The first step in managing difficult behavior is to recognize the point at which a behavior should be considered a problem. A behavior becomes a problem when it is harmful or noxious to the individual performing that behavior or to others.4

The most serious problem behaviors involve self-injury or aggression, as they can pose real threats to life and limb. Illustrations of such severe problem behaviors include:

• biting or hitting oneself or others so as to cause callusing or bleeding
• gouging at one's eyes so as to cause pain and tissue damage
• engaging in pica (i.e., eating inedible objects as glass, paper clips, cigarettes, or coffee grounds)

Another type of problem behavior interferes with the acquisition of academic or social skills. For example, if a child begins to scream when the teacher tries to teach new vocabulary words, the lesson must be stopped so that the teacher can intervene in the screaming, and the child loses the opportunity to increase verbal skills. In another example of this type, people may be excluded from social interaction because their behavior is either unacceptable or dangerous to others. The individual’s opportunity to develop and practice social skills is limited. For instance, a 9-year-old child with autistic disorder who disrobes in the classroom or in a shopping mall will find these social opportunities closed until he or she learns to remain clothed in public.

Finally, a behavior becomes a problem when its frequency, severity, or duration is significantly outside the range of what is acceptable by everyday conventions.4 For example, we all have screamed, cried, scratched, or used unacceptable language. When affected individuals scratch and pick at their fingers until they bleed, the intensity has escalated into a problem behavior. When someone cries constantly regardless of what is occurring, the crying is a problem behavior.

What behaviors are NOT a problem?

Just as important as recognizing when a behavior has become a problem is recognizing when a behavior is not a problem. For example, is it a problem when an individual with autistic disorder cannot go to sleep unless all the window shades in the group home are at a particular angle? Clinicians or caregivers have to ask themselves whether the frequency or severity of the behavior is outside the acceptable level in the particular context and whether the behavior interferes with the quality of life or infringes on the health or well-being of the a person or his or her housemates. In this particular case, the answer to all these questions is no, so this behavior should not be considered a problem.

It is important to recognize that when individuals with developmental disabilities express a personal preference, such as a desire to eat peaches rather than apples or to watch basketball rather than baseball, they are not engaging in problem behavior. Acknowledging and respecting the personal choices of these individuals is as important as for anyone else, as long as those choices do not cause injury or damage, do not substantially limit access to the benefits of academic or social settings, and are not associated with risk of physical harm.

Adapted from: Sudhalter V. Problem behaviors in individuals with developmental disabilities. In: Devinsky O and Westbrook LE, eds. Epilepsy and Developmental Disabilities. Boston: Butterworth-Heinemann; 2001;165–174.
With permission from Elsevier (www.elsevier.com).
Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.