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SCREENING AND ASSESSMENT

Screening, Assessment, and Measurement of Challenging Behavior in Autism Spectrum

Disorder

William E. Sullivan, PhD

Golisano Center for Special Needs

SUNY Upstate Medical University

Amanda N. Zangrillo, PsyD, BCBA-D

University of Nebraska Medical Center

Luther G. Kalb, PhD, MHS

Kennedy Krieger Institute

Johns Hopkins Bloomberg School of Public Health

Carla A. Mazefsky, PhD

University of Pittsburgh
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Acknowledgments

The Autism Speaks Thought Leadership Summit on Challenging Behaviors, held in December
2020, convened leaders in autism care and research across North America. The Summit aimed to
characterize the landscape of services and supports for people with autism with challenging
behavior and acted as a catalyst for innovations in programs and policies to improve systems of
care for this population. Six workgroups were formed, utilizing Summit participants, to develop
recommendations and priorities related to both practice and public policy.

The following document covers screening, assessment, and measurement of challenging

behavior, a need identified by Summit leaders and participants, to better understand what is
currently known about outcomes for autistic individuals with severe challenging behaviors, and
which practices, programs, and policies have demonstrated impacts; what existing or new
mechanism can help in scaling up such efforts; and what potential opportunities exist to enhance
capacities in systems supporting services to aid in scaling-up or improving quality of
implementation in this topical area.

Special thanks to Autism Speaks for driving and supporting this initiative, to Jordan DeBrine and
Jamie Peven for contributing to this effort, and to SUNY Upstate Medical University, the
University of Nebraska Medical Center, John Hopkins Bloomberg School of Public Health, and
the University of Pittsburgh for lending additional support and resources. Additional thanks to
Thought Summit leaders Drs. Matthew Siegel, Henry Roane, Eric Butter, and Donna Murray, as
well as Jackie Perlmeter, for their leadership, feedback, and guidance throughout the process.
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How to Cite this Document

Sullivan, W.E., Zangrillo, A. N., Kalb, L. G., Mazefsky, C. A. (2021). Screening, Assessment,

and Measurement of Challenging Behavior in Autism Spectrum Disorder. Autism Speaks

Thought Leadership Summit on Challenging Behaviors. Autism Speaks, Princeton, NJ.

{Autism Speaks URL for the document}

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Outline

● Introduction

● Prevalence of Challenging Behavior among Children with ASD

o Introduction
o Methods
o Results
▪ Aggression
▪ Self-Injurious Behavior
▪ Elopement
▪ Mental Health Crises in ASD
o Summary

● Screeners and Standardized Assessments

o Informant-Based Screeners
o Direct Screeners
o Standardized Measures on Challenging Behaviors
o Psychiatric Assessment
o Summary

● Functional Behavior Assessment

o Indirect Assessment
o Direct Measurement
▪ Continuous Measurement
▪ Discontinuous Measurement
o Descriptive Assessment
o Functional Analysis
o Summary

● Multi-Tiered Systems of Support

o Primary-Care Pathway
o Progress Monitoring
o Summary

● Conclusion
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Screening, Assessment, and Measurement of Challenging Behavior in Autism Spectrum
Disorder

Introduction

Children commonly display challenging behaviors in early childhood as they learn to

navigate their social worlds and develop language (Fletcher, 2011). Challenging behaviors (e.g.,

tantrums, self-injury), while considered a normal part of development, tend to decrease between

the ages of 3 and 5 years old given development of positive social behaviors (e.g., language

skills and emotional regulation; Underwood, 2003). For some children, challenging behavior

persists beyond this typical developmental window. These behaviors begin to gain the attention

of caregivers, physicians, educators, and other key stakeholders when they produce emotional or

physical harm to the individual or others, and impact the individual’s participation in home,

school, or community settings. Individuals with autism spectrum disorder (ASD) and other

developmental disabilities, demonstrate a higher prevalence of challenging behavior relative to

same-aged peers without documented diagnoses (Fahmie et al., 2020; Hill et al., 2014; Kanne &

Mazurek, 2011, Schroeder et al., 2014). This is of particular importance as individuals displaying

challenging behaviors experience increased risk for persistent stress, abuse, decreased access to

much needed supports and services, as well as caregiver burnout, and lower quality of life

(Fitzpatrick et al., 2016).

There are several theories that have attempted to explain the etiology of challenging

behavior displayed by individuals with ASD. Behavior equivalents theory (Emerson, 2001)

suggests that challenging behavior may be an alternative manifestation of psychopathology. For

example, social situations may elicit feelings of anxiety that manifest as challenging behavior for

individuals with ASD. Neurobiological models implicate brain dysfunction as a cause for

challenging behavior. Frontal cortex dysfunction, leading to poor inhibitory control, and
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increased activation of the amygdala and hypothalamus have been suggested to contribute to

aggression (e.g., Siever, 2008); whereas impairment of the basal ganglia and fronto-striatal

circuits have been linked to self-injurious behavior (Bodfish & Lewis, 2002; Turner & Lewis,

2002). A variety of underlying genetic factors that produce specific behavioral phenotypes are

also associated with challenging behavior (e.g., Oliver et al., 2013). Furthermore, difficulty

regulating emotions has been shown to contribute to challenging behavior when environmental

demands exceed self-regulatory capacity. Individuals with ASD are four times more likely than

the general population to exceed clinical cut-offs for impairing emotion dysregulation (Conner et

al., 2021), which has been specifically associated with aggression (Mazefsky et al., 2018, Conner

et al., 2020; Northrup et al., in press).

The most prominent theory explaining the cause of challenging behavior, however,

suggests that challenging behavior is learned through the process of operant conditioning

(Skinner, 1938). In this model, it is purported that challenging behavior is selected by the

environmental situations that evoke it and the consequences that maintain it. For example, if an

individual with ASD engages in challenging behavior when their caregiver’s attention is

diverted, and when the challenging behavior occurs attention is provided, the individual may

learn to engage in challenging behavior to obtain caregiver attention. That is, challenging

behavior may be reinforced by producing or being associated with a favorable consequence, and

thus, likely to occur again in the future under similar conditions.

Taken together, the factors that contribute to challenging behavior in ASD are complex.

It is plausible that many of the above factors, in combination, contribute to the occurrence and

maintenance of challenging behavior. For example, genetics and patterns of neural reactivity

may contribute to underlying irritability and poor emotion regulation that is understood as
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manifesting as challenging behavior when an individual is confronted with an aversive situation.

Then, when challenging behavior results in the removal of that aversive situation, the individual

may learn that challenging behavior is an effective way to communicate their needs and continue

to engage in challenging behavior when confronted with similar situations.

A variety of evidence-based approaches to assessment and treatment have been

developed and shown to effectively reduce challenging behavior displayed by individuals with

ASD (refer to Evidence Based Practices document). The dosage, complexity, and modality of

these interventions vary widely and will ultimately depend on the needs of the individual and the

capacity of the local/regional support system. An individual who engages in severe forms of self-

injurious behavior (SIB), for example, may require more intense intervention than a child who

engages in mild disruptive behavior. Moreover, individuals with ASD who engage in challenging

behavior and their families often solicit help from multiple support systems. The child’s parents

may report these challenging behaviors to their pediatrician, the teacher may make a referral to

their school psychologist, or community mental-health providers may offer family support.

Across these systems, however, there is not a recognized and widely disseminated systematic

framework for: (a) screening for challenging behavior in individuals with ASD, (b) connecting

them with appropriate treatment services, and (c) surveillance of these individuals over time to

promote behavioral health across the lifespan.

Overall, the goal of this document is to provide general recommendations regarding the

identification and assessment of challenging behavior in ASD based on the existing literature,

provide directions for future research, and highlight areas for advocacy to promote the well-

being of those affected by challenging behavior in the ASD population. In the following sections

we first provide a review of the literature concerning the prevalence of challenging behavior and
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mental-health crises among children with ASD. Next, we describe the broad and complex

process of screening, standardized assessment, and function-based assessment of challenging

behavior in ASD. Finally, a multi-tiered system of support (MTSS; Sugai & Horner, 2002) is

discussed as an example of a framework in which challenging behavior displayed by individuals

with ASD can be assessed, linked to appropriate treatments, and monitored over time to promote

wellness.

Prevalence of Challenging Behavior among Children with ASD

The prevalence of psychiatric and behavioral disorders is elevated among youth with

ASD. In community samples, 70% of youth with ASD have at least one psychiatric disorder, a

prevalence that is 3.5 times greater than in the non-ASD population (Simonoff et al., 2008). The

prevalence of comorbid psychiatric disorders is even higher in clinical samples with 95% and

74% of youth with ASD exhibiting three and five disorders (e.g., attention deficit hyperactivity

disorder, anxiety disorders), respectively (Joshi et al., 2010). The pressing need to manage these

psychiatric and behavioral symptoms has resulted in high rates of polypharmacy, emergency

room visits, and inpatient psychiatric hospitalization among youth with ASD (Jobski et al., 2016;

Kalb et al., 2012; Mandell, 2008). There is even evidence to suggest youth with ASD are four

times more likely to visit the emergency room for mental-health purposes, relative to their peers

without ASD (Liu et al., 2017).

While data on diagnoses, treatments, and service use all point to increased prevalence of

challenging behaviors, data are lacking on the population prevalence of specific challenging

behaviors. Understanding the prevalence of specific challenging behaviors is critical as they may

not fit neatly into diagnostic categories (e.g., elopement). The purpose of this section is to

provide a comprehensive, up-to-date review of the literature concerning the prevalence of

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challenging behavior among children with ASD. Three behaviors were evaluated: 1) aggression;

2) SIB; and 3) elopement. These behaviors were selected as they are among the most common

and impairing externalizing problems for children with ASD. Note this section is not intended to

meet the criteria of systematic review. Rather, the findings provide current information on the

prevalence of these challenging behaviors to set the stage for the following discussions.

Methods

The literature search was conducted using PsychInfo, Google Scholar, and PubMed

databases. Search terms were performed by including variations of a particular behavior with

autism terms. For instance, the search terms used for aggression were “(aggression OR

aggressive behavior OR aggressiveness) AND (autism OR ASD OR autism spectrum disorder).”

For SIB, the search terms were “(self-injurious behavior OR self-injury OR self-harm) AND

(autism OR ASD OR autism spectrum disorder).” Finally, the search terms for elopement were

“(elopement OR elope OR wandering) AND (autism OR ASD OR autism spectrum disorder).”

Each study was screened for inclusion using several additional criteria. Inclusion criteria

were: 1) the study must be published within the last 10 years; 2) the study has a sample size of at

least 100 participants; and 3) the participants must be predominantly less than 18 years of age.

Studies focusing on adults with ASD were excluded given their relative scarcity, differential

approaches to informant and measurement, and small sample sizes.

Once an article met inclusion criteria, a custom database housed information about each

study. The database captured: 1) authorship; 2) year of publication; 3) sample size; 4) setting; 5)

measurement; and 6) prevalence. Setting was classified as single-site clinical study, multi-site

clinical study, population-based (i.e., a community-based study or a national survey), or meta-

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analysis. Measurement details, concerning the actual tool used to assess the behavior and

relevant cutoffs, were captured. Prevalence reflected the proportion of the overall sample that

met criteria for the behavior. Details on how prevalence was defined is provided.

Table 1
Aggression

Author Year of Sample Setting Measurement Prevalence Definition

Publication Size

Kanne and Mazurek 2011 1380 Population- ADI-R Aggression 68% towards Yes/No
based study Items parents No Aggression – score of 0 on
49% towards aggression questions
non-caregiver Definite Aggression – score of 2 or 3 on
aggression questions

McTiernan et al. 2011 174 Population- BPI-01 56.3% Aggressive Subscale, 1 or 11 items
based study rated weekly or more

Maskey et al. 2012 843 Population- Parent 21.8% Yes/No

based study Questionnaire Parent Report Question “Aggression
developed by study towards other people”
authors
Mayes et al. 2012 435 Single-site PBS – 8 aggression 16.6% Raw Scores on subscale items or
Clinical items Maternal Ratings of behavior problems
study (No = 0, Yes = 1,2, or 3)

Medeiros et al. 2012 221 Single-Site BISCA Part 3 for 78.5% Yes/No
Clinical Challenging No = item score of 0
Study Behavior Yes = item score of 1 or 2

Mazurek et al. 2013 1584 Multi-site Autism Treatment 53% Yes/No

Clinical Network (ATN) – Is child currently demonstrating
Study single item from physical aggression?
ATN Parent Survey

Hill et al. 2014 400 Single-Site CBCL 25% T-score > 70

Clinical ABC
Study
Farmer et al. 2015 414 Multi-site CBCL 19% T-score > 70
Clinical Aggression
Study Subscale

Note. Autism Diagnostic Interview – Revised (ADI-R); Baby and Infant Screening for Child with Autism (BISCA);
Behavior Problem Inventory (BPI-01); Child Behavior Checklist (CBCL); Pediatric Behavior Scale (PBS)
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Results

Shown in Table 1, eight studies met inclusion criteria for Aggression. These studies

included a total of 5,451 participants. Prevalence of aggression ranged from 17% to 68%, with a

pooled prevalence of 42%. The settings in which these studies were conducted included

population-based (37%), single-site clinical (37%), and multi-site clinical (25%). Two of the

eight studies used the Aggressive Behavior subscale from the Child Behavior Checklist (CBCL).

The remaining six studies used a variety of different measures which included: 1) the Autism

Diagnostic Interview – Revised (ADI-R); 2) the Behavior Problem Inventory (BPI-01); 3) the

Pediatric Behavior Scale (PBS); 4) the Baby and Infant Screening for Child with Autism

(BISCA); and 5) custom aggression items from study specific questionnaires. Of the seven

different measures used to assess aggression, 29% were single-item measures, whereas the

majority (71%) of the measures used consisted of multi-item assessments. Given aggression was

broadly defined, using both single items and subscales, the results are heterogenous. They reflect

a variety of aggressive behaviors, including aggression (e.g., hitting, kicking), verbal aggression

(e.g., yelling, inappropriate language), and aggression to property and/or objects. As such, these

findings should be interpreted accordingly.

Eleven studies were included in the SIB literature review; see Table 2 for details. This

constituted a total of 10,968 participants and one meta-analysis, of which 14,379 participants

were included in the meta-analysis. For the ten unique studies, the prevalence of SIB ranged

from 14% to 67%, with a pooled prevalence of 46%. The meta-analysis provided a very similar

prevalence estimate at 42%. The settings in which these studies were conducted primarily

included population-based (45%) and multi-site clinical studies (36%), with one single-site

clinical study and one meta-analysis. Excluding the meta-analysis, 20% of the studies used the
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SIB subscale of the BPI-01, and 30% used the SIB subscale of the Repetitive Behavior Scale-

Revised (RBS-R). Half of the remaining sample used a variety of different measures, including

the ADI-R, the Aberrant Behavior Checklist (ABC), the Challenging Behavior Questionnaire

(CBQ), the Social and Communication Questionnaire (SCQ), and custom items. Of the seven

different measures used to assess SIB, 29% were single item measures with the majority (71%)

consisting of multi-item scales.

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Table 2 SCREENING AND ASSESSMENT

Self-Injurious Behavior

Author Year of Sample Size Setting Measurement Prevalence Definition

Publication
SIB Subscale, 1 or 15 items rated
McTiernan 2011 174 Population- BPI-01 48.9% weekly or more
et al. based study

Duerden et al. 2012 241 Multi-site ADI-R (241 Severity (S) Likert scale: 0 - 3
Clinical parent responses)/ Frequency (F) Likert scale: 0 - 4
Study RBS-R: 171 ADI-R: 52.3% SIB-S and SIB-F = 0 – No SIB
Parent responses RBS-R: 64.9% Raw score over 3 in SIB-F. = High F.
Raw score over 2 in SIB-S. = High S.

Maskey et al. 2012 843 Population- Parent 14% Yes/No

based study Questionnaire Parent Report Question “Injury to
developed by Self”
study authors Yes – Sometimes, Frequently, Past
Only
No - Never

Rattaz et al. 2015 152 Multi-site ABC 35.8% Likert scale: 0 (behavior not a
Clinical problem) to 3 (behavior significant
study problem)
No SIB - total score of 0 on 3 items
Low SIB - total score of 1 or 2 on 3
items
High SIB - total score > 3 on 3 items

Siegel et al. 2015 147 Multi-Site RBS-R Self- 26.5% Yes/No Parent Report
Clinical injury subscale SIB defined as the presence of at least
Study daily attempts at self-injury, as
determined by the unit psychologist or
board-certified behavior analyst.

Soke et al. 2016 8065 Population– Autism and 27.7% Yes/No

based study Developmental (Present or Not Present in the
Disabilities child’s available records of any
Monitoring behaviors that were considered as SIB
Network by the ADDM clinician who reviewed
child's records to determine if child
met the ADDM Network case
definition)
Richards et al. 2017 208 Population- CBQ – 8 items 45.7% Yes/No: No = 0, Yes = 1,2,3, or 4
based study about topography
of SIB
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Handen et al. 2018 302 Multi-site RBS-R – 8 SIB 67.5% - home and/or Low/No SIB - score of less than 2 for
Clinical item subscale hospital any form of SIB on parent report
study 49.2% home only RBS-R
24.8% home and Home SIB - score of 2 or more on at
hospital least one SIB item of RBSR by parent
Hospital SIB - No parent report of 2
or more on SIB items, but observed
engaging in SIB daily while inpatient
Home and Hospital SIB - Both parent
report of SIB and daily observation of
SIB inpatient

Soke et al. 2018 691 Population- Parent Report of 29.4% Yes/No

based study SIB based on Parent report to question: "Does the
question in SCQ child
ever injure her/himself deliberately,
such as by biting her/his arm or
banging her/his head"

Flowers et al. 2020 145 Single-site BPI-01 – Short 50% - High F. /High S. Severity (S) Likert scale: 0 - 3
Clinical Form 11% - Low F. /Low S. Frequency (F) Likert scale: 0 - 4
Study 10% - Low F. /High S. SIB-S and SIB-F = 0 – No SIB
6% High F. /Low S. Raw score over 3 in Freq. = High
Freq.
Raw score over 2 in Sev. = High
Severity
Steenfeldt- 2020 14,379 Meta- Yes, 42 % Multiple measures
Kristensen analysis
et al.

Note. Aberrant Behavior Checklist (ABC); Autism Diagnostic Interview – Revised (ADI-R); Behavior Problem
Inventory (BPI-01); Challenging Behavior Questionnaire (CBQ); Repetitive Behavior Scale-Revised (RBS-R);
Social and Communication Questionnaire (SCQ).

Shown in Table 3, a total of eight studies met inclusion criteria for Elopement, reporting

on 9,398 participants. The pooled prevalence estimate of elopement was 48%, with estimates

ranging from 27% to 68%. Almost all the studies (87%) were population-based, with one single

site study. Six of the studies used a custom item/questionnaire, with the remaining using the

CBCL or the Children’s Social Behavior Questionnaire (C-SBQ).

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Table 3
Elopement
Author Year of Sample Setting Measurement Prevalence Definition
Publication Size
Yes/No (Ever vs. Never and Missing (for children
Anderson et al. 2012 1218 Population- Elopement 49% were gone long enough to cause concern) vs. non-
based study Questionnaire Missing)
(developed by
study authors)

Kiely et al. 2016 1416 Population- C-SBQ 26.7% Yes/No/Don't Know/Refuse

based study Prevalence calculated as percentage of those
responding with "Yes"

Rice et al. 2016 1420 Population- National Survey 37.7% Yes/No to Question:
based study of Children with "Within the past year, has [Child] wandered off or
Special Health became lost from
Care Needs (NS- a. your home?
CSHCN) b. someone else’s home such as a relative, friend,
Elopement neighbor, or babysitter?
Questions c. school, day care, or summer camp?
d. a store, restaurant, playground, campsite, or any
other public place?"

Barnard-Brak et al. 2016 1744 Population- NS-CSHSN 28% Yes/No to Question:

based study Elopement "Within the past year, has [Child] wandered off or
Questions became lost from
a. your home?
b. someone else’s home such as a relative, friend,
neighbor, or babysitter?
c. school, day care, or summer camp?
d. a store, restaurant, playground, campsite, or any
other public place?"

McLaughlin et al. 2018 1454 Population- Anonymous 68% Yes/No Parent Report
based study Online “Has your child ever wandered from adult
Questionnaire supervision?”

Andersen et al. 2019 526 Population– Elopement 49% Participants were asked to select from one of seven
based study Prevention options regarding the frequency that their
Questionnaire child/dependent tried to leave safe spaces and/or the
(developed by supervision of caregivers during the past year, with
study authors) options ranging from less than once a month to many
times daily
Pereira-Smith et al. 2019 394 Single-site Questionnaire 68% Yes/No (Likert Scale:
clinical study developed by No: Never (Zero),
study authors Yes: Occasionally (1-2 times), Frequently (3-5
times), Very Frequently (5+ times)

Wiggins et al. 2020 1196 Population- CBCL 60.4% Yes/No

based study No - Parent response = not true
Yes - Parent response = Sometimes true or often true
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Note. Child Behavior Checklist (CBCL); Children’s Social Behavior Questionnaire (C-SBQ); National Survey of Children
with Special Health Care Needs (NS-CSHCN)

Mental Health Crises in ASD

Beyond the challenging behaviors described above, the core features of ASD (i.e.,

social deficits, communication delays, and the presence of restricted and repetitive behaviors)

may themselves be an intrinsic diathesis for crisis. For instance, complex interactions between

ASD symptoms, cognitive features of ASD (e.g., intellectual disability, Newschaffer et al.,

2007), and environmental stressors (e.g., bullying; Zablotsky et al., 2014) may place these

children at high risk for crisis compared to their neurotypical peers. The term “mental health

crisis” is analogous to a psychiatric emergency, which according to the American Psychiatric

Association (APA), includes two key components: (a) an acute psychiatric event that requires

immediate intervention and (b) the lack of perceived resources to manage the event (Allen et

al., 2002). In ASD, the term mental health crisis may be more befitting than a psychiatric

emergency since behavior problems associated with crisis in this population often do not neatly

fit into a psychiatric diagnosis. For example, elopement, which is not a psychiatric disorder and

refers to a child wandering or running away, is a common problem in ASD and can lead to

dangerous outcomes (Anderson et al., 2012).

Although the concept of crisis has been well established, only a handful of measures that

capture this construct exist. Currently available instruments include the Psychiatric Emergency

Service Interview (Perlmutter & Jones, 1985), the Crisis Rating Scale (Bengelsdorf et al.,

1984), the Color-Risk Psychiatric Triage Scale (Molina-Lopez et al., 2016), the Crisis Triage

Rating Scale (Bengelsdorf et al., 1984), the Triage Assessment Form (Hamm et al., 2010), and

the Crisis Risk and Adaptive Functioning Tool (Stokoe, 2012). The main drawbacks of these
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scales are their narrow focus on suicidality as the precipitating psychiatric event as well as their

reliance on clinician administration, which limits the measure’s use in epidemiologic research

due to the costs of conducting clinical assessments in large populations. Most importantly, none

of these measures were designed for youth, in general, or specific populations who may be at

greatest risk for crisis, namely those with ASD.

Recently, Weiss and Lunsky explored the measurement of crisis among families raising

a child with ASD (Weiss & Lunsky, 2011; Weiss et al., 2014). Their qualitative work suggested

that parents’ conceptualized crisis across four themes: (a) the child’s behavioral problems and

difficulty with service providers, (b) the deleterious effects of crisis on the family, (c) frequent

use of emergency services for crises, and (d) the parents’ need for social and professional

support to manage crisis-related events. These themes informed the development of the Brief

Family Distress Scale (BFDS; Weiss et al., 2014), a single item rating that considers the global

or overall state of the family as it relates to crisis. Their data show that the BFDS is positively

associated with a host of adverse outcomes including negative life events, financial problems,

poor quality of life, and the child’s problem behavior (Weiss et al., 2014). While the BFDS

differs from previous crisis measures because it focuses on availability of family resources

versus psychopathology (e.g., suicidality) as the precipitant of crisis, this item is likely valuable

in identifying families who could use a referral for social work, family navigation services

and/or close psychosocial monitoring by the primary care provider (PCP).

To overcome the shortage of assessment tools available to evaluate whether youth with

ASD are at risk for a mental health crisis, Kalb et al. (2017) developed the Mental Health Crisis

Scale (MCAS). This publicly available, caregiver-report measure takes about 10 minutes to

complete. There are three sections of the MCAS with the first two sections identifying the
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severity of behaviors while items from section three are summed for a total score. A cutoff of 16

places the child at risk for a crisis. This cutoff is highly accurate in relation to clinicians’

determination of crisis (ROC=.86; 83% Sensitivity; 86% Specificity; 88% Correctly Classified).

The original MCAS development study also demonstrated strong alignment with clinician

determination of crisis (Kalb et al., 2018). Beyond criterion validity, the MCAS has

demonstrated strong psychometric characteristics. This includes construct (via factor-analytic

methods), concurrent (correlations with other related constructs, like the BFDS and parental

stress), and ecological validity (association with previous psychiatric hospitalization; Kalb et al.,

2018). The measure is also reliable, as measured by internal consistency (Cronbach’s alpha =

.88).

The MCAS has been used to measure the prevalence of crisis across a sample of youth

and young adults with ASD at 32% (Vasa et al., 2020). These data were gathered from an online

sample of N = 462 community youth and young adults with ASD (not clinically referred).

Younger age, increased parental depressive symptoms, and lower family quality of life were

significantly correlated with higher crisis scores (Vasa et al., 2020).

The elevated estimate of crisis among youth with ASD suggests a need for substantial

mental-health support. Unfortunately, results from a national study of child and adolescent

psychiatrists found these providers lacked access to specialized resources, such as social workers

and psychiatric crisis evaluation centers, needed to assess and treat mental-health crises in youth

with ASD (Kalb et al., 2016). That finding is concurrent with parental-report in terms of

difficulty accessing high-quality mental-health care for their child (Brookman-Frazee et al.,

2010; Chiri et al., 2012). Psychiatrists also expressed concerns about the ability of emergency

department (ED) professionals and emergency responders to manage mental-health crises among
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youth with ASD in a safe and developmentally appropriate fashion (Kalb et al., 2016). These

findings, coupled with a recent national study showing only half of mental-health providers will

treat youth with ASD, suggest greater outpatient services are needed for those with ASD (Cantor

et al., 2021).

Summary

Challenging behavior among children with ASD is highly prevalent. After reviewing

studies that covered almost 25,000 children, greater than 4 in 10 engaged in at least one

challenging behavior. Interestingly, the prevalence of each behavior was quite similar. Moreover,

mental-health crises in youth and young adults with ASD have been reported to be common. It

should be noted that a preponderance of these studies were based in clinical settings (i.e., many

of these children were likely referred for these or related challenges). Nevertheless, population-

based studies, that present less issues with selection bias, often produced similar estimates.

Another important finding is the measurement variability within and across constructs

and studies. This heterogeneity makes cross-study comparisons difficult. This is particularly true

when attempting to: a) synthesize the literature regarding severity and b) identify risk factors for

challenging behaviors. When parents serve as the informant, use of standardized, normative

measures such as the CBCL is recommended. Normative measures naturally provide comparison

groups to understand severity/level of impairment, through the use of T-scores.

Screeners and Standardized Assessments

Given the prevalence of challenging behavior in the ASD population, and the potential

negative health outcomes associated with its occurrence (e.g., persistent stress, lower quality of

life; Fitzpatrick et al., 2016), early identification and targeted assessment is needed. Screeners

and informant-based measures of challenging behavior can be helpful for identifying problems,
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determining the degree of impairment, and in some cases (when shown to be reliable and

sensitive to change), monitoring progress. In the following sections we detail screening and

standardized assessment procedures used to assess challenging behavior in the ASD population.

We highlight common informant-based and direct screeners, standardized questionnaires that

focus on challenging behaviors, and psychiatric assessments. This is not a systematic review of

available questionnaires and their psychometrics; rather it provides an overview of commonly

used measures and highlights their strengths and weaknesses.

Informant-based Screeners

One class of standardized questionnaires includes broad-based screeners that tap various

forms of emotional and behavioral difficulties. Benefits of these measures is that they assess a

wide range of problems, provide standardized norms for comparison, and have versions that

cover the full lifespan. A drawback is that they are generally all copyrighted; thus, both

administration and scoring forms (or online uses) must be purchased. While their

comprehensiveness is a strength, this also means that they are often lengthy to complete. Broad

screeners are widely used at initial mental-health evaluation appointments or within school

system evaluations. Since scoring is often based on normative data from large samples, cutoffs

are usually available to aid interpretation of scores. These screeners can be helpful to identify

areas requiring more in-depth assessment and to quantify the magnitude of difficulty across

different areas of functioning.

One of the most common measures in this category is the Achenbach System of

Empirically Based Assessment (ASEBA) System (Achenbach, 2009), which includes caregiver

report forms (e.g., CBCL for ages 1.5-5 or 6-18 and the Adult Behavior Checklist [ABCL]), self-

report forms (Youth Self-Report [YSR] for ages 11-17 and Adult Self-Report Form [ASR]), and
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a Teacher Report Form (TSR). The ASEBA system generates scores that map onto Diagnostic

and Statistical Manual of Mental Disorders (DSM) criteria (DSM-oriented scales) as well as

syndrome scale scores, which tap various problem behaviors, including an Aggression Scale.

Although developed for the general population, the ASEBA system is widely used with

individuals with ASD. A measure like the ASEBA scales that has been utilized somewhat less in

autism, but has some unique strengths, is the Behavioral Assessment System for Children – 3

(BASC-3; Reynolds & Kamphaus, 2015). One disadvantage of the BASC-3 compared to the

ASEBA scales is the lack of an adult version. However, advantages include its assessment of

adaptive behaviors, executive functioning, and strengths in addition to coverage of the topics

assessed by ASEBA. It also includes a validity index. The BASC-3 has an accompanying

Behavioral and Emotional Screening System that is meant to be completed in five minutes to

identify behavioral and emotional strengths and weaknesses.

Direct Screeners

One concern with informant-based measures is that challenging behavior is not actually

measured in the time and place in which it is reported to occur, making it difficult to assess the

specific topography of challenging behavior in question and the environmental variables

responsible for its occurrence. A functional approach to screening for challenging behavior, that

relies on direct observation and compliments the informant-based measures described above, was

developed by Fahmie and colleagues (2016; 2020). Here, “sensitivity tests” are designed to

screen for emerging challenging behavior under a set of situations that commonly occasion

challenging behavior. These procedures mimic those of a functional analysis (described below)

but are brief and embedded within a small-group play context. Children are exposed to brief

periods of time when (1) a caregiver’s attention is diverted away from them, (2) preferred
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tangible items are restricted, and (3) demands are presented to them. If challenging behavior

occurs during these situations, the caregiver either (1) delivers attention, (2) provides access to

the tangible item, or (3) terminates demands. These situations are then compared with a free-play

situation in which the child has access to toys and attention in the absence of demands.

Situations that occasion challenging behavior, relative to the free-play context, are then

suspected to be functionally related to challenging behavior. Stated differently, the situations that

produce challenging behavior likely mimic the learning environment in which challenging

behavior may occur and develop. By identifying those situations, and the consequences that are

likely to reinforce challenging behavior, the child can be taught alternative and more socially

appropriate ways to behave and communicate under those same situations. This screening model,

however, is early in its development and further research is needed to determine its efficacy.

In addition, there are also developmental assessments that rely on direct observation of

behavior that more generally measure global development. For example, the Bayley Scales of

Infant and Toddler Development—4th Edition (Bayley—4; Bayley & Aylward, 2019), is a

standardized, norm-referenced tool that measures a child’s cognitive, language, motor, social-

emotional, and adaptive development. During this assessment several tasks are given to examine

how the child explores new toys, solves problems, and completes puzzles, for example. The

child’s behavior is then scored and compared with other children their age to make normative

comparisons of development. Although developmental assessments, such as the Bayley—4, are

not specifically focused on challenging behavior, if challenging behavior is observed in a child

with ASD during these assessments, pursuing assessments targeting challenging behavior should

be considered.

Standardized Measures of Challenging Behaviors

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SCREENING AND ASSESSMENT

Once a presenting concern has been identified, another class of standardized measures

that focuses more specifically on challenging behavior may ensue. These scales often measure

multiple forms of challenging, atypical, or disruptive behaviors, though, at times, users focus on

just a single subscale related to challenging behaviors. Four of the most widely used options

include the ABC-2, Emotion Dysregulation Inventory (EDI), BPI-01, and the SIB subscale of the

RBS-R; key characteristics and strengths and weaknesses of these measures are described below,

with some additional options included in Table 4.

The ABC-2 (Aman & Singh, 2017) is one of the most widely utilized standardized

questionnaires related to challenging behaviors in ASD. It includes five broad scales (irritability,

hyperactivity, lethargy, repetitive behaviors, and inappropriate speech) and has decades of

support from research in autism and other intellectual and developmental disabilities for its

psychometrics. The Irritability subscale, which is most commonly employed in research,

includes a constellation of items tapping into tantrums, SIB, and one item on aggression. The

ABC-2 Irritability subscale has been used to support FDA approval of medications to treat

irritability and is widely used as an outcome measure related to challenging behaviors in ASD.

The ABC-2 also includes a Hyperactivity subscale, which can be very relevant to challenging

behaviors as well. The ABC-2 can be utilized across the lifespan.

The EDI (Mazefsky et al., 2018) is a standardized questionnaire of reactivity (intense

negative emotional reactions) and dysphoria (low positive affect, unease). The Reactivity scale

may be particularly relevant when challenging behavior is accompanied by emotional outbursts.

The EDI includes a young child (2- 5-year-old) and 6+ caregiver report versions; a self-report

version for ages 11 and older (including adults) and adult caregiver norms are being developed.

The EDI has strong evidence to support its use in ASD, as well as general community and
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clinical samples, making it suitable for use in both settings specializing in ASD and those that

serve broad populations including ASD. Advantages of the EDI include its validity for both

nonverbal and verbal individuals, its brevity, change-sensitivity, and the availability of clinical

cut-offs. The EDI is freely available for use (requests can be made at: www.reaact.pitt.edu by

completing the EDI Inquiry Form).

The BPI-01 (Rojan et al., 2001) is an informant questionnaire that measures the

frequency and severity of different types of challenging behaviors. Originally developed for

individuals with intellectual disability, the BPI-01 produces scores for aggressive/destructive

behavior, SIB, and stereotyped behavior. It also has a short form which reduces the item number

from 49 to 30 (Rojahn et al., 2012). The BPI-01 is only applicable to those who have

demonstrated a behavior at least once in the past two months and is therefore more appropriate

when challenging behavior is a referral concern.

The SIB scale of the RBS-R (Bodfish et al., 2000; Lam & Aman, 2007) is perhaps the

most common applied standardized measure of SIB. It is part of a broader scale focused on

repetitive behaviors. It is a 43-item measure that assesses behavior in the past month. It is

appropriate for use with children, adolescents, and adults. Unlike the other measures, the RBS-R

is freely available.
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Table 4
Summary of Standardized Measures of Challenging Behavior that have been Used in or Developed for Individuals with
ASD or Intellectual and Developmental Disabilities

Measure Author (year) Versions Subscales/Diagnoses Age Range

Informant-based Screeners
Achenbach & Rescorla Parent, Self, DSM-oriented (psychiatric diagnosis) scales; Syndrome 1.5-5 years; 6-18
ASEBA Measures (2000; 2001; 2003) Teacher scales (including Aggression); Internalizing Problems, years; Adult
(CBCL/ABCL, Externalizing Problems, Total Problems
YSR/ASR, TRF)

Reynolds & Kamphaus Parent, Self, Child and family interaction scale, Personal adjustment 2-25
BASC – 3 (2015) Teacher and interpersonal relationships scale, School and
academic performance, Self-directed problem behavior,
Emotional/Internalizing and Externalizing problem
behavior scales
Standardized Measures on Challenging Behaviors
Aman & Singh (2017) Parent Irritability, Social Withdrawal, Stereotypic Behavior, 3+ years (through
ABC-2 Hyperactivity/Noncompliance, Inappropriate Speech adulthood)

BPI-01 Rojahn et al. (2001) Informant Self-injury, stereotypy, aggressive/destructive 14-91

behaviors
Children’s Scale of Farmer & Aman (2010) Parent Problem Scale, Provocation Scale; measures 5 domains 1-21 years
Hostility and of aggression
Aggression:
Reactive/Proactive
EDI Mazefsky et al. (2018, Informant, Self Reactivity, Dysphoria Ages 2 and older
2020)

Eyberg Child Behavior Eyberg & Pincus Parent Externalizing behaviors Children
Inventory (1999)

Home Situations Chowdhury et al. Behavioral non-compliance: Socially Inflexible, 3-14 years
Questionnaire – (2016) Demand Specific
Modified for ASD
Nisonger Child Behavior Aman et al. (1996); Parent, teacher Social Competence, Problem Behaviors: Conduct 3-16 years
Rating Form Tasse et al. (1996) Problem, Insecure/Anxious, Hyperactive, Self-
Injury/Stereotypic, Self-Isolated/Ritualistic, Overly
Sensitive (parent)/Irritable (teacher)

Note. Achenbach System of Empirically Based Assessment (ASEBA); Adult Behavior Checklist (ABCL); Adult Self-
Report Form (ASR); Behavioral Assessment System for Children – 3 (BASC-3); Child Behavior Checklist (CBCL);
Emotion Dysregulation Inventory (EDI); Youth Self-Report Form (YSR); Teacher Report Form (TSR).
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Psychiatric Assessments

Beyond the measures of challenging behavior reviewed above, there are psychiatric

assessments that may be warranted when challenging behavior is accompanied by other

symptoms of a psychiatric disorder. Individuals with ASD have high rates of co-occurring

psychiatric conditions (Rosen et al., 2018). Challenging behaviors may occur in the context of, or

even be due to, a wide range of psychiatric disorders. Therefore, it is important to consider

assessment of psychiatric conditions, particularly in the context of a new onset of challenging

behavior or a worsening of challenging behavior. Psychiatric assessment should be viewed as

complementary to behavioral assessment as the identification of co-occurring psychiatric

conditions should be incorporated into case conceptualization and treatment planning. There are

existing resources that cover the topic of psychiatric conditions in ASD in depth (i.e., The Oxford

Handbook of Autism and Co-Occurring Psychiatric Conditions, White et al., 2020). Below we

cover some of the key themes regarding psychiatric assessment in ASD.

Notably, there are no preferred or gold-standard validated mental-health assessments that

reliably identify co-occurring psychiatric conditions in addition to ASD. In general, structured

interviews are considered the most comprehensive psychiatric diagnostic assessments, but they

can be time consuming. The Schedule for Affective Disorders and Schizophrenia for School-Age

Children-Present and Lifetime version (Kaufman et al., 1997) and Structured Clinical Interview

for DSM‐5 (First et al., 2014) are perhaps the mostly widely used structured psychiatric

interviews in general; both can take several hours to complete and require a substantial amount

of training in administration and score. The MINI International Neuropsychiatric Interview

(Lecrubier et al., 1997) has been considered in ASD with promising psychometrics (Mosner et

al., 2019). Although additional evaluation is needed, it may offer a brief (~15 min) alternative to
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longer structured interviews. While some interviews have been developed for intellectual and

developmental disabilities and ASD populations (e.g., Autism Comorbidity Interview [Leyfer et

al., 2006]; Baby and Infant Screen for Children with Autism Traits [Matson et al., 2007]), they

are also not in widespread use and are more likely to be utilized in research contexts.

Questionnaires may be a more feasible initial screen for psychiatric diagnoses. The Child

and Adolescent Symptom Inventory (Gadow, 2015) has been widely utilized in ASD and is

designed to map onto DSM-5 criteria. It is a standardized behavior rating scale for children ages

5 to 18. It provides symptom count cutoff scores, symptom severity scores, impairment cutoff

scores, and clinical cutoff scores for all major DSM-5 disorders. The previously described

ASEBA measures and BASC-3 also provide indices of psychiatric diagnoses and can be useful

as psychiatric screening questionnaires. One caution is that it is not uncommon for individuals

with ASD to score high on the CBCL and BASC-3 psychiatric diagnoses indicators even when

not meeting criteria for co-occurring diagnoses. It is possible that these measures also capture

common impairments seen in ASD even when a separate diagnosis is not warranted. This may

reflect difficulty in the differential diagnosis of psychiatric symptoms in ASD as well as

symptom overlap (e.g., symptoms of withdrawal in both ASD and depression, repetitive actions

in both ASD and OCD, etc.).

Further, the Academic Autism Spectrum Partnership in Research and Education

(AASPIRE), a partnership between researchers and autistic adults, is developing a toolbox of

mental health measures for adults, many of which have been modified to be more appropriate

and valid in ASD (Nicolaidis et al, 2020). There are also some recent and ongoing initiatives to

develop new psychiatric symptoms measures for autism (e.g., the Pediatric Anxiety Rating
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Scale; Maddox et al., 2020). As such, the assessment of mental health concerns in ASD is an

area with anticipated future growth.

Summary

Standardized, informant-based questionnaires can be useful for efficiently determining

the presence and degree of challenging behaviors. As can be seen in review of Tables 1-3, these

measures are underutilized. Often, studies employ single items or custom measures that lack

reliability, validity, and sensitivity to change. The measures described above and summarized in

Table 4 offer a starting point for the standardized assessment of challenging behaviors in ASD.

The specific measures employed in practice should be based on clinical expertise, empirical

evidence, and tailored to the individual’s needs and preferences (APA, 2006). Nonetheless, most

options produce summary scores for clusters of challenging behaviors (i.e., an externalizing

behaviors score, irritability score) versus specific scores for different types of challenging

behaviors (e.g., aggression, SIB). Of note, we were unable to identify any standardized measure

of elopement.

Future research should focus on the development of efficient, precise, and change

sensitive standardized assessments of specific challenging behaviors across the lifespan as well

as consideration of the psychometrics of standardized questionnaires that are utilized in non-

ASD populations. For example, the Multidimensional Assessment of Preschool-Disruptive

Behavior Scale (MAP-DB; Wakschlag et al., 2014) is a particularly psychometrically strong

measure of challenging behaviors (Mazefsky et al., 2021). It offers versions now available across

the childhood years (Infant/Toddler, Preschool, School Age, and Adolescence; Biedzio &

Wakschlag, 2018), including early childhood which is a gap in measure options of specific

challenging behaviors in ASD and is a particularly difficult period of assessment given the
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occurrence of dysregulation even among normative samples at that age. The MAP-DB is widely

utilized outside of ASD but has thus far not been considered within the ASD community.

Two other directions for measurement include the use of self-report measures and a focus

on non-suicidal self-injury. All the measures listed in Table 4 require informant report. However,

many adolescents and adults with ASD have the verbal abilities to complete measures

themselves. For instance, the Buss-Perry Aggression Questionnaire (Buss & Perry, 1992; Buss &

Warren, 2000) is a self-report questionnaire of aggression, verbal aggression, hostility, and anger

that has been used in hundreds of studies outside of ASD. Understanding its utility in ASD is

worth consideration. There is also recent interest in considering measures of non-suicidal self-

injury in ASD, which may offer important insights into SIB in ASD, particularly among more

cognitively able individuals.

When challenging behavior is associated with comorbid psychiatric symptoms,

psychiatric assessments should also be considered to complement behavioral assessments.

Comorbid psychiatric conditions are common in ASD and should be integrated into case

conceptualization and treatment planning related to challenging behaviors. It is worth noting that

considerable resources also exist for the assessment of prosocial behaviors. Understanding

individual strengths and specific behavioral repertoires that may lessen or even prevent the

development of challenging behaviors is critical to the ongoing comprehensive developmental

proactive care for individuals with ASD. For instance, the Values in Action (VIA) Inventory of

Strengths has shown promise in terms of identifying prosocial aspects of character among

persons with intellectual and developmental disabilities (Shogren et al., 2018). Once identified,

well-being may be promoted by leveraging the individual’s strengths rather than focusing on

reducing deficits. Although merging the disability field with positive psychology is quite
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nascent, it does hold promise for improving academic, social, and mental-health outcomes (Lai et

al., 2018; Vuorinen et al., 2018; Raley et al., 2020) and should be considered in future research.

Finally, direct screening procedures of challenging behavior rely on observation of

behavior during situations that commonly contribute to the occurrence and maintenance of

challenging behavior in the ASD population. This structured observational functional approach

to screening holds much promise in those situations for which children are sensitive to reactions

(i.e., engage in emerging forms of challenging behavior) and can be immediately targeted for

prevention-level treatment. For example, a child may be taught to engage in context-specific

communication that would deter further development of challenging behavior occasioned by

those situations. The long-term benefits of this approach are unknown at this time but warrant

future research. Nevertheless, the notion of assessing the environmental variables that may

contribute to the development of challenging behavior highlights the goal of function-based

assessment as well, which is described next.

Function-Based Assessment

Once challenging behaviors have been identified, timely and accurate assessment of the

level, severity, and maintaining variables related to the challenging behavior is critical to

matching appropriate type and levels of care. Of key importance is identifying the target

behavior in need of treatment and the environmental variables responsible for its maintenance.

Standardized assessments, like those described above, are helpful in making normative

comparisons; however, they are limited in their ability to detect the environmental variables that

contribute to challenging behavior. As a complement to these standardized approaches, indirect,

direct, and experimental assessment procedures have been developed and packaged into what has

been termed functional behavior assessment (FBA). These assessment methods provide
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a means for objective measurement of challenging behavior, understanding of behavioral

function, and a prescription for later development of intervention.

FBAs are comprised of various procedures that assess the environmental variables

suspected to evoke and maintain challenging behavior in the natural environment. These

assessment procedures are based on a number of key assumptions (Dunlap et al., 1991; Horner &

Carr, 1997; Martens & Ardoin, 2010; O’Neill et al., 1997; Sullivan et al., 2021): (a) the focus of

the assessment is on challenging behavior itself, rather than viewing challenging behavior as a

sign indicating an underlying disorder, (b) challenging behavior varies systematically across

environmental situations and has been learned from past experiences, (c) through repeated

measurement predictable patterns of challenging behavior can be identified, and (d) the

contingencies supporting challenging behavior that are identified through functional assessment

can be modified during treatment. Overall, the purpose of an FBA is to improve effectiveness

and efficiency of the behavioral treatment (Horner, 1994), and treatments based on the function

of challenging behavior have consistently been shown to be more effective than non-function-

based interventions (Didden et al., 1997; Iwata et al., 1994; Saini et al., 2021).

The assessment procedures available to practitioners when conducting an FBA are not

static and prescribed. Instead, they are intended to be a menu of techniques available to

practitioners to arrive at the identification of the specific controlling variables that maintain a

behavior, and to use that information to guide selection of evidence-based interventions (see

Evidence Based Practices document). For example, if physical aggression is found to be

maintained by obtaining access to preferred activities, then in treatment the individual may be

taught to request preferred activities using a more socially appropriate, communicative response

(Carr & Durand, 1985; Saini & Sullivan, 2021). It should also be noted that FBAs are helpful in
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identifying individual strengths and preferences that may be incorporated in treatment. For

instance, preference assessments (e.g., Fisher et al., 1992; DeLeon et al., 1996; Roane et al.,

1998) may be used to identify reinforcers specific to the individual, and through direct

observation adaptive skills may be highlighted. For present purposes, however, the most

common strategies used to assess the function of challenging behavior will be reviewed and have

generally fallen into three categories (Roane et al., 2019): (1) indirect assessment, (2) descriptive

assessment, and (3) functional analysis. In the following sections we will briefly describe

common FBA strategies to clarify how functions of challenging behavior are assessed.

Indirect Assessment

Indirect functional assessment (Gadaire et al., 2021) describes a group of procedures that

aim to efficiently gather information about an individual’s challenging behavior and the events

that surround its occurrence. More specifically, these procedures focus on identifying the

antecedent events that precede challenging behavior and the responses that follow challenging

behavior which may serve as reinforcement. Common procedures include record reviews (e.g.,

medical, school), behavioral interviews (structured or semi structured), and various checklists,

questionnaires, and rating scales. Below, commonly used indirect assessments to hypothesize

function(s) of challenging behavior (Gadaire et al., 2021) are reviewed.

The Questions About Behavioral Function (QABF; Matson & Vollmer, 1995) is a rating

scale designed to assess possible functions of challenging behavior. The QABF contains 25 items

that correspond with five potential sources of reinforcement: attention, escape, non-social

(automatic-positive), physical (automatic-negative), and tangible. Items are scored based on how

often the challenging behavior is reported to occur across situations using a 4-point Likert-type

scale (0=Never, 3=Often). Matson et al. (2012) conducted a review of the QABF and reported
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good test-retest reliability, acceptable inter-rater reliability, and good internal consistency.

Additionally, conclusions drawn from the QABF were found to be like those from functional

analyses.

The Functional Analysis Screening Tool (FAST; Iwata & DeLeaon, 1996) is a self-

reported 16-item questionnaire designed to identify antecedent and consequent events that may

contribute to the occurrence and maintenance of challenging behavior. The 16 items are

categorized into four sections that describe the conditions under which the behavior occurs.

Relevant stakeholders (i.e., caregivers, teachers) complete a structured questionnaire designed to

gather information about functional characteristics of the problem behavior to analyze potential

sources of reinforcement. Although Iwata et al. (2013) found the FAST to produce somewhat

reliable and valid reports, it is not recommended that practitioners conduct the FAST without

additional descriptive and/or experimental assessments to inform function.

The Motivation Assessment Scale (MAS; Durand & Crimmins, 1988), is a 16-item

checklist used to develop hypotheses regarding behavioral function. Informants rate how often

the individual engages in challenging behavior using a 7-point Likert-type scale ranging from 0

(Never) to 6 (Always). Item ratings are summed and categorized by potential sources of

reinforcement: sensory, escape, attention, and tangible. Durand and Crimmins reported evidence

of good test-retest reliability over a 30-day period (r = .89-.98), adequate interrater reliability (r

= .66-.92), and good predictive validity between ranked scores on the MAS and functional

analysis outcomes. However, others have reported suboptimal psychometrics (see Sigafoos et al.,

1994; Zarcone et al., 1991).

O’Neill et al. (1997), developed an indirect-assessment system titled, The Functional

Analysis Interview (FAI). The FAI is a structured interview that includes eleven sections
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designed to identify potential functions of challenging behavior. The FAI takes approximately

45-90 minutes to complete and provides a guide for the interviewer across content areas. For

example, the FAI helps to define the challenging behavior, identify the antecedents and

consequences for challenging behavior, determine the individual’s communicative abilities,

identify potential reinforcers, and review the history of previous interventions.

Each of these indirect assessments allow for hypotheses regarding the function(s) of

challenging behavior to be developed based on the environmental events that were reported to

occasion challenging behavior. These procedures are practical and efficient, however, because

the outcomes are based on the informant’s perception and recall of past events, potential biases

in reporting may lead to inaccurate identification of function (Gadaire et al., 2021; Iwata et al.,

2013). To address these concerns, direct observation and measurement of challenging behavior is

needed. Below, various behavioral measurement strategies are described with their relative

strengths and weaknesses.

Direct Measurement

This section outlines strategies for directly measuring and recording challenging

behavior. Each strategy has its own strengths and limitations. We do not provide direct

recommendations that one procedure should be used over another. Instead, we highlight each of

the strategies benefits and drawbacks, and provide readers with a decision tree for selecting an

appropriate measurement system. Key to any direct and reliable measurement of challenging

behavior is the development of operational definitions for the target responses. Definitions must

be objective and clear, with well-established understanding of when a response begins and ends.

The operational definition must also include examples and non-example such that any observer
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clearly understands what a behavior is and is not. Table 5 provides a list of common

topographies and corresponding operational definitions for challenging behaviors.

Table 5
Sample Operational Definitions of Common Challenging Behaviors

Response Topography Operational Definition

Physical aggression Any completed, attempted, or blocked response that could cause injury to another person. This includes but is not
limited to slapping, scratching, kicking, pinching, pushing, head butting, and throwing objects at people.
Examples include: forceful contact of hand (open or closed) or arm (with or without another object) against any
part of the therapist’s body. Non-examples include: giving high-five, giving someone a hug.

Self-injury Any completed or blocked response that is self-directed such that repetition of the behavior over time has or will
cause bodily injury. This includes but is not limited to head banging, self-hitting, biting, eye-poking, hair pulling
and pinching. Examples include: forceful contact or attempted contact of client’s hand (open or closed, with or
without object) or foot against any part of the client’s own body from at least 2 inches away or greater. Non-
examples include: scratching head, tapping foot against floor.

Property destruction Any completed or blocked response that could cause damage to materials or any other objects or surfaces within
the immediate environment. This includes throwing objects, kicking/hitting objects, over-turning furniture,
climbing on objects, and swiping objects from a table or other surface. Examples include: Patient projects an
object from a distance of at least 6 inches with force (not directed at therapist). Non-examples include: Playing
catch during play or bumping into table and knocking off materials.

Elopement Any completed, attempted, or blocked instance of a patient leaving a supervised. Examples include: moving from
a supervised room or area without permission or moving more than 5 feet away from the therapist. Non-example
includes leaving assigned area when instructed to do so.

Flopping Any completed, attempted, or blocked instance in which the client’s body falls from a standing position to the
floor or ground such that his or her midsection (i.e., back, buttocks, stomach, or shins) contacts the floor or
ground). Non-example includes laying on floor playing with toy or watching television.

Once operational definitions are developed, strategies for direct measurement should be

selected. There are many measurement strategies available to practitioners each with strengths

and limitations. Table 6 provides a summary of the measurement procedures discussed below

with associated strengths, potential limitations, and examples of use from the published

literature. These data may be collected through a variety of means including paper and pencil

data collection, use of response clickers and timers, or computer-based data collection software

(e.g., BDataPro; Bullock, 2017). Deciding what data-collection strategy to use and the manner in
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which challenging behavior should be measured are important considerations. Thus, a decision-

making tree for determining the appropriate measurement strategies is provided in Figure 4.

Continuous measurement. Continuous measurement requires constant observation and,

therefore, may not be possible to conduct in applied settings. Although labor-intensive,

continuous measurement systems provide a comprehensive and ongoing account of the behavior

of interest. Frequency, duration, latency, and intensity are the most commonly measured

dimensions of behavior in which continuous measurement procedures are used.

Frequency measures attempt to capture the repeatability dimension of a target

response and require minimal instrumentation. To conduct a frequency measure, one simply

counts the occurrence of the target response. One could also divide the total count of the target

response by the duration of the observation period to produce response rate. Response rate is an

important frequency summary measure because it controls for unequal observation periods. That

is, in scenarios where session durations are not constant, comparing frequency

without considering observation time may skew the data; response rate equates across these

different observation durations.

Duration recording is used to capture the temporal extent, or the time that passes

between the onset and offset of a target response. To use a duration measure, one must identify

the onset and offset criteria, then begin a timing device (e.g., stopwatch or timer) when onset

criteria are met and stop the timing device when offset criteria are met. Duration is helpful when

targeting responses with a long temporal extent. It may also be beneficial for responses with a

brief temporal extent, which also have a rapid rate of occurrence. Duration can be summarized

in several ways. The measure can be summarized with the frequency of the target response to

produce the duration per occurrence of target responses. The total duration of a target
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response can be divided by the observation period to derive a percentage duration. Lastly, the

duration per occurrence of the target response can be averaged to determine the mean duration of

the response.

Latency is similar to duration but captures the temporal locus of two events. Latency is

typically used to identify when a target response occurred in relation to some other

environmental event. For instance, if an instruction is given to a student, and then she aggresses

toward the instructor, the time that elapses between instruction and challenging behavior is

the response latency. To conduct this measurement procedure, clear criteria are needed for when

the observer is to start and stop their timing device. Interresponse time is a variation of the

latency procedure where, instead of timing the latency from evocative stimulus (e.g.,

instruction) to target response (e.g., challenging behavior), one records the latency between the

cessation of one target response to the onset of the next.

Intensity recording captures the magnitude of a target response. This measurement

strategy may be more difficult to conduct in applied settings due to instrumentation

requirements. Intensity is measured depending on the topography of the target response. For

instance, if an individual engages in screaming behavior, intensity may be captured by decibel

meter. If the target response includes challenging behavior toward others, intensity could be

measured by a pressure plate (though, to date, intensity measures of challenging behavior have

been understudied). It is often easier to measure intensity by the permanent products the target

response leaves after its occurrence or by rating scale. Figure 1 provides an example of a rating

scale that may be used to gather information regarding intensity or severity of challenging

behavior.
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Figure 1
Sample Rating Scale Depicting Varying Levels of Challenging-Behavior Severity

Severity Range (check all that apply)

Challenging behavior resulting in (a) no marks on body and (b) no blows close to or
Level 1
= contacting the eyes
Level 2 Challenging behavior resulting in (a) reddening of skin, and/or (b) mild swelling
=
Challenging behavior resulting in (a) light scratches, (b) small or shallow breaks in skin,
Level 3
= and/or (c) moderate to severe swelling
Challenging behavior involving blows close to or contacting the eyes or resulting in (a)
Level 4 scratches that leave scars, (b) breaks in skin that leave scars, and/or (c) trauma resulting in
=
broken bones or lasting tissue damage or disfigurement

This rating scale is a less desirable measure to determine the occurrence of challenging

behavior as observers must make a subjective evaluation of the intensity of the

target response. Thus, it is not suggested that rating scales be used alone in measuring challenging

behavior unless there is no other option. In resource-limited situations, it may be best to use a

visible product of the response (called permanent-product recording), which would allow

practitioners to gather additional information related to the frequency and intensity of target

challenging behaviors. It is important to note that this permanent-product data is not a direct

measure of the target response and requires a degree of inference, which sacrifices some

accuracy and validity of these data. The tactics of measuring permanent products vary depending

on the topography of interest. For example, when collecting the pictorial examples of a sustained

bite mark provided in Figure 2 permanent-product data would include the outcome (i.e., tissue

damage) that resulted from the bite mark; however, additional information of the aggressive act,

such as the number of bites (frequency) that occurred would not be represented.
 39

SCREENING AND ASSESSMENT

Figure 2
Pictorial Example of Sustained Bite Marks

Note. Picture reprinted from Zangrillo et al., 2021

Other adaptations of established measures for recording damage produced by a response may

also be relied upon. For instance, SIB may be measured via description of surface tissue damage

via the Self-injurious Trauma (SIT) Scale (Iwata et al., 1990). Although the SIT Scale may be

used to document the surface tissue damage targeted toward implementers of behavioral

interventions, that is not its original intention.

Discontinuous measurement. Discontinuous measures are most frequently employed

when a practitioner desires to record sample measures of a target response during a prescribed

observation period. Discontinuous measurement procedures require dividing an observation

period into equal intervals and recording the occurrence of responses across those intervals.

Discontinuous measures are most appropriate for target responses where the dimension of

interest is repeatability and temporal extent. Relative to continuous measurement that requires

constant observation, discontinuous measurement breaks down the observation into specific

intervals and may not capture every instance of behavior thereby producing only an estimate of

the occurrence of the target response.

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SCREENING AND ASSESSMENT

The primary benefit of discontinuous recording procedures is that they are typically

easier to use than frequency or duration measures as they do not require precision in the

recording of the exact occurrence of the target response. Three main types of discontinuous

measurement are common: (1) partial-interval recording, (2) whole-interval recording,

and (3) momentary time sampling. When summarizing the following discontinuous measures, it

is standard practice to report the occurrence of the target response in percentage of intervals or

percentage of the observation period.

Partial-interval recording involves recording whether the target response is observed or is

not observed during a specified time interval. After an observation time is identified, the

timeframe is divided into smaller intervals of equal length. Partial-interval recording is likely

suitable to record high-rate behavior across multiple forms (LeBlanc, 2016). Partial-

interval recording often overestimates the occurrence of a target response.

Whole-interval recording involves first dividing the observation period into equal

intervals. The occurrence of the target response is only reported if the target response persists for

the entirety of an interval. Due to the requirement that the response persists for the whole

interval, it tends to underestimate the occurrence of the target response. Because of

this underestimation, it is not advised that whole-interval recording be used for responses which

are targeted for reduction. To illustrate whole-interval recording, suppose we again divided a

one-minute observation window into 6, 10-second intervals, we might observe the student to

engage in challenging behavior at least once in 4 of the 6 intervals but only throughout the entire

interval twice. Given this, whole-interval recording of her challenging behavior would be

33.3%.
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SCREENING AND ASSESSMENT

The final common discontinuous measurement procedure is momentary time sampling.

Like the above discontinuous procedures, the observation period is split into equal observation

intervals. For most of the interval, the observer does not look for the occurrence of the target

response, but rather looks up at the end of each interval for an observation check of

approximately 1-3 s. If the target response occurs at any point during the observation check, the

target response is recorded for the entire interval. Momentary time sampling has the potential

to both over- and underestimate the occurrence of target responses. These errors are typically a

function of the observation interval length and characteristics of the target response. Fiske

and Delmolino (2012) provide a more in-depth discussion of the factors that impact error rate in

momentary time sampling than what is possible in this document. Suppose that student’s

aggressive behavior is being observed in her classroom. She might be observed for 3 seconds at

the end of each 10-second interval but not during the remaining 7 seconds of each interval. As

with the previous examples, if the student engaged in some challenging behavior during 4 of 6

total intervals, but only three of those occurrences in the 3-second observation window, the

momentary time sampling measure would reveal challenging behavior to occur during 50% of

the observation (i.e., underestimation relative to partial-interval and overestimation relative to

whole-interval). Table 6 provides a summary of the aforementioned measurement procedures

with associated strengths, potential limitations, and examples of use from the published

literature. Figure 3 provides a decision-making model for selecting appropriate measurement

procedures.
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Table 6
Measurement Procedures for Challenging Behavior

Measurement Description Resulting measure(s) Strength(s) Potential limitations

procedure

Event recording Record each instance Frequency, rate, Direct measures of the Requires constant vigilance; may
of behavior as it occurs percentage of behavior be impractical for high-frequency
opportunities (for or non-discrete behavior
restricted operants)

Duration recording Record the amount of Total duration, mean Direct measures of the Requires constant vigilance;
time from onset to duration, percentage behavior (including requires a timing device
offset for each duration frequency)
behavior as it occurs

Latency recording Record the amount of Mean latency Direct measures of the Requires constant vigilance;
time that passes temporal relation between requires a timing device
between the the discriminative
discriminative stimulus stimulus and the behavior
and the onset of the
behavior
Intensity recording Record a dimension of Various (e.g., mean Direct measures of the Requires a reliable and valid
intensity (e.g., force, decibel, mean rating per behavior; automated measurement device (e.g., decibel
volume) for each event) recording possible with meter) or rating system; requires
instance of the some dimensions (e.g., constant vigilance
behavior volume)
Permanent-product Document the effects Various (e.g., wound size, Allows measurement of An indirect assessment of behavior;
recording of a behavior on the number of holes in wall) behavior that occurs at behavior must reliably produce the
environment inaccessible times product and be the only source of
the product
Partial-interval recording Record whether a Percentage of intervals in Does not require constant Generates an estimate of behavior;
behavior occurred at all which the behavior vigilance systematically overestimates the
during specific time occurred occurrence of behavior; requires a
intervals for defined timing device
observation period(s)

Momentary time Record whether a Percentage of samples or Allows concurrent Generates an estimate of behavior.
sampling behavior occurred at a intervals in which the measurement of multiple Inappropriate for short-duration or
given moment for behavior occurred individuals or behaviors; low-frequency behavior; requires a
defined observation does not require constant timing device.
period(s) vigilance; good
correspondence to event
recording compared to
other discontinuous
procedures
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SCREENING AND ASSESSMENT

Figure 3
A Decision-Making Model for Selecting Data Measures

No

Note. Adapted by W. E. Sullivan from LeBlanc et al. (2016). A proposed model for selecting

measurement procedures for the assessment and treatment of challenging behavior.

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Descriptive Assessment

Once challenging behavior is operationally defined and a measurement system is

selected, descriptive assessments (Castillo et al., 2018; Lerman & Iwata, 1993; Mace & Lalli,

1991; Martens et al., 2008) may ensue. Descriptive assessments utilize direct observation and

data collection of the challenging behavior under naturalistic environmental conditions, thereby

addressing the concerns with informant reports of past events. One assessment tool, the

scatterplot (Touchette et al., 1985), can be used to visually depict the occurrence and temporal

relationship of the response(s) to various environmental events illuminating possible patterns not

readily observed in a graph or extrapolated from indirect assessments. Additionally, descriptive

assessments can be helpful in generating hypotheses regarding the function of challenging

behavior (Lerman & Iwata, 1993). Descriptive assessments provide information about the

environmental situations under which challenging behavior does and does not occur, and most

importantly, provides crucial information needed to develop socially valid experimental analyses

of the putative variables influencing challenging behavior (i.e., functional analysis, described

below).

Within the context of FBAs, descriptive assessment procedures typically begin by

observing problem behavior across different antecedent conditions (Erchul & Martens, 2010)

referred to as scatterplot recording (Touchette et al., 1985). Scatterplot recording examines under

what conditions challenging behavior is most likely to occur but does not measure the

consequences that follow challenging behavior. Thus, hypotheses regarding behavioral function

based on scatterplot recordings are limited. Scatterplots may still be informative, however, in

determining the optimal time to engage in recording of behavior and its consequences (Eckert et

al., 2005).
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Another way to determine under what conditions challenging behavior is most likely to

occur while simultaneously examining consequences is to engage in Antecedent-Behavior-

Consequence (A-B-C) recording (Bijou et al., 1968). This type of assessment involves recording

the occurrence of problem behavior, under what conditions it occurred (antecedents), and what

consequence(s) were provided. This process continues until a clear pattern of antecedents and

consequences associated with problem behavior emerges (Lee & Miltenberger, 1997).

A-B-C recording is advantageous in that it can provide descriptive information in a

systematic manner about the events that surround behavior. For example, Tustin (1995) utilized

A-B-C recording procedures to determine possible functions of stereotypy in a 28-year-old male

diagnosed with autism. Results suggested that stereotypy was associated with changes between

work activities (e.g., packing materials). However, there are several limitations with A-B-C

recordings outlined by Iwata et al. (2000). First, because A-B-C recordings typically do not

provide operational definitions for each antecedent and consequence, their reliability is

questionable. Second, there is no uniform way to summarize and interpret the data, which may

produce subjective and biased conclusions. Finally, because data collection only focuses on

problem behavior, frequently delivered consequences (e.g., attention) may follow problem

behavior by chance, leading to an inaccurate functional hypothesis (Thompson & Iwata, 2007).

An alternative strategy for examining the relationship between behavior and its

consequences is to conduct sequential recordings and examine the conditional probability of a

consequence given behavior. This type of assessment typically involves recording behavior and

its consequences in brief (e.g., 10 s) intervals as they occur in sequence throughout an

observation period (Vollmer et al., 2001; Martens et al., 2008). Prior to collecting these data,

specific challenging behavior(s) and consequences are defined so that behavior categories (i.e.,
 46

SCREENING AND ASSESSMENT

challenging behavior and all other behavior) are mutually exclusive and consequences represent

broad categories of reinforcement (i.e., social-positive, social-negative, automatic positive or

negative). Following data collection, conditional probabilities are calculated and those

consequences that have a high probability of following challenging behavior indicate potential

functions.

Functional Analysis

Although indirect and descriptive FBA strategies are helpful in identifying patterns of

challenging behavior, these procedures fall short in being able to demonstrate a functional

relation between challenging behavior and the environmental events suspected to produce it.

That is, although hypotheses regarding the function of challenging behavior can be formed these

assessments do not allow for those hypotheses to be confirmed. To address this issue, Iwata and

colleagues (1982/1994) developed a functional analysis that systematically manipulated the

environmental variables hypothesized to occasion self-injurious behavior within a single-case

experimental design. In a functional analysis, various test conditions are designed to test specific

hypotheses regarding behavioral function, which are then compared with a control condition to

demonstrate a functional relation. In each test condition, a specific situation that is suspected to

evoke challenging behavior is presented and contingent on challenging behavior a specific

consequence is provided that may increase the chances of challenging behavior occurring again

in the future under similar situations (i.e., reinforcement). The relative benefit of functional

analysis over other functional assessment procedures discussed above is that the clinician has

direct control over the contingencies that are influencing challenging behavior, which permits a

more detailed level of analysis and hypothesis testing (Vollmer et al., 2012). Below, common

test and control conditions (see Saini et al., 2021) are described in Table 7.
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Table 7
Description of Functional Analysis Test and Control Conditions

Test Conditions Antecedent Situation Consequence

Attention Diverted or divided attention (e.g., reading a magazine or Social disapproval or reprimands (e.g., “Do not do that. It
talking to another person). is not nice.”).

Tangible Restricted access to preferred activity or toys (e.g., Access to restricted activity or toy.
removal of preferred toy).

Escape Presentation of nonpreferred or aversive situation (e.g., Removal of the aversive situation (e.g., a break from work
presentation of academic demands or loud noises). or removal of noise).

Ignore/ Alone No interaction. Sensory outcomes of the challenging behavior.

Control Condition Antecedent Situation Consequence

Toy play Near continuous attention and access to preferred tangible No differential consequences are provided.
item in the absence of aversive stimulation.

Since the initial development of the functional analysis procedure by Iwata et al.

(1982/1994), its use has been validated across hundreds of studies targeting various topographies

and severity levels of challenging behavior (Beavers et al., 2013; Hanley et al., 2003).

Furthermore, it has been modified in a number of ways to increase efficiency (Falcomata et al.,

2016), to develop novel conditions (Owen et al., 2020; McCord et al., 2001), and to implement

across a variety of settings (e.g., school; Bloom et al., 2013). Nonetheless, functional analyses of

challenging behavior require specialized training and inclusion of safety precautions to minimize

risk (e.g., session termination criteria, personal protective equipment; Weeden et al., 2010; Saini

et al., 2021) and may not be appropriate in all situations. Ultimately, by identifying the
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SCREENING AND ASSESSMENT

function(s) of challenging behavior, the contingencies of reinforcement that contribute to the

occurrence of challenging behavior can be directly altered in treatment. Thus, identifying the

function of behavior is directly prescriptive of treatment.

Summary

The goal of FBAs is to identify the antecedent conditions that evoke challenging behavior

and the consequences that maintain it. By identifying the reinforcement contingencies that

occasion challenging behavior, treatment can be arranged to directly affect those contingencies

and reduce challenging behavior. Utilization of informant report (i.e., indirect assessment) and

measurement of challenging behavior via direct observation (i.e., descriptive assessment) can

lead to the development of functional hypotheses. Only functional analysis, however, can

confirm those hypotheses by manipulating the antecedent and consequent variables within an

experimental arrangement.

The specific FBA methods (e.g., indirect assessments, functional analysis) employed will

ultimately depend on the practice setting and training of the individual conducting the

assessment. These decisions should be rooted in evidence-based practice that includes

consideration of empirical evidence, clinical expertise, and the client’s preferences and values

(APA, 2006). Although functional analysis can confirm the function(s) of challenging behavior,

for example, it may not be appropriate for every case and in all settings (e.g., dangerous forms of

challenging behavior; limited resources or training). For example, if a young child with ASD

begins to engage in disruptive behavior in the classroom, a school-based FBA that utilizes

indirect assessments to develop functional hypotheses and design intervention may be sufficient.

However, if treatment is ineffective and challenging behavior persists or worsens, a more

sophisticated functional analysis may be needed to confirm which contingencies are functionally
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SCREENING AND ASSESSMENT

related to the child’s challenging behavior. In the following sections, we will outline a

framework for identifying and assessing challenging behavior that can be used to inform the

level of care needed over time.

Multi-Tiered Systems of Support

As noted above, individuals with ASD that engage in challenging behavior and their

families may interact with multiple support systems from the time a child is born through

adulthood. To date, however, there are no uniform screening measures for youth with ASD in

relation to development of challenging behavior or a framework for connecting them with

appropriate treatment services and monitoring their progress across the lifespan. Take for

example a child with ASD that engages in their first severe tantrum. The child’s caregiver may

reach out to their pediatrician and school system for help. Perhaps this tantrum was an isolated

incident, and no further intervention is necessary. On the other hand, perhaps this tantrum set the

stage for an escalating pattern of challenging behavior across school and community settings. In

either case, it is imperative that the child’s behavior be monitored to either confirm that no

further intervention is needed or to provide appropriate referrals to specialized treatment

providers. For this reason, a coordinated system of care for (a) screening for challenging

behavior in individuals with ASD, (b) connecting them with appropriate treatment services, and

(c) surveillance of these individuals over time is needed.

An example of such a framework is termed a multi-tiered system of support (MTSS). An

MTSS is an evidence-based framework that takes a data-based problem-solving approach to

integrate assessment and intervention across a continuum of services (Sugai & Horner, 2009).

The MTSS described here is based on the decades of work that have been done on response-to-

intervention, a commonly adopted model in schools to promote positive behavior change (e.g.,
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SCREENING AND ASSESSMENT

Caplan, 1964; Sugai et al., 2000; Sugai & Horner, 2009; 2010; Walker et al., 1996), and mimics

the triage systems in many medical interventions (e.g., seek care when problem emerges, begin

with general pediatrician, and refer to specialist). An MTSS is designed to combat the “wait it

out” approach by which caregivers are advised to wait to see if skills develop or symptoms

subside. This “wait it out” approach is chronically characterized by delayed service delivery.

That is, rather than waiting for severe forms of challenging behavior to emerge, and then

obtaining treatment services, MTSS utilizes on-going screening and assessment measures to

more immediately identify individuals in need of intervention and links assessment outcomes to

evidence-based treatments (see Evidence Based Practices document).

Thus, the primary purpose of a MTSS is to prevent the development of more severe

forms of challenging behavior in the ASD population. The National Research Council and

Institute of Medicine conducted an extensive review on interdisciplinary research on prevention

and suggested that childhood behavior disorders are “preventable” (O’Connell et al., 2009, pp.

xii-xiv; Fahmie et al., 2020) suggesting that early identification and targeted treatments can

mitigate the occurrence and development of challenging behavior. Since challenging behavior

may persist over time, prevention should be of high priority to avoid costly and harmful

outcomes (Waddell et al., 2018). A MTSS addresses prevention from a problem-solving

approach (e.g., Lewis et al., 2010) by providing a continuum of supports that utilizes empirical

data to select, evaluate, and monitor the effects of interventions.

For example, if a 3-year-old child with ASD is reported to engage in mild forms of

challenging behavior (severity levels operationalized below), a MTSS would provide a

framework for (a) detecting the presence of challenging behavior using empirically validated

screening methods, (b) linking the outcomes to evidence-based early intervention programs
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SCREENING AND ASSESSMENT

(Peters-Scheffer et al., 2011) to prevent the further development of challenging behavior, and (c)

monitoring progress over time with on-going modifications to treatment as needed. Thus, if

treatment is not found to produce socially significant reductions in challenging behavior, an

MTSS can facilitate the direction of increasingly individualized and specialized intervention.

Primary-Care Pathway

As an example of how an MTSS system may be utilized to address challenging behavior

in the ASD population, McGuire et al. (2016) developed a practice pathway designed to help

primary care providers (PCPs) screen, assess, coordinate treatment, and monitor challenging

behavior displayed by their patients with ASD in collaboration with parents, schools, and

specialized-care providers. From birth, caregivers form close and collaborative relationships with

their PCPs. These relationships and the frequency of visits with the PCP allow for close and

consistent monitoring of developmental progress ranging from routine hearing and vision checks

to developmental milestones (reflexes, social skills, motoric development). At approximately 9

to 18 months of age, and even earlier in some cases (e.g., present risk factors including children

with history of preterm birth, low birth weight, or sibling with autism spectrum disorder), PCPs

incorporate screening practices to identify developmental delays. The American Academy of

Pediatrics supports universal autism screening, recommending screening at children’s 18- and

24-month well visits, as research has shown that screening leads to earlier referral and diagnosis.

Children who are screened earlier, receive services earlier, which leads to better outcomes

(McPheeters et al., 2016). Thus, PCPs offer a unique relationship in which on-going assessment

and monitoring of challenging behavior can occur, a hallmark of an MTSS framework.

McGuire and colleagues (2016) first recommended to screen for the presence of

challenging behavior. Next, if challenging behavior is found to occur, safety is assessed. That is,
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SCREENING AND ASSESSMENT

it should be determined if the individual is at imminent risk of injuring themselves or others. At

this juncture, if challenging behavior that presents a safety risk is occurring, and the resources

are available, the PCP should refer the individual to a more specialized provider with experience

in assessment and treatment of challenging behavior. If a safety risk is not present, or more

specialized resources are not available, then the PCP can review the patient’s psychosocial

history and level of functioning before and after the onset of challenging behavior. This would

include assessment of the individual’s medical, developmental, communicative, and psychiatric

history, and may require referrals to specialists with expertise in these areas. Further, assessment

of the individual’s current environment, those providing care for the individual, and the

individual’s adaptive functioning are recommended. Fourth, challenging behavior should be

prioritized based on safety, severity, and the impact that it has on the individual’s daily life.

From there, all potential contributors to challenging behavior should be considered, such as:

underlying medical problems (e.g., pain, seizures, gastrointestinal issues), functional

communication difficulties, psychosocial stressors, maladaptive reinforcement patterns, and co-

occurring psychiatric disorders. Then, based on these outcomes, referrals should be made to

specialized providers to coordinate an individualized treatment plan. Finally, the treatment plan

should be implemented, by the appropriate providers, and monitored for effectiveness at 3-month

follow-up and every 3 months thereafter. If challenging behavior improves, less intense

intervention may be considered; if challenging behavior worsens, a higher level of care may be

needed. Below, a schematic of this pathway is provided in Figure 5.

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Figure 5
Primary-Care pathway
Assess for challenging behavior

Unsafe
Consider transfer to higher-level
Assess for safety care

Safe

Review the patient’s history and level of functioning

Prioritize and qualify challenging behaviors for treatment

Consider potential contributors to challenging behavior

Current medical Functional Psychosocial Maladaptive Co-occurring

problems communication stressors reinforcement psychiatric
difficulties patterns disorders

Consider psychopharmological interventions for challenging behavior

ç Coordinate individualized treatment and safety plans

Monitor individualized treatment and safety plans

Yes No
At 3 months
ç
do symptoms Re-evaluate every 3 months thereafter
persist?
ç

Note. A practice pathway for primary care. Adapted by W. E. Sullivan from McGuire et al.
(2016).
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SCREENING AND ASSESSMENT

Progress Monitoring

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, and although these tactics are good for monitoring progress, they are extremely

resource intensive. It is not feasible, for example, to directly observe an individual’s daily

behavior over months and years. Therefore, alternative measurement strategies that are sensitive

to change, but less resource intensive are needed.

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
 55

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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 (see Primary-Care Pathway).

Indirect measures (e.g., structured and unstructured interviews, rating scales, questionnaires;
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specific tools are detailed below) 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.

Conclusion

Caregivers, pediatricians, community mental-health providers, and school personnel

should all engage in a collaborative effort to identify deviations from developmentally normative

and clinically significant levels of challenging behavior in children with ASD. Initially,

stakeholders in an individual’s care (e.g., PCP, school psychologist) screen for challenging

behavior by employing a combination of indirect and direct assessment strategies to gather

information about a child’s developmental presentation and presence of challenging behavior in

relation to same-aged peers. These assessment strategies identify concerns related to the form,

frequency, duration, and/or intensity of challenging behaviors, as well as consideration of the

individual’s strengths and preferences. The information gathered from these assessments

illuminate next steps for clinical decision making. Then, FBA may be needed to directly examine
 57

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the environmental influences on challenging behavior, which in turn is prescriptive for treatment

(see Treatment section).

By continuing to monitor challenging behavior over time, perhaps during routine PCP

visits, individuals can be linked to the assessment and treatment approaches that meet their, and

their families, unique and ever-changing needs. For example, for more severe and frequent forms

of challenging behavior, specialized settings that provide psychiatric assessment and functional

analysis methodologies to inform treatment may be recommended (e.g., inpatient care). Over

time, however, adaptive functioning may improve, and outpatient or community-based care may

be better suited and preferred. Repeated measurement of challenging behavior over time and

across services is needed to match treatment to each individual’s needs and strengths. In closing,

challenging behavior is prevalent in the ASD population and associated with a host of negative

health outcomes. Early identification and assessment are needed to provide earlier intervention

and improve quality of life.

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