I/PB in ASD: Detailed Practice Pathway for Pediatric Primary Care

1 □Assess for I/PB.
Has this patient recently shown:If yes, how much of a problem?Safety risk?
Tantrums, meltdowns, rages?  No □ Yes □ None □ Mild–Moderate □ Severe □ No □ Yes □
Property destruction?  No □ Yes □ None □ Mild–Moderate □ Severe □ No □ Yes □
Aggression to others? No □ Yes □ None □ Mild–Moderate Severe □ No □ Yes □
Self-injury? No □ Yes □ None □ Mild–Moderate Severe □ No □ Yes □
2 □Assess safety.
 Has patient ever been aggressive to others or engaged in self-injurious behavior?  No □ Yes □
 Has patient ever caused tissue damage to self or others?  No □ Yes □
 If yes, accidental?  No □ Yes □
 Is patient at imminent risk of injuring self or others at home or in other settings?  No □ Yes □
If yes, is the family in crisis (unable to cope with managing the patient’s behavior)?  No □ Yes □
Enlist home-based crisis services and consider partial or inpatient hospitalization.
 Is patient at risk now of hurting self or others in the office?  No □ Yes □
If yes, and if the patient has a history of I/PB and safety concerns outweigh risk of another escalation, consider safe escort to an emergency department. Notify the emergency department in advance of special needs.
If safety permits, proceed with the practice pathway.
3 □Review the patient’s history and level of functioning before and after the onset of I/PB.
Medical: Genetic disorder, preterm birth, epilepsy, brain injury, typical stooling pattern, chronic medical problems, as well as all medications and supplements taken
 Take lifetime history of all medication and, for psychotropic medications, obtain dosages, duration of treatment, and blood levels (when applicable)
Developmental: Global delay or intellectual disability, specific learning disability, developmental age and adaptive functioning versus chronological age, toilet training, motor problems, sensory deficits and sensitivities
Communication: Means of communication (verbal, sign or modified sign, communication tools), indicators of pain, means of learning new information, ability for functional communication
Psychiatric: Previously diagnosed psychiatric disorder (eg, anxiety disorders including obsessive–compulsive disorder, ADHD, mood and psychotic disorders), treatments, activity level, preoccupations, special interests, stereotypies, transition problems, social reciprocity, typical responses of care providers to I/PB
Current context
Settings: Home (family home, group home in community, group home institutional, hospital), school (mainstream no accommodations, mainstream with accommodations, mainstream with resource, full inclusion, partial inclusion, self-contained special education, home instruction, early intervention at home, center)
Caretaker characteristics: Two parents, single parent, foster, adoptive; primary language, ethnicity, recently immigrated psychiatric history, number of children in home, number of adults in home, case manager
Functioning before and after onset of I/PB
Loss of skills: Does the patient no longer exhibit skills used on a regular basis before onset of I/PB? No □ Yes □
Interference with self-care and functioning at home □ learning and participation at school or program □ travel in public or out in the community □ acceptance by peers □ family and caregiver relationships
4 □Prioritize for assessment and treatment on the basis of safety, severity, and impact on daily life
□ Qualify I/PB target behaviors: acute or chronic, frequency and severity, episodic or continuous, discrepancy in behaviors across settings (eg, influenced by environment, caretaker, and task).
□ Specifically assess for property damage or injury to self or others.
□ Know how incidents have been handled and what has happened as a result.
5 □Consider all potential contributors to I/PB.
5a □Assess and address any current medical problems.
□ Conduct a medical review of systems.
□ Treat any pain, seizures, sleep, GI, ear/nose/throat, dental problems, or other medical conditions. Monitor I/PB after medical treatment is applied to determine whether problems may have been secondary to a medical condition.
□ Consider the possibility of medications being responsible for I/PB.
□ When a medication is suspected, consider stopping, decreasing, or switching to another agent in discussion with the prescribing provider or consulting with a colleague experienced in psychopharmacology in developmental disabilities, particularly when a patient is taking multiple medications.
5b □Assess and address difficulties using functional communication: Evaluate the level of patient’s functional communication skills and whether I/PB may be related to difficulties communicating. If yes:
□ Make appropriate referrals for a speech and language evaluation to ensure incorporation of an adequate and functional communication system consistently across settings.
□ Make appropriate referrals to psychologist or behavior analyst to include a communication component in a behavior treatment plan.
5c □Assess and address any psychosocial stressors.
□ Physical or sexual abuse. If yes: Consider specialist referral, contacting child protective services.
□ Bully victimization. If yes: Consider 504 accommodations in school to avoid exposure.
□ Parental stress. If yes: Consider referrals for financial or psychological assistance.
□ Poor match between the patient and his or her psychosocial context
□ Classroom or program characteristics. If yes: □ Request classroom program change.
□ Family characteristics. If yes: □ Consider parent training or other referrals.
5d □Assess and address any maladaptive reinforcement patterns.
□ Are there triggers for I/PB? Do caregivers react in a manner that may inadvertently reinforce I/PB?
If yes: □Advise caregivers on how to respond to I/PB accordingly. If problems persist or are severe:
□ Make appropriate referrals to a psychologist or behavior analyst with specialization in functional behavioral assessment and treatment of I/PB.
5e □Assess and address any co-occurring psychiatric disorders.
□ Screen for co-occurring psychiatric disorders (in ASD most commonly anxiety, ADHD, obsessive–compulsive, mood and psychotic disorders).
□ For any screen-positive disorders (or others suspected), conduct or refer for more detailed diagnostic assessment.
□ As indicated, treat or refer for treatment of any co-occurring disorders with medications.
□ Cognitive–behavioral therapy conducted by a mental health provider with necessary expertise.
6 □Consider psychopharmacologic interventions for I/PB.
□ When there is no current risk to safety or loss of educational placement, consider N-acetylcysteine and clonidine.
□ Under the following circumstances, consider risperidone or aripiprazole:
□ Safety is an issue.
□ Change in an otherwise satisfactory education or school placement will be necessary without treatment.
□ Other indicated interventions have resulted in no or incomplete improvement of behavior that continues to interfere with daily function.
□ I/PB is judged to be unrelated to medical conditions, communication difficulties, psychosocial stressors, or maladaptive reinforcement patterns or
□ Lower-risk interventions cannot be implemented.
7 □Develop the individualized treatment and safety plan: Coordinate an individualized treatment plan for patient based on information gathered from steps 5a–5e, taking preferences of care providers and feasibility of implementation into account.
8 □Implement and monitor the treatment plan: After beginning to implement treatment plan, monitor with regular visits based on the severity and frequency of the I/PB behavior.
□ Clear and measureable treatment goals should be established.
□ Carefully track response to intervention as determined by report of caregivers, direct observation, and objective rating scales, such as the ABC or longitudinal behavioral data from the school or home setting.
□ Expect improvements within 4–8 wk.
9 □At 3 mo do symptom(s) persist?
If yes: Restart assessment and revise treatment plan.
10 □Reevaluate every 3 mo thereafter.
□ Enrich positive behavioral support plan and address quality of life goals.
□ After a 12-mo symptom-free period, consider tapering or discontinuing any medications used for the treatment of I/PB behavior.
□ Positive behavioral supports, communication aides, and psychosocial supports should be left in place.