Quality statement 8: Interventions for behaviour that challenges

Quality statement

People with autism and behaviour that challenges are not offered antipsychotic medication for the behaviour unless it is being considered because psychosocial or other interventions are insufficient or cannot be delivered because of the severity of the behaviour.

Rationale

The first-line intervention for behaviour that challenges should be appropriate psychosocial interventions or interventions to address any identified triggers for that behaviour. In some cases psychosocial or other interventions are not sufficient on their own, or they cannot be delivered because of the severity of the behaviour. In this situation a paediatrician or psychiatrist, working with the person with autism and their family and carers, might consider starting a trial of antipsychotic medication in an attempt to manage the behaviour that challenges. The professional should continue to monitor any subsequent use of antipsychotic medication.

Quality measures

Structure

Evidence of local arrangements to monitor the use of antipsychotic medication in people with autism and behaviour that challenges.

Data source: Local data collection.

Process

The proportion of people with autism and behaviour that challenges having antipsychotic medication for the treatment of their behaviour that challenges in whom psychosocial interventions are insufficient or cannot be delivered because of the severity of the behaviour.

Numerator – The number of people in the denominator for whom psychosocial interventions are insufficient or cannot be delivered because of the severity of the behaviour.

Denominator – The number of people with autism and behaviour that challenges currently receiving antipsychotic medication to manage their behaviour that challenges.

Data source: Local data collection. NICE clinical audit tool: Autism in adults: challenging behaviour, audit standards 3 and 4.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that staff working with people with autism and behaviour that challenges do not offer antipsychotic medication for the person's behaviour unless it is being considered because psychosocial or other interventions are insufficient or cannot be delivered because of the severity of the behaviour.

Health and social care practitioners ensure that they do not offer people with autism and behaviour that challenges antipsychotic medication for the behaviour unless it is being considered because psychosocial or other interventions are insufficient or cannot be delivered because of the severity of the behaviour. If antipsychotic medication is prescribed it should be monitored by a suitable expert.

Commissioners require providers to monitor the use of antipsychotic medication for the treatment of behaviour that challenges and look for evidence to ensure that when antipsychotic medication was prescribed, psychosocial or other interventions had been attempted or considered but had been insufficient or could not be delivered because of the severity of the behaviour.

What the quality statement means for service users and carers

People with autism who behave in a way that other people find difficult should not be offered medication to treat their behaviour unless other treatments are not helping or cannot be used, either because of the seriousness of the person's behaviour or because of the risk to the person or others.

Source guidance

  • Autism: the management and support of children and young people on the autism spectrum (NICE clinical guideline 170), recommendation 1.4.10 (key priority for implementation)

  • Autism: recognition, referral, diagnosis and management of adults on the autism spectrum (NICE clinical guideline 142), recommendations 1.5.6 and 1.5.8

Definitions of terms used in this quality statement

Behaviour that challenges

This is defined as culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities

[Taken from the Challenging Behaviour Foundation: Emerson E (2001) Challenging Behaviour: Analysis and intervention in people with learning disabilities. Cambridge: Cambridge University Press]

Psychosocial interventions

Psychosocial interventions for behaviour that challenges should include:

  • clearly identified target behaviour(s)

  • a focus on outcomes that are linked to quality of life

  • assessment and modification of environmental factors that may contribute to starting or maintaining the behaviour

  • a clearly defined intervention strategy

  • a clear schedule of reinforcement, and capacity to offer reinforcement promptly and contingently on demonstration of the desired behaviour

  • a specified timescale to meet intervention goals (to promote modification of intervention strategies that do not lead to change within a specified time)

  • a systematic measure of the target behaviour(s) taken before and after the intervention to check whether the agreed outcomes are being met

  • consistent application in all areas of a child or young person's environment (for example, at home and at school)

  • for a child or young person, agreement among parents, carers and professionals in all settings about how to implement the intervention.

In addition to the above interventions, the assessment of potential triggers for behaviour that challenges referred to in quality statement 7 should also be carried out before introducing any treatment.

[Adapted from Autism: the management and support of children and young people on the autism spectrum (NICE clinical guideline 170), recommendation 1.4.9; and Autism: recognition, referral, diagnosis and management of adults on the autism spectrum (NICE clinical guideline 142), recommendation 1.5.6]