A Safer, Smarter Approach: Managing Aggressive Behaviours in Neurodivergent and Developmentally Disabled Individuals

Supporting neurodivergent and developmentally disabled individuals who exhibit severe aggression presents multifaceted challenges for families and support staff. These challenges encompass physical safety concerns, emotional and psychological stress, social isolation, financial burdens, and systemic inadequacies.

Challenges Faced by Families and Support Staff

1. Physical Safety Concerns: Aggressive behaviours, including hitting, biting, or property destruction, pose immediate risks to both the individual and those around them. Ensuring safety while managing such behaviours requires constant vigilance and can lead to physical injuries.

2. Emotional and Psychological Stress: The persistent need to manage unpredictable aggressive episodes can lead to chronic stress, anxiety, and burnout among caregivers and support staff. This continuous strain affects mental health and overall well-being.

3. Social Isolation: Families may withdraw from social activities due to fear of public outbursts or judgment, leading to isolation. This withdrawal limits social support networks essential for coping and resilience.

4. Financial Burdens: Costs associated with specialized care, therapies, and potential property damage can be substantial. Additionally, caregivers might reduce work hours or leave employment to provide necessary support, impacting household income.

5. Systemic Inadequacies: Accessing appropriate services and interventions can be challenging due to limited availability, long waiting lists, or lack of specialized programs. Navigating these systems adds to the existing stressors faced by families and support staff.

Prevalence and Societal Impact

When families and agencies who are trying to support individuals with extreme and challenging behaviours do not have adequate resources or sufficient knowledge of Positive Systems Approach, they are inevitably going to rely on extreme measures to try and suppress and control the individual who is acting out.  There have been countless accounts in the media of instances where neurodivergent individuals or others with developmental disabilities have been subject to abusive practices in an effort to try and stop the collateral damage that results from out-of-control behaviours.  For instance, recently, there was an article written in The Guardian (“Watchdog ‘appalled’ by use of restraint on autistic children at London school”.  The Guardian.  Sally Weale Education correspondent.  Wed 27 Nov 2024) talking about the abuse that children who display challenging behaviours in the U.K. face where they are subject to physical restraints and seclusion for long periods of time in padded rooms.  The article quotes the Children’s Commission in the U.K., stating that: “The children’s commissioner, Rachel de Souza, said: “The experiences of these children are absolutely appalling. My heart goes out to them and their families. No child should ever be physically restrained under such conditions and with such a lack of compassion, especially those who are so vulnerable.”  

The author of this article (Sally Weale) noted that “…..calming rooms have not been used at Whitefield since 2017, but parents whose children are still struggling with the consequences of their traumatic experiences are outraged that no one has been held to account.  According to the BBC, about 40 children with learning disabilities and severe mental disorders were confined for hours, often without food or drink. After viewing the CCTV for the first time, the mother of one of the abused children said: “It broke my heart. You wouldn’t even do that to a dog.”….De Souza expressed frustration that a serious case review to identify failings and lessons to be learned had yet to take place. “Since the allegations of abuse at Whitefield school first came to light, I have pushed for a formal review of the circumstances to be carried out. This was agreed but it must now happen without delay to uncover where children who were so badly failed could have been kept safe,” she said.  “Restraint against children should only ever be used when it is essential to keep a child safe. We need to look again at the guidance and regulation around restraint and so-called ‘calming rooms’ so that, when it is truly necessary, professions have much clearer understanding that it should be used only in the most serious cases and for the shortest time possible.” 

According to U.S. data (Smith et al, 2022: “Aggressive challenging behaviour in adults with intellectual disability: An electronic register-based cohort study of clinical outcome and service use”), aggressive behaviours are notably prevalent among individuals with developmental disabilities. Studies indicate that up to 25% of individuals with intellectual disabilities exhibit challenging behaviours such as self-injury, aggression, and stereotyped actions.   The societal implications of managing severe aggression in neurodivergent individuals are profound. These behaviours can strain educational and healthcare systems, necessitate specialized interventions, and influence public perceptions of neurodiversity. Moreover, the economic impact includes both direct costs (medical care, specialized services) and indirect costs (lost productivity, long-term care).  The authors of this study also note that “Although prevalence estimates vary depending on the population studied, method of assessment, and definition, aggressive challenging behaviour has a point prevalence of approximately 10% amongst adults with intellectual disability and tends to persist over time, with an estimated 25% remission rate at 2 years. Aggressive challenging behaviour is a common reason for referral to health services of adults with intellectual disability and can have serious consequences including exclusion from services, admission to hospital, and contact with the criminal justice system.”

In our opinion, addressing these challenges requires a comprehensive approach that includes adequate support systems, accessible services, and societal awareness to foster inclusion and understanding.  Throughout our 35 years in clinical practice, it was evident that managing severe aggression and violence in neurodivergent and developmentally disabled individuals presents significant challenges for caregivers, educators, and healthcare professionals. Traditional approaches often focus on punitive measures or symptom suppression, which may not address the underlying causes of such behaviours. In contrast, the Positive Systems Approach (PSA), as in our book "Managing Disruptive Behaviours with a Positive Systems Approach," offers a holistic framework that emphasizes understanding, prevention, and positive reinforcement.

Understanding the Positive Systems Approach

The Positive Systems Approach integrates principles from applied behaviour analysis, systems theory, and strength-based practices to create supportive environments that pre-emptively address disruptive behaviours. This method focuses on understanding the individual's needs, the contexts in which behaviours occur, and the systemic factors influencing these behaviours. By doing so, PSA aims to prevent challenging behaviours before they manifest, rather than merely reacting to them after they occur.

Key Components of PSA:

1. Comprehensive Assessment: Understanding the individual's history, preferences, strengths, and the contexts in which aggressive behaviours occur.

2. Environmental Modification: Altering physical and social environments to reduce triggers and promote positive behaviours.

3. Skill Development: Teaching alternative behaviours and coping strategies to replace aggression.

4. Positive Reinforcement: Encouraging desired behaviours through consistent and meaningful rewards.

5. Collaborative Team Approach: Involving caregivers, professionals, and the individuals themselves in planning and intervention.

Case Study: Implementing PSA with a Neurodivergent Individual Exhibiting Severe Aggression

Background:

John, a 16-year-old diagnosed with autism spectrum disorder (ASD) and an intellectual disability, had been exhibiting severe physical aggression, including hitting and biting, particularly during transitions between activities. These behaviours posed safety concerns and limited his participation in educational and community settings.

Assessment:

A multidisciplinary team conducted a comprehensive assessment, including:

• Functional Behaviour Analysis (FBA): Identified that John's aggression often occurred during unexpected changes in routine, suggesting anxiety and difficulty with transitions.

• Sensory Profile: Revealed hypersensitivity to loud noises and crowded environments, contributing to sensory overload.

• Communication Evaluation: Noted limited expressive language skills, hindering his ability to express discomfort or needs effectively.

Intervention Plan:

Based on the assessment, the team developed a PSA-based intervention plan:

1. Environmental Modifications:

   • Structured Routine: Established a consistent daily schedule with visual supports to prepare John for upcoming activities.

   • Sensory-Friendly Spaces: Created quiet areas where John could retreat when feeling overwhelmed.

2. Skill Development:

   • Communication Training: Introduced augmentative and alternative communication (AAC) methods, such as picture exchange systems, to help John express needs and emotions.

   • Coping Strategies: Taught relaxation techniques, like deep breathing and the use of stress-relief tools, to manage anxiety during transitions.

3. Positive Reinforcement:

   • Reinforcement Schedule: Implemented a system where John received immediate positive feedback and preferred activities for using appropriate communication instead of aggression.

4. Collaborative Approach:

   • Team Meetings: Regularly scheduled meetings with family members, educators, and therapists to ensure consistency and address emerging challenges.

Managing John's Behaviour During a Crisis: Redirection and De-escalation Techniques

During moments of crisis, when John exhibited severe aggression, such as hitting or biting, the support staff employed various proactive and reactive strategies to help him regain control and prevent escalation. Their approach focused on minimizing distress, ensuring safety, and reinforcing positive coping mechanisms.

1. Early Intervention and Preventative Strategies

Before a crisis fully developed, staff members were trained to recognize early warning signs of distress, such as increased agitation, vocal outbursts, or repetitive behaviours. By identifying these cues, they could intervene promptly using redirection techniques to shift John's focus away from potential triggers.

• Visual Supports and Transition Warnings: Staff used visual schedules, timers, and social stories to help John anticipate upcoming transitions, reducing anxiety that often led to aggression.

• Choice-Making Opportunities: Allowing John to choose between two preferred activities before a transition gave him a sense of control and reduced resistance.

• Sensory Strategies: If staff noticed signs of sensory overload (e.g., covering ears, pacing), they guided John to a designated quiet space before his distress escalated.

2. Crisis Management: De-escalation Techniques

When John was in the middle of a crisis, staff prioritized safety and emotional regulation using calm, structured approaches to reduce aggression.

• Remaining Calm and Non-Threatening: Staff maintained a neutral tone, used simple and clear language, and avoided making direct eye contact, which could be perceived as confrontational.

• Verbal and Visual Cues: Instead of lengthy verbal explanations, staff used gestures, picture cards, or written cues to communicate expectations and de-escalation steps.

• Guided Breathing and Sensory Tools: Encouraging John to use a previously taught relaxation technique (e.g., deep breathing, squeezing a stress ball) helped him redirect his focus from aggression to self-regulation.

3. Redirection to Preferred or Calming Activities

Once the immediate aggression subsided, staff guided John toward a preferred or calming activity to help him regain emotional balance.

• Engaging in a Preferred Task: If John enjoyed puzzles or fidget toys, offering one of these items helped shift his attention from frustration to a constructive activity.

• Physical Movement: If his agitation was high, staff encouraged walking, stretching, or using a sensory-friendly object (e.g., weighted blanket) to help release tension.

• Music or White Noise: Playing soft, familiar music or providing noise-canceling headphones helped soothe sensory overload.

4. Post-Crisis Reflection and Positive Reinforcement

Once John was calm, staff provided positive reinforcement to acknowledge appropriate behaviours and encourage coping skills for future situations.

• Using AAC to Express Feelings: Staff encouraged John to use his picture exchange system to describe what made him upset and how he felt after calming down.

• Praise for Appropriate Coping Skills: If John successfully used a coping strategy instead of aggression, he received immediate positive reinforcement (e.g., verbal praise, extra time with a favorite activity).

• Reviewing Strategies for Future Situations: Staff and caregivers debriefed after each incident, noting which techniques worked best and making adjustments to his support plan.

Impact of These Strategies

By consistently implementing these redirection and de-escalation techniques, the support team helped John:

✔ Reduce the frequency and intensity of aggressive outbursts

✔ Develop alternative coping skills to manage transitions and anxiety

✔ Improve communication abilities to express frustration constructively

✔ Increase his engagement in learning and community activities

Over six months, the following positive changes were observed:

• Reduction in Aggression: Incidents of physical aggression decreased by 80%, as John became more comfortable with transitions and could express his needs.

• Improved Communication: John began using AAC methods consistently, reducing frustration associated with unmet needs.

• Enhanced Participation: With reduced aggression and better coping mechanisms, John engaged more in educational activities and community outings.

Discussion:

This case illustrates the effectiveness of the Positive Systems Approach in addressing severe aggression in a neurodivergent individual. By focusing on understanding the root causes of behaviour, modifying environments, teaching alternative skills, and reinforcing positive behaviours, PSA provides a comprehensive framework that promotes lasting change.

Conclusion

Managing severe aggression and violence in neurodivergent and developmentally disabled individuals requires a compassionate and systematic approach. The Positive Systems Approach, as outlined by Dr. Bob Carey and Terry Kirkpatrick, offers a valuable framework that emphasizes prevention, skill-building, and positive reinforcement. By implementing PSA, caregivers and professionals can create supportive environments that not only reduce challenging behaviours but also enhance the quality of life for individuals like John.

For more detailed information on PSA and its application, consider exploring the resources available on our website at: drbobcarey.com