate intervention.

Challenging behaviour in a child with autism spectrum disorder may be acute or longstanding. It is often best understood to be a means by which the child, intentionally or unintentionally, is communicating something that is important for them in the best way they can with the skills that they have (eg pain, discomfort, distress, expressing a need for something). These circumstances can be accentuated for a child who is unable to communicate using spoken language; see also Communicating with a person with developmental disability. Challenging behaviour may manifest differently depending on the child’s age and ability to respond to change.

When managing challenging behaviour in a child with autism spectrum disorder:

• consider the principles of good practice
• undertake a thorough assessment, which includes an assessment of the child’s physical and mental health, and social and environmental circumstances
• consider whether management of an acute behavioural disturbance is required
• consider the harms and necessity of restrictive practices
• consider the legislation pertaining to restrictive practices.

Behaviour support for a child with autism spectrum disorder requires a multidisciplinary approach to properly assess the behaviour and implement a comprehensive management approach, including:

• defining the challenging behaviour
• establishing agreed goals
• establishing preventive strategies
• establishing an emergency plan
• implementing behavioural interventions
• considering pharmacological interventions
• implementing strategies for monitoring and review.

In conjunction with a comprehensive multidisciplinary management approach, pharmacotherapy may be considered by a clinician with expertise in using psychotropics in children (eg child psychiatrist, paediatrician, general practitioner). Use of an antipsychotic for challenging behaviour in a child with autism spectrum disorder may improve the behaviour by reducing excitation and aggression; however, antipsychotic use in children has:

• limited evidence of efficacy with short-term use
• a risk of significant adverse effects, including extrapyramidal, endocrine and metabolic adverse effects
• a lack of long-term safety data.

Risperidone and aripiprazole have the most evidence of efficacy for challenging behaviour in children with autism spectrum disorder. Although aripiprazole has similar clinical efficacy to risperidone, there is less trial data to support its use—aripiprazole has been shown to be effective in treating irritability in children with autism spectrum disorder in several open-label studies and placebo-controlled trials¹.

There is limited evidence for the effectiveness of other antipsychotics for challenging behaviour in children with autism spectrum disorder. Quetiapine is sometimes used if risperidone or aripiprazole are not suitable or available, but evidence is limited to open-label trials. Chlorpromazine, haloperidol and periciazine have very limited efficacy and safety data for the treatment of children with severe behavioural disturbances and are rarely used.

Discuss the following with the child, and their family or carers so they can make an informed decision about antipsychotic use:

• the purpose, limitations and risks associated with antipsychotic use and the role of the antipsychotic within the comprehensive management approach
• which antipsychotic adverse effects are acceptable to the patient and how these effects are monitored, prevented and addressed.

If antipsychotic therapy is agreed upon, perform baseline tests to guide antipsychotic choice and to give a reference point for future monitoring. For a schedule for monitoring antipsychotic adverse effects, see here. Antipsychotics should be used as a time-limited trial with periodic review every 3 to 6 months to assess efficacy and determine whether treatment should be continued.

A clinician with expertise in using psychotropics in children may consider using an antipsychotic for challenging behaviour in a child with autism spectrum disorder. A suitable regimen is: