After challenging behavior has been identified, and appropriate services have been accessed, the effects of treatment need to be monitored such that if approaches are showing to be ineffective, alternative treatment modalities can be explored before challenging behavior worsens. Direct observation of challenging behavior is a highly sensitive measurement strategy that can detect subtle changes in challenging behavior over time, making it ideal for progress monitoring. Strategies for directly measuring challenging behavior are discussed at length earlier in this document.
The electronic medical records (EMR) system is also an important source to capture and monitor progress. The EMR allows for reviewing and visualizing changes in the child’s developmental profile. It also promotes consistent measurement, as providers will be more likely to utilize the same measure when it has been used previously and its contents are built into the EMR. Without consistent utilization of the same measure, it is hard to understand changes over time. Use of the EMR allows for pre-programmed alerts, which remind the provider to screen on a routine basis.
There are, however, times when a child’s behaviors change rapidly or stakeholders are unable to catch the red flags prior to the behaviors becoming particularly impactful or harmful (i.e., no history of less intense responses occur prior to behavioral escalation). In these cases, the frequency and intensity of the behavioral incident may warrant emergent (e.g., emergency room visit, crisis center) versus planned or programmed action (e.g., behavioral surveillance, routine check-ups, formative/summative academic meeting) from caregivers and practitioners.
Unfortunately, even isolated instances of severe challenging behavior can have deep and lasting impact for the youth, family, and community warranting immediate intervention. Practitioners may employ additional interviews, checklists, questionnaires, and rating scales that are more specifically targeted at better understanding the level, frequency, and intensity of the presenting concerns in relation to same-aged peers. In addition, practitioners may recommend more intensive progress monitoring on a denser schedule. Potential adverse events associated with the assessment and treatment of challenging behavior should also be measured to ensure the individual is receiving appropriate care.
Future research is needed to develop sensitive and standardized measures that could specifically be used for monitoring progress over time and further differentiating acute versus chronic episodes of challenging behavior.
Summary
Overall, an organized network for screening and surveilling youth with ASD for development of challenging behavior does not exist and the current procedures are inadequate. It is critical to prevent severe challenging behavior from emerging that routine well-child checkups (early childhood) and annual well-checks (later childhood adolescents, adulthood) occur and include screening and follow-up for challenging behaviors. During these visits, challenging behaviors need to be discussed and brought to the attention of the child’s PCP. Similarly, assessment for development of socially appropriate behaviors should also be cataloged such that caregivers and practitioners actively work towards skill development when gaps or delays are identified (i.e., unlearning the “wait it out” model).
Ideally, screeners should then be employed and used to inform the referral to appropriate service providers. Indirect measures are often a first choice given ease of implementation and lower cost, relative to direct and experimental methods of assessment. That being said, the benefit of low-resource intensiveness and accessibility also comes with a drawback in the areas of accuracy and reliability (Iwata et al., 2000). Unlike direct assessment, indirect assessments do not require direct observation of the patient. Thus, when considering the use of indirect assessments, practitioners should consider employing these measures in combination with other direct or structured observation methods to optimize reliability and accuracy.
Since many practitioners may only observe patients in the context of routine well-child check-ups, we strongly recommend that practitioners ask caregivers to support indirect measures with samples of the child’s behavior by providing video samples or pictures whenever possible (Iwata & DeLeon, 1996). On-going assessment should then be employed to monitor progress and direct future referrals if needed.
