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Published in final edited form as: Policy Insights Behav Brain Sci. 2023 Mar 15;10(1):68–74. doi: 10.1177/23727322221144653

Barriers to Accessing Effective Treatments for Destructive Behavior

Brian D Greer 1,2,3
PMCID: PMC11150915  NIHMSID: NIHMS1945364  PMID: 38840711

Abstract

The field of applied behavior analysis has developed and refined a comprehensive methodology for the assessment and successful treatment of destructive behavior: An individualized approach emphasizes (a) function of responding (or its cause) over its form; (b) objective and reliable measurement of behavior; (c) systematic procedures and their application; (d) rigorous, single-case experimental designs; and (e) determinations of successful intervention judged by improvements in the same individual’s performance. Outcomes of this approach are often dramatic and reliably surpass those obtained by alternative means. However, significant barriers limit the accessibility of this proven therapy. Too few intensive behavioral intervention units, diagnosis- and age-dependent insurance authorization and reimbursement practices, long waitlists and slow approval processes, and the possibility of treatment relapse represent a few such barriers. This article describes these barriers and suggests some potential solutions.

Keywords: applied behavior analysis, destructive behavior, function-based treatment, intensive behavioral intervention units, reducing barriers to care

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Individuals with neurodevelopmental disorders face obstacles to effective, function-based treatments for destructive behavior (e.g., self-injury, aggression). This article provides potential solutions.

Destructive behavior is an umbrella term for responding that injures self or others or damages property. Destructive behavior includes self-injury (e.g., head hitting, head banging), risky behavior (e.g., touching dangerous surfaces or materials), aggression (e.g., hitting, biting others), property destruction (e.g., putting holes in walls, breaking doors), and pica (e.g., eating batteries, drinking cleaning fluid). Notably absent from the definition and examples of destructive behavior is responding that is disruptive or inconvenient to others but does not rise to the severity of being destructive. As such, mild tantrums, stereotypy, vocal protests, and the like may be challenging for others or for the situation (e.g., during classroom instruction), but such challenging behavior is rarely destructive.

Destructive behavior is common amongst individuals with neurodevelopmental disorders (Emerson et al., 2001; Esteves et al., 2021; Richards et al., 2012), especially with increases in intellectual disability severity, communication deficits, and co-occurring autism spectrum disorder (Holden & Gitlesen, 2006). For example, self-injurious behavior is reported for one half of autistic individuals (Richards et al., 2012). Similarly, 68% of children dually diagnosed with autism and intellectual disability exhibit aggression, and 51% display self-injurious behavior (Esteves et al., 2021). Such dually diagnosed individuals are common in the United States (Maenner et al., 2020).

Despite strong associations between destructive behavior and neurodevelopmental disorders, the presence of destructive behavior is not a defining characteristic of any neurodevelopmental disorder (American Psychiatric Association, 2013). Even recent attempts to better define subtypes or classes of autism have not required the presence of destructive behavior. For example, the National Council on Severe Autism acknowledges that only a subset of individuals with severe autism exhibits destructive behavior (National Council on Severe Autism, n.d.). Similarly, the recently proposed classification of profound autism does not require the presence of destructive behavior (Lord et al., 2022), even though such problematic responding may be more likely in individuals with profound autism than in those less-severely impacted.

Individuals diagnosed with disruptive, impulsive-control, and conduct disorders often display similarly problematic topographies of destructive behavior. These individuals may or may not have a neurodevelopmental disorder. Therefore, destructive behavior as a referral concern and target for treatment cuts across diagnoses and is not synonymous with any one form of disability.

The Detrimental Impacts of Destructive Behavior

The impacts of destructive behavior are tremendous. Annual costs of destructive behavior exceeded $3.5 billion in the United States in 1994 (Thompson & Gray, 1994) and are likely considerably higher today. Self-injurious behavior causes health complications, such as blindness, self-amputation, fractures, brain trauma, and even death (Hyman et al., 1990). Aggressive behavior increases the risk for institutionalization, social isolation, physical restraint, medication overuse, service denial, and abuse (Antonacci et al., 2008).

Parental and caregiver stress reliably results from destructive behavior in dependents (e.g., Brobst et al., 2009; Estes, Munson et al., 2009; Estes, Olson et al., 2013; Hastings et al., 2005), and it lowers martial satisfaction (e.g., Brobst et al., 2009; Hartley et al., 2012). Other detrimental impacts on the families of individuals who display destructive behavior are sometimes overlooked but are similarly concerning (Celia et al., 2020; Gorlin et al., 2016).

Long-term detrimental impacts are common because destructive behavior rarely improves if left untreated. In a recent longitudinal study (Laverty et al., 2020), self-injurious behavior persisted over a 10-year period in 44% of participants. Such discouraging longitudinal data suggest that the detrimental impacts of destructive behavior may be a lifelong reality for those without effective treatment.

Assessing and Treating Destructive Behavior

The field of applied behavior analysis has developed and refined a comprehensive methodology for the assessment and successful treatment of destructive behavior. This individualized approach emphasizes (a) function of responding (or its cause) over its form; (b) objective and reliable measurement of behavior; (c) systematic procedures and their application; (d) rigorous, single-case experimental designs; and (e) successful interventions judged by improvements in the same individual’s performance. Board Certified Behavior Analysts (BCBAs), along with the assistance of Registered Behavior Technicians (RBTs), begin by defining the destructive response to be targeted in clear and measurable terms. The team then typically conducts one or more preference assessments to determine preferred toys and attention for inclusion in a systematic assessment of behavioral function (Iwata et al., 1982/1994).

The logic of a functional analysis is similar to that of an allergy skin-prick test. During an allergy skin-prick test, the patient’s skin is systematically exposed to an array of potential or suspected allergens to determine whether the patient has an allergic reaction at each test site when judged against control sites designed to produce either a skin response (e.g., histamine exposure site) or no skin response (e.g., glycerin or saline exposure site). That is, skin response across test and control sites determines positive and negative reactions. Positive reactions inform an individualized treatment plan specific to each allergen detected.

Functional analysis reveals what destructive behavior does for the individual. For example, head banging might interrupt an aversive tutoring session. Destructive behavior (e.g., head banging) is systematically exposed to common contingencies (e.g., stopping the lesson) suspected to reinforce the challenging behavior. In a control condition, these putative reinforcement contingencies are absent. For example, destructive behavior may produce brief escape from tutoring in the test condition of a functional analysis, if destructive behavior is suspected to be reinforced by such breaks. In the control condition of this same functional analysis, breaks would occur independently of destructive behavior. Higher rates of destructive behavior in the test condition relative to those in the control condition of a functional analysis indicate a source of reinforcement for the individual’s destructive behavior. Like the allergy skin-prick test, the results of the functional analysis then inform an individualized treatment plan specific to each reinforcement contingency shown to maintain destructive behavior. Functional analyses are but one class of functional behavior assessment that applied behavior analysts use to identify the reinforcing contingencies that maintain destructive behavior. Many empirically validated modifications allow applied behavior analysts to adapt the functional analysis methodology to unique situations (e.g., time constraints, highly severe or low-rate destructive behavior; see Iwata & Dozier, 2013, for an overview).

Applied behavior analysts use functional behavior assessments to develop and then evaluate a function-based treatment. For example, the individual who displays destructive behavior to escape from nonpreferred activities might be taught a more appropriate way to request breaks (e.g., by saying, “break please” or by exchanging a communication card that indicates they want a break; Carr & Durand, 1985). When feasible, destructive behavior is placed on extinction during treatment, meaning that challenging behavior no longer produces reinforcement. Treatments that arrange extinction for destructive behavior often produce superior outcomes when compared to treatments that allow continued reinforcement of destructive behavior (Hagopian et al., 1998). Numerous studies, including meta-analyses and experimental–epidemiological analyses, have demonstrated the superiority of function-based approaches to treating destructive behavior (e.g., Didden et al., 1997; Iwata et al., 1994; Richman et al., 2015).

Function-based approaches to treating destructive behavior ensure that the procedures implemented in treatment are guided by an understanding of the underlying contingencies maintaining destructive behavior. In this way, applied behavior analysts ensure that the procedures included in the treatment plan are necessary and sufficient to produce robust reductions in destructive behavior and high levels of appropriate behavior (e.g., compliance, appropriate requests). Treatment efficacy is validated within each individual using rigorous, single-case experimental designs to verify that the treatment procedures produce their intended effect.

A substantial portion of the treatment process is ensuring that the treatment procedures developed are practical and remain effective when implemented by parents and caregivers in settings outside of the original training context. Treatment components are tested and modified or removed as needed to satisfy the treatment goals. As such, caregiver involvement throughout the assessment and treatment process is critically important for treatment success, as is ongoing interaction with collaborating professionals (e.g., coordinating medication management with a prescribing physician).

Treatment Outcomes

The function-based approach to treating destructive behavior is highly effective. For example, a function-based approach (Greer et al., 2016) treated the destructive behavior of 20 consecutively enrolled intensive outpatients meeting the study’s inclusion criteria. No datasets meeting the study’s inclusion criteria were omitted from analysis, which allowed the researchers to examine all outcome data, regardless of treatment efficacy (Hagopian, 2020). Multiple participants displayed destructive behavior maintained by more than one function (e.g., to escape nonpreferred activities and to access preferred toys). For these participants, distinct treatment procedures were developed for each function, resulting in 25 consecutive applications of function-based treatment.

Reductions in destructive behavior averaged 96% (range, 77–100%) across the 25 consecutive applications of function-based treatment in Greer et al. (2016) when each participant’s rates of destructive behavior at discharge were compared to their own baseline response rates. Additionally, these outcome data were collected following reinforcement schedule thinning, which is when the patient learns that the functional reinforcer is sometimes unavailable for the newly taught communication response. During these times, the therapist displayed a cue (e.g., by placing a red colored band on their wrist) to inform the participant that the functional reinforcer was unavailable, and the participant was expected to wait patiently or tolerate the same nonpreferred activities (e.g., completing schoolwork) shown earlier in the functional analysis to produce destructive behavior. Twenty two of the 25 applications of function-based treatment (88%) had at least a 4-min period without access to the functional reinforcer at the time the outcome data were collected.

Granted, treatment-resistant subtypes of destructive behavior (Hagopian et al., 2015) warrant different approaches to function-based treatment (e.g., Hagopian et al., 2020). However, the Greer et al. (2016) results are representative of other studies that have employed a function-based approach to treating similar functions of destructive behavior. That is, these outcomes are not specific to intensive outpatient hospitals. Similar improvements in destructive behavior have been achieved in a variety of settings, including via telehealth when caregivers implemented treatment under the guidance of a remote behavioral consultant (Lindgren et al., 2020).

Barriers to Treatment Accessibility

Despite the demonstrated success of the function-based approach to the assessment and treatment of destructive behavior, significant barriers impede accessing this proven therapy. The sections below highlight a few such barriers and suggest some potential solutions.

Too Few Intensive Behavioral Intervention Units

The successful treatment of destructive behavior sometimes requires an intensive level of care delivered in a facility uniquely designed to mitigate the safety concerns that can arise outside of a well-controlled environment. Common components of such intensive behavioral intervention units include dense, foam padding on the walls and floors; electromagnetic door locks; one-way observation windows; two-way intercom systems; and high staff-to-patient ratios. Highly trained staff who can safely manage destructive behavior often wear protective padding and helmets to keep themselves safe from intense aggression (see Briggs & Greer, 2021, for elaboration on such facilities, and Fisher et al., 2013, for details on protective equipment). Absent these protective features, destructive behavior can and does result in personal injury and substantial damage to property; with them, such behavior can be safely assessed and treated.

Unfortunately, such specialized facilities and highly trained staff are rare throughout the country, and most of the U.S. population does not have access to intensive programs of this sort. Instead, would-be patients fill emergency departments that are not designed to care for such individuals, are frequent admits to short-term stabilization programs and inpatient psychiatric wards that infrequently address the underlying etiologies of destructive behavior, or are placed into highly expensive and restrictive residential programs. Model outpatient and inpatient programs located sporadically across the country offer a better and safer approach to the assessment and treatment of destructive behavior.

A recently published toolkit from Autism Speaks (Fisher et al., 2022) outlines the major considerations for designing, building, staffing, and funding intensive behavioral intervention units. It is a rich resource that policy makers throughout the country will surely find informative when seeking a more cost-effective and comprehensive approach to serving some of the most vulnerable members of their constituencies. A hyperlink to this freely available resource is located here: https://docs.autismspeaks.org/behavior-program/.

Diagnosis- and Age-Dependent Insurance Authorization and Reimbursement Practices

A major hurdle to the accessibility of effective treatments for destructive behavior throughout the country revolves around third-party payor authorization and reimbursement practices related to intensive assessment and treatment services. As discussed, the function-based approach to the assessment and treatment of destructive behavior is conducted by applied behavior analysts with relevant training and expertise. However, the discipline of applied behavior analysis transcends this specific focus area, and to many third-party payors, applied behavior analysis is synonymous not with intensive services for destructive behavior but with early intensive behavioral intervention, which focuses on skill development (e.g., social and preacademic skills) and less on behavior reduction. The substantially higher costs associated with intensive services for destructive behavior, relative to those for early intensive behavioral intervention, can be a nonstarter for productive discussions with third-party payers surrounding authorization and reimbursement.

A related issue is that many third-party payors tend to equate the discipline of applied behavior analysis with autism treatment. Although a substantial portion of the field does work with autistic individuals, this is far from a requirement, and the same impressive outcomes from a function-based approach to the assessment and treatment of destructive behavior spans individuals with and without autism. As just one example, in the Greer et al. (2016) data, only seven of the 20 outpatients (35%) carried a diagnosis of autism. Additionally, nine of the 20 outpatients (45%) had no documented or indicated intellectual disability. The treatment gains reported by Greer et al. reflective many other studies in applied behavior analysis. Meaningful improvements in socially significant responding span autistic and non-autistic individuals, as well as those with and without intellectual disability. The assumption by third-party payers that applied behavior analysis is autism-specific and focused on early intensive behavioral intervention needs revision. Individuals with and without neurodevelopmental disorders benefit equally from intensive, function-based services for destructive behavior.

Another issue limiting the accessibility of effective treatments for destructive behavior is that although many states now mandate certain health insurance policies and health benefit plans to provide services for beneficiaries diagnosed with autism, mandated coverage varies across states, and many mandated benefits end at adulthood. Many caregivers of adults in need of assessment and treatment services struggle to find appropriate care. Intensive, function-based assessment and treatment services for adults who engage in destructive behavior simply do not exist in most states throughout the country.

Solutions to the concerns expressed here are complex and are unlikely to come quickly. However, policy makers willing to engage their constituency are likely to find that these and other issues present very real barriers to accessing effective treatments for destructive behavior. Other than continued education and collaboration with third-party payors and intensive behavioral intervention units, one strategy policy makers may find helpful is to consider the long-term financial savings entailed by a relatively brief, well-defined, yet intensive assessment and treatment program when compared to the alternative of a lifelong residential placement. When viewed from this angle, the financial savings afforded by the former approach clearly outweigh the latter.

Long Waitlists and Slow Approval Processes

Even when treatment is approvable, long waitlists and slow approval processes often delay intensive services for destructive behavior. Such delays to service are common because waitlists for intensive services for destructive behavior can be prohibitively long (often months to years) due to an overwhelming demand for care. Adding to these delays, intensive behavioral intervention units often must rely on obtaining single-case agreements for each patient authorized for services by third-party payors. These present additional barriers to the accessibility of effective treatments for destructive behavior.

Policy makers should support third-party payer contracts that streamline the clearance process for eligible patients, as well as establishing seed grants to help existing intensive behavioral intervention units expand their services (e.g., to a new geographic area, to establish a new service line). In areas of the country lacking intensive, function-based services for destructive behavior, policy makers should consider developing an intensive behavioral intervention unit, potentially using state or other funds to establish a center of excellence. Again, the Autism Speaks Toolkit for Developing a Severe Behavior Program (Fisher et al., 2022; located here: https://docs.autismspeaks.org/behavior-program/) is an invaluable resource for navigating the complexities of developing intensive behavioral intervention units.

Mitigating Treatment Relapse

Common function-based treatments for destructive behavior are susceptible to treatment relapse, so clinicians must actively plan for and work toward mitigating treatment relapse (e.g., Briggs et al., 2018; Mitteer et al., 2022). As such, intensive behavioral intervention units are increasingly focused on maintaining the treatment gains established through intensive services. Ongoing treatment services through more traditional outpatient appointments should focus on continued caregiver training and addressing new difficulties the family experiences over time. Thus, patients should check-in often following discharge from the intensive program. In situations in which the commute or other responsibilities present barriers to participation in follow-up services, telehealth appointments can facilitate ongoing participation. Follow-up services may fade in frequency over time as the family shows continued success with the treatment plan. Modifications to the treatment plan are made as needed to support the maintenance of treatment gains.

Policy makers should understand that the long-term treatment of destructive behavior often requires a continued commitment on the part of multiple individuals. Supporting caregivers with the implementation of the treatment plan developed during an intensive admission is critically important for ensuring continued treatment success. As such, systems of care need to prioritize empowering caregivers to adhere to treatment recommendations developed by the treatment team. Creative strategies that incentivize collaboration between stakeholders to increase the likelihood of caregiver adherence to the treatment plan may further mitigate the likelihood of treatment relapse.

Conclusion

Destructive behavior in individuals with neurodevelopmental disorders is prevalent, and its detrimental impacts are tremendous, often affecting multiple important areas of overall functioning in these individuals and life satisfaction in caregivers. The field of applied behavior analysis has developed and refined a comprehensive methodology for the assessment and successful treatment of destructive behavior that uses an individualized approach which emphasizes (a) function of responding (or its cause) over its form; (b) objective and reliable measurement of behavior; (c) systematic procedures and the application thereof; (d) rigorous, single-case experimental designs; and (e) determinations of successful intervention judged by improvements in the same individual’s performance. Outcomes of this approach are often dramatic and reliably surpass those obtained by alternative means. However, significant barriers limit the accessibility of this proven therapy. A few such barriers include too few intensive behavioral intervention units, diagnosis- and age-dependent insurance authorization and reimbursement practices, long waitlists and slow approval processes, and the possibility of treatment relapse. Some potential solutions to these barriers are promising. However, meaningful progress will require that policy makers engage with their constituency to identify solutions tailored to these and other barriers to necessary care experienced by their community, as none will be solved without collaboration between key stakeholders and a solution-oriented approach.

Bulleted Highlights.

  • Individuals with neurodevelopmental disorders often behave destructively, to the detriment of their own overall functioning and the life satisfaction of their caregivers.

  • The field of applied behavior analysis has a refined, comprehensive methodology for assessing and treating destructive behavior.

  • Outcomes of this approach are often dramatic and reliably surpass those obtained by alternative means.

  • However, significant barriers limit the accessibility of this proven therapy, including too few intensive behavioral-intervention units, diagnosis- and age-dependent insurance authorization and reimbursement practices, long waitlists and slow approval processes, and the possibility of treatment relapse.

  • Policy makers, engaged with their constituency, should identify solutions tailored to the barriers to necessary care experienced by their community.

Acknowledgments

Grants 2R01HD079113 and 5R01HD093734 from the National Institute of Child Health and Human Development provided partial support for this work. The author directed the Severe Behavior Program at CSH-RUCARES and received full-time salary for this work while writing this manuscript. The author also serves on the editorial boards of behavior-analytic journals and provides consultation on the assessment and treatment of destructive behavior.

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