Aggression is a common issue for both children and adults with autism spectrum disorder (ASD). It may be verbal (shouting, screaming, cursing) and/or physical (hitting, kicking, biting, destroying property, self-injury).
Some research suggests that children with autism are more likely to show aggressive behaviors than typically developing children and children with other developmental disabilities. People with an intellectual disability alongside autism may also be aggressive more often than those with just an intellectual disability. Furthermore, neurotypical boys are more likely to display aggression than neurotypical girls, but autistic boys and girls are equally likely to do so.
Aggression can damage relationships, disrupt learning in the classroom, physically harm the child or others, and even result in criminal charges.
Clearly, aggression needs to be managed so that the autistic person can be happy and healthy. Why do some people with autism act aggressively, and what is the best way to treat them? Let’s take a look.
What triggers aggression in children with autism?
Children with autism may be aggressive for any number of reasons, such as…
Attempts to communicate
Difficulty with communication is one of the main symptoms of autistic disorder. Whether the person has poor language skills or is completely nonverbal, many children with autism go misunderstood. This can lead to frustration and desperation, which may cause the child to lash out as they try to communicate their needs.
This one is tied to the one above—sometimes, autistic children may be in physical pain and be unable to describe what’s wrong. Attempts to alleviate the pain can cause self-harming behaviors like head-banging. Temper tantrums could also be the child’s signal that they don’t feel well.
Sensory issues are also very common in children with autism spectrum disorders. Certain sounds, textures, smells, and lights can cause lots of stress and send a child into sensory overload. The child will often respond with a meltdown, which can include aggressive behaviors.
Attempts to get something they want
Like typically developing children, kids with autism sometimes become aggressive to express their anger at being denied something they want. They may also use it to get attention from others or avoid tasks.
Breaks in routine
Children with autism tend to be very attached to strict, predictable schedules. They may lash out because of the anxiety caused when a routine is disrupted.
Trauma and aggression in autism
In both neurotypical children and children with ASD, traumatic experiences may lead to a higher risk of aggression. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists “irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums)” as a symptom of PTSD in children.
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There’s been relatively little research into the relationship between PTSD and autism. But for kids with autism who are aggressive because of post-traumatic stress, trauma-centered therapy might be the right approach.
How do you treat aggression in people with autism?
First, professionals should rule out any medical issues that could be causing aggression and self-injury. Some children simply need to have their pain or illness resolved in order to behave more calmly.
Otherwise, treating aggression usually involves therapy, medication, or both.
Applied Behavior Analysis Therapy
Applied Behavior Analysis (ABA) is one of the most common behavioral interventions for children with autism. This therapy rests on the concept that all behaviors are performed for some sort of purpose.
The first part of ABA is a functional behavior assessment, which tries to understand why a child carries out a certain behavior. In this case, the ABA therapist would look for the reason a patient shows aggression. The functional behavior assessment may include a caregiver questionnaire, direct observation of the patient, or even experiments in which the events that precede and follow a behavior are manipulated.
Next, the ABA therapist puts together a reinforcement strategy. Reinforcers are good consequences that motivate the child to perform a behavior again. There are a few different types of reinforcement strategies in ABA, from positive reinforcement to natural reinforcement to differential reinforcement.
Some autism research shows that differential reinforcement is highly effective when treating violence in children on the spectrum. This strategy involves providing reinforcement when the problem behavior is not performed. It contains some different subtypes:
- Reinforcement whenever the problem behavior is absent
- Reinforcement when the child performs a behavior that’s incompatible with the problem behavior (the two can’t be completed at the same time)
- Reinforcement when they perform an alternate, appropriate behavior that fulfills the same purpose as the problem behavior
ABA therapy may not be right for every child, but it is a highly research-backed tool for changing harmful actions. Check out Autism Parenting Magazine’s list of ABA providers in the United States for more resources.
Functional Communication Training
This therapy may be effective for children whose aggression and self-injury are rooted in difficulty communicating. Functional communication training teaches patients to request something in a more appropriate way, including non-vocally. For example, a child might be taught how to request a toy by touching a picture of it, instead of hitting their caregiver. Functional communication training often goes hand-in-hand with ABA and reinforcement strategies.
Dialectical Behavioral Therapy
Dialectical Behavioral Therapy (DBT) is another behavioral intervention that’s closely related to Applied Behavior Analysis. It encourages patients to practice mindfulness, self-awareness, and emotional regulation.
Some research has found that DBT may help people with autism or intellectual disabilities to better manage their emotional responses—potentially leading to reduced aggressive behavior.
Medications for aggression in autism
The United States Food and Drug Administration (FDA) has approved two drugs to treat irritability in children and adolescents with ASD: risperidone and aripiprazole.
Both are known as “atypical antipsychotics” or “second-generation antipsychotics” (SGAs). Atypical antipsychotics were developed as an alternative to the first-generation antipsychotics, which were released in the 1950s but had severe side effects. Risperidone and aripiprazole are also both used to treat schizophrenia and bipolar disorder.
The first randomized, double-blind, placebo-controlled study of risperidone for autism was conducted in 1998 by McDougle et al. Let’s break down what exactly that means, so we know why the study is considered valid.
A double-blind, randomized, placebo-controlled trial tests the effectiveness of a new medical intervention in humans. One group is given the intervention, while the other is given a placebo, which is an ineffective substance. Neither group knows which one they’ve received, so their expectations won’t affect the results.
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Managing Autism Meltdowns, Tantrums and Aggression
When a study is double-blind, it means the researchers also initially don’t know who’s received what substance, which prevents them from accidentally hinting to the patients. Finally, if a clinical trial is randomized, that means the participants are randomly assigned to one group or the other. That way, external factors will be less likely to skew the results.
Overall, randomized, double-blind, placebo-controlled trials are considered the gold standard in clinical trials. They’re the best at accurately determining whether a medication has truly made a difference.
Back to McDougle et al.—this trial examined the use of risperidone in adults with autistic disorder. By the end, the risperidone group showed improvement in aggression, self-injury, and irritability. In the years following, more trials studying risperidone for patients with autism were held. It became the first drug FDA-approved for autism in 2006. However, it’s only approved for children ages 5-16, not adults.
Aripiprazole has also been extensively studied for the treatment of aggression in autism. The first large-scale, placebo-controlled trial was completed in 2009. After promising results and further research, it received FDA approval for children with autism ages 6-17.
However, both aripiprazole and risperidone may come with side effects, the most common being weight gain. Children with autism are at higher risk of becoming obese, so some parents are concerned about the health problems that could be caused by weight gain. Others believe the decrease in aggression is worth the trade-off. For other potential side effects, see Autism Parenting Magazine’s article on risperidone.
More atypical antipsychotics have been researched for aggression in people with autism. However, as of now, risperidone and aripiprazole are the only ones with a long history of high-quality trials and the FDA’s sign-off.
This is the only first-generation psychotic to show promise in improving aggression in patients with autism. Although FGAs tend to have more significant side effects than SGAs, they’re still used when symptoms don’t respond to other treatments.
Studies of haloperidol initially focused on other autism symptoms, like withdrawal and repetitive behavior. But it also resulted in less aggression.
Haloperidol does come with a significant risk of dyskinesia, which are involuntary movements like fidgeting, swaying, grimacing, and tremors.
This medication is a beta-blocker, meaning it reduces blood pressure and uneven heart rate. However, it’s also shown some psychological benefits, including decreased violent behavior in people with schizophrenia, intellectual disabilities, and autism.
Fluvoxamine is an antidepressant that is FDA-approved to treat obsessive-compulsive disorder (OCD). It’s also shown some potential in reducing temper tantrums, social difficulties, repetitive behavior, and anxiety in adults with autism. Children and adolescents on the spectrum, however, do not seem to benefit much from it.
Dextromethorphan and quinidine
These are two separate drugs commonly used together to treat a condition called “pseudobulbar affect”, in which sufferers display involuntary laughter or crying. Pseudobulbar affect is associated with diseases like ALS and multiple sclerosis.
Chez et al. (2020), a randomized, double-blind study of dextromethorphan and quinidine in adults with autism, resulted in improvements in irritability.
A couple of autism studies—Elliott et al. (1994) and Allison et al. (1991)—have noted the benefits of aerobic exercise for autistic adults. These studies involved jogging or running on a treadmill, and both demonstrated a reduction in aggressive incidents.
Therapy or medication: which is better?
Every person with autism is different, so what works for one won’t necessarily work for another. It often takes time, trial-and-error, and patience to find a treatment that works.
Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review by David S. Im is an overview of multiple scholarly articles on this topic. Im concluded that the strongest evidence—mainly controlled trials—supported the use of “risperidone, propranolol, fluvoxamine, [and] vigorous aerobic exercise”. However, it’s worth noting that medications can come with uncomfortable, and sometimes serious, side effects.
Im wrote that “First…a functional assessment of the behavior could be conducted to identify factors underlying the aggression… Once such factors are identified, a behavioral approach utilizing principles of applied behavior analysis could be used to target the aggression, given the minimal adverse effects and long-term risks associated with this approach… If such interventions are unavailable or ineffective, or if the acuity of the individual’s aggression is too high to permit safe and effective implementation of these approaches, pharmacotherapy can be used, ideally after a discussion with the individual…”
In other words, therapy should be tried first, possibly combined with a physical exercise regimen. If that’s ineffective, or if the behavior is already extremely severe, then medication is the next step. I’m also emphasized that risperidone would be a good drug to start with, given the amount of research behind it.
Tantrums, self-harm, and aggression in children with autism can be very serious. As parents, you want to do whatever you can so your child is happy and productive.
Although there’s still more research to be done about how to best address these symptoms, there are many treatment options available for kids on the spectrum. Work with your healthcare provider to find the right one for your unique child. With your love and support, it’s possible to manage this behavior.
Applied Behavior Analysis Programs Guide. “Do Applied Behavior Analysts Use DBT (Dialectical Behavior Therapy)?” Applied Behavior Analysis Programs Guide, https://www.appliedbehavioranalysisprograms.com/faq/do-applied-behavior-analysts-use-dbt/.
Chez, Michael et al. “A Randomized, Placebo-Controlled, Blinded, Crossover, Pilot Study of the Effects of Dextromethorphan/Quinidine for the Treatment of Neurobehavioral Symptoms in Adults with Autism.” Journal of autism and developmental disorders vol. 50,5 (2020): 1532-1538. doi:10.1007/s10803-018-3703-x
Doyle, Carolyn A, and Christopher J McDougle. “Pharmacologic treatments for the behavioral symptoms associated with autism spectrum disorders across the lifespan.” Dialogues in clinical neuroscience vol. 14,3 (2012): 263-79. doi:10.31887/DCNS.2012.14.3/cdoyle
Fitzpatrick, Sarah E et al. “Aggression in autism spectrum disorder: presentation and treatment options.” Neuropsychiatric disease and treatment vol. 12 1525-38. 23 Jun. 2016, doi:10.2147/NDT.S84585
Im, David S. MD Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review, Harvard Review of Psychiatry: 1/2 2021 – Volume 29 – Issue 1 – p 35-80 doi: 10.1097/HRP.0000000000000282
London, Eric B. MD∗; Yoo, J. Helen PhD∗; Fethke, Eric D. MD†; Zimmerman-Bier, Barbie MD‡ The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders, Journal of Clinical Psychopharmacology: 3/4 2020 – Volume 40 – Issue 2 – p 122-129 doi: 10.1097/JCP.0000000000001175
MedlinePlus. “Dextromethorphan and Quinidine.” MedlinePlus, 2016, https://medlineplus.gov/druginfo/meds/a611048.html.
Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. “DSM-5 CHANGES: IMPLICATIONS FOR CHILD SERIOUS EMOTIONAL DISTURBANCE.” Substance Abuse and Mental Health Services Administration, June 2016, https://www.samhsa.gov/data/sites/default/files/NSDUH-DSM5ImpactChildSED-2016.pdf