CCPR: Please tell us a little about the work you do.
Dr. Brookman-Frazee: Most of my research is focused on children who have mental health needs, including those on the autism spectrum. I’m focused on ensuring that children, in community services and routine care, have access to evidence-based mental health practices. The “laboratory” of much of my research is in publicly funded mental health services: outpatient or school-based services funded through Medicaid or school districts. They don’t necessarily specialize in autism, but they may see a number of children on the autism spectrum for their co-occurring mental health needs.

CCPR: What are the main problems that the clinicians face with these kids?
Dr. Brookman-Frazee: ADHD, disruptive behaviors, trauma, anxiety, and depression are common conditions addressed in children’s mental health services, but for the kids on the spectrum, challenging behaviors, broadly defined, are the most common reasons for the referral.

CCPR: What kinds of challenging behaviors?
Dr. Brookman-Frazee: There could be noncompliance, physical or verbal aggression, tantrums—those are some common examples.

CCPR: Often, behavioral plans use dramatic or confusing terminology—words like “assault” and “elopement”—but when we ask about the events, they turn out to just be a touch or a walking away.
Dr. Brookman-Frazee: Yes. Language matters. We try to be concrete and as simple as possible for everybody, honing in on the specific behavior and removing the subjective interpretation of that behavior. Sometimes it’s helpful to ask: “How would I know that what you’re seeing is the same thing that I’m seeing?” We need to use specific, observable behaviors. Moreover, in our training package we emphasize positive terms—telling a child what to do rather than what not to do is helpful—and we use terms that are as simple as possible.

CCPR: Tell us about the training you developed to help mental health professionals understand these kinds of behaviors.
Dr. Brookman-Frazee: Over a decade ago, community mental health providers and program managers started asking for help with strategies, treatment planning, and psychotherapy adaptations for children on the autism spectrum. That led to the development of “An Individualized Mental Health Intervention for ASD” (AIM HI) (www.teamsasdstudy.org/about-aim-hi). It’s a package of evidence-based strategies that are both parent mediated and child focused to reduce challenging behaviors.

CCPR: Can you talk about looking at behaviors vs diagnoses?
Dr. Brookman-Frazee: We certainly consider co-occurring psychiatric conditions in assessing challenging behaviors. For specific behaviors, such as tantrums, physical or verbal aggression, or not following instructions, there could be multiple causes underlying those challenging behaviors, and they don’t line up with one specific disorder—they’re multiply determined. Core autism symptoms might interact with anxiety or ADHD, all contributing to challenging behaviors. That’s what led us to focus on the presenting problem vs the different diagnoses.

CCPR: How do you assess these behaviors?
Dr. Brookman-Frazee: We use a function-based approach to assess challenging behaviors in which we take into account the child’s co-occurring psychiatric conditions. We teach therapists how to define the behaviors that are most interfering for a child and a family. It’s tempting to interpret behavior, for instance, as oppositional. But we push therapists to clearly define what the behaviors are, such as yelling, pushing, hitting, ignoring instructions, or making rude comments. We give therapists the guideline that a behavior is something that you can see and that multiple people can recognize when the behavior is occurring. It’s something that you can count or measure—so, either being able to count how often it occurs or how long a tantrum lasts. We ask: “Can we count it, and can we see it?”

CCPR: Then what?
Dr. Brookman-Frazee: Once we’ve identified a few behaviors that are interfering, we use a functional behavior assessment approach teaching therapists to interview parents thoroughly about specific occurrences of identified behaviors. We ask, “Which of the behaviors occurred?” “Where did it occur (which setting or context, eg, a social interaction, a daily routine)?” “What immediately preceded the behavior—was the child given an instruction? Was the child told ‘no’?” And then, “What was the immediate outcome of the behavior—how did others respond to it? Did the parents engage in a lengthy discussion with the child about the behavior, delaying action on the child’s request?”

CCPR: That’s a lot of detail.
Dr. Brookman-Frazee: It’s important. After gathering information about a number of occurrences of challenging behaviors, therapists collaborate with parents and families to develop a hypothesis about the functions that the behaviors serve. We ask: “What is the most common outcome of a behavior?” These include avoiding things like a demand, an interaction, or sensory input. Or the child might be seeking to obtain something such as attention or engagement, access to a desired activity, or sensory input. Then we consider the co-occurring symptoms. For example, if a child seems to display symptoms of anxiety, we might expect to see that challenging behaviors are often for the purpose of avoiding an anxiety-provoking or fearful situation.

CCPR: How do you use these hypotheses?
Dr. Brookman-Frazee: Once we have informed guesses on the common contexts and purposes of behavior, we develop a plan to reduce behaviors. Multiple types of behaviors can serve the same purpose, so we develop a plan for the most common purposes and settings. That usually involves identifying skills that, if learned, would reduce the need for the child to engage in challenging behaviors. 

CCPR: What sorts of skills?
Dr. Brookman-Frazee: They may be skills related to emotion regulation and tolerance of feared situations or unexpected events. They could be related to social interaction, so the child is less likely to avoid social interactions or engage in challenging behaviors in order to avoid them. They might be organizational skills or independence skills related to managing daily routines. We emphasize that skills are linked to the patterns of challenging behaviors. There are lots of skills that we can teach any child, but we want therapists to focus on those that are related to challenging behaviors.

CCPR: You have a catalog of skills, but you have to fit them to what’s going on.
Dr. Brookman-Frazee: Right. We don’t have a pre-planned curriculum, such as for social skills. It’s individually determined. We also identify complementary strategies that a parent or other caregiver can use to help to support the child using positive new skills or new behaviors, and to help prevent the occurrence of challenging behaviors. These may include simple strategies like modifying the environment so that it’s more predictable for a child, such as using routine charts, schedules, and providing warnings for transition between activities. We also identify strategies that a parent or caregiver could use to promote the child’s use of new skills, such as prompting or reminding a child to use a new strategy. We might teach a parent to say: “I see that you’re starting to get a little frustrated. You can ask for help.” When children are learning new skills that aren’t yet natural or automatic for them, we encourage parents to use rewards. But our overall approach is to focus on positive ways to prevent challenging behaviors and promote new skills for parents and children.

CCPR: I worry that when parents get a child to comply under duress, it inhibits the child’s ability to develop an internal compass. Could you speak to that sort of conundrum?
Dr. Brookman-Frazee: Yes. There are lots of things that kids need to do in their daily life—at home, after school, homework, routines. We really emphasize proactive approaches, before kids get upset, to help them to follow through on what they need to do. Routine charts and helpful warnings happen before a child is upset. Once children are upset, it’s harder for them to engage in anything challenging or non-preferred. We try to prevent that and help parents to help their child regulate and anticipate when instructions will be provided.

CCPR: Some kids seem to be waiting for it. They’re easily triggered by anything the parent says. How do you deal with these reactive, overlearned responses?
Dr. Brookman-Frazee: We focus on prevention, co-creating plans with kids as much as possible. Challenging behaviors often occur in transitions to non-preferred activities, so we encourage parents to provide warnings, stay calm, use brief and specific instructions, and help their child succeed. We find that adding a motivating activity after complying or following directions can help. But the goal is prevention and setting up for success, so that we don’t need to focus on reactive strategies when a child is already activated.

CCPR: Sometimes kids become dependent on external rewards. How do you fade external prompts and support the development of internal self-confidence?
Dr. Brookman-Frazee: I think there are two things. Prompting and rewards are short term, setting up successful experiences and practicing new behaviors. But we want it to become more natural, so we start fading prompts and fading rewards, or transitioning rewards from something delivered by a parent to something self-delivered and managed by the child. The child gets to ask: “Did I do the new skill?” and if so, self-delivers a reward. This moves the control from external to internal through prompt fading, reward fading, and self-management. And those strategies can help children to generalize the skills that they’re learning.

CCPR: Got an example?
Dr. Brookman-Frazee: Families and therapists often use token economies. For example, if the child transitions from one activity to the next in a certain period of time or without argument, then the parent gives the child a sticker. After the child earns 4 stickers, the parent allows the child to have extra time on a video game or some preferred activity. Moving to self-management, the child would determine whether the desired behavior occurred and self-provide the sticker and the reward. As the behaviors become more natural, then things like reward systems aren’t needed anymore.

CCPR: Tell us more about the reasons for challenging behaviors—beyond avoiding situations, wanting things, self-stimulation, or attention-seeking. What is underlying these behaviors? Are there other dynamics or stresses involved? How do you incorporate a deeper understanding of a child’s motivations?
Dr. Brookman-Frazee: There may be many factors underlying challenging behaviors and the external functions that serve them, such as co-occurring conditions, challenges with information or social processing, or sensory sensitivity. We pay especially close attention to the context of behaviors. For example, a child at school might initiate a social interaction engagement in a somewhat inappropriate way. That cues us to what’s going on underneath that behavior—for example, that the child is trying to initiate. In this case, we would teach the child to initiate in a way that elicits a positive response and gets positive feedback from the other kids on the playground.

CCPR: This is so helpful—tell us more about the AIM HI training.
Dr. Brookman-Frazee: Our current goal for the AIM HI intervention is focused on clinicians providing psychotherapy and has been done in the context of community-based research projects. For those who are not able to access AIM HI training through research participation, there are resources that offer information on these approaches. The National Professional Development Center on Autism Spectrum Disorder is a website listing evidence-based practice for ASD (https://autismpdc.fpg.unc.edu). There are brief training modules on specific strategies that are relevant to challenging behaviors, on functional assessment (how to define a behavior), and on antecedent (proactive) strategies that families, teachers, and others in the child’s life can use to modify the environment to support the child’s learning and behaviors. These modules could be helpful for individuals who are not necessarily delivering psychotherapy, to help them become familiar with terminology and general approaches.

CCPR: Thank you for your time, Dr. Brookman-Frazee.