Positive Approaches Journal, Volume 14, Issue 2

Volume 14 ► Issue 2 ► September 2025

Positive Impacts of Environmental Modifications for Individuals with Autism and Dual Diagnosis Conditions

Carly L. Staples, MEd, NADD-DDS

Abstract

A common misconception in society is that all people with autism, intellectual developmental disability (IDD), and co-occurring mental health (MH) present similarly and therefore are treated by generalized supports and interventions. This could not be further from the truth.  People with autism, IDD, and co-occurring MH are diverse, exhibiting a wide range of strengths, challenges, and personalities. The best approach to supporting an individual with the aforementioned diagnoses is utilizing person-centered supports. Person-centered supports are tailored to the uniqueness of each person, centering their care around their specific needs and preferences, rather than applying a generalized approach¹. This article will highlight how specified environmental modifications can be implemented in order to best support a person with autism, IDD, and co-occurring MH conditions, who engages in severe, self-injurious behaviors, to promote both safety and quality of life.

Introduction

Supporting people with autism, IDD, and co-occurring MH disorders often presents unique and arduous challenges. These challenges are increasingly compounded when self-injury is present. When an individual with autism engages in self-injury, such as head banging, this is often classified as a type of stereotypical movement disorder. These are repetitive, purposeless movements that may appear self-stimulatory or instinctual. The causes of head banging are complex and not fully understood.  Researchers believe that abnormalities in brain circuits, especially within the basal ganglia and dopaminergic pathways, play a significant role. These abnormalities can result in neurotransmitter imbalances involving dopamine and gamma-aminobutyric acid (GABA), which are crucial in movement regulation.

In individuals with autism, head banging can be more frequent and severe compared to neurotypical peers and is often in response to sensory issues. While head banging is common in autism, it is classified as a separate disorder when it causes serious self-injury or interferes with daily functioning. Especially when it is not solely driven by autism but also by underlying neurological or behavioral factors, understanding the underlying causes can help guide effective interventions. Addressing factors such as sensory needs, communication difficulties, and emotional distress is crucial in managing head banging behaviors.  The complexities of supporting a person with a myriad of diagnoses along with self-injurious behavior (SIB) require intricate, specialized environmental modifications in order to ensure health, safety and a heightened quality of life.

Synopsis

Charles was born of a normal pregnancy with no complications. He met most of his gross motor developmental milestones typically, while not meeting developmental milestones related to communication typically. After year three, more significant delays were identified and by year four, Charles was diagnosed with autism and IDD. Charles attended private special education schools throughout his adolescence. His behaviors were typical for an individual diagnosed with autism and IDD until around age 13 with the onset of puberty. During this time, more significant behaviors were noted such as several SIB, physical aggression, and property destruction. By age 15, his family was no longer able to maintain his safety within their family home due to these behaviors. At this time, Charles was placed within a residential treatment facility (RTF). Charles resided in the RTF from the age of 15 until 21. At this time, Person Directed Supports (PDS) was contacted regarding his emergent need for placement. During interim meetings with the RTF, it was discovered that Charles was previously accepted into PDS’ adult program, but this was quickly rescinded without reason.

With minimal notice and minimal information regarding any maladaptive behaviors, PDS accepted Charles into the program, and he moved in with PDS in November of 2024 after a request by an Administrative Entity (AE) on an emergency basis (with less than 24-hours’ notice). It was quickly discovered that Charles had very intensive behaviors including SIB, excessive head banging on surfaces, both superficial and substantial, such as walls, tables, floors, windows—any surface near him during the time of escalation—and biting his hands. The behavior was paired with physical aggression in the form of hitting, kicking, head butting, throwing items at others, property destruction, ingesting non-food items, eating feces, and engaging in fecal play, excessive masturbation—both at home and in public, and disrobing—both at home and in public.  An initial functional behavioral assessment (FBA) was conducted during his first 60 days of service with PDS. The initial assessment involved direct observation of Charles by the behavior specialist (BS) and occupational therapist (OT), a comprehensive sensory evaluation conducted by the OT, a sensory profile also completed by the OT, interviews with family members and supporters of Charles, review of what minimal records were available regarding behavioral data and psychological assessment history, review of developmental history, and review of behavioral data that was collected daily by direct support staff within his home. Behavioral data collected included the frequency, duration, and intensity of behaviors, antecedents of behavior, consequences of behavior, detailed narrative of behavior, strategies utilized to deescalate the behavior, Charles’ response to strategies, and any other strategies utilized to get Charles to return to his baseline. Behavioral and occupational assessment data hypothesized that he was seeking vestibular input through engaging in head banging. Head banging in individuals with autism can be linked to sensory processing differences, particularly within the vestibular system, which regulates balance and spatial orientation. Some individuals might seek out the proprioceptive and vestibular input provided by head banging to regulate sensory input, either to calm down or to stimulate themselves when under stimulated; others might use it as a form of communication, to express frustration, anxiety, or a need for attention. In Charles' case, this would align with his diagnosis of stereotypic movement disorder. Behavioral data suggested that he would exhibit said behaviors in response to stress, frustration, boredom, or sensory overload.

Initially, Charles moved into a one-person home with 1:1 staffing with what were thought to be appropriate modifications to the home for safety, including single layer padding on the walls, door chimes, corner protectors, accessible bathroom, and sensory items. Shortly after Charles’ move into PDS’ home, PDS received additional information from his previous placement that Charles was head banging over 3000 times a month and it was evident through the review of behavioral data mentioned above that the extent of his behavior was not conveyed during his time of transition from the RTF. It became increasingly evident that the level of modifications to the home was in no way adequate. Due to the severity of his self-injurious behavior, his home was further modified to ensure his health and safety. All modifications were recommended by a licensed OT and behavior specialist and made in conjunction with Charles and his family so that the home became a sensory-friendly environment completely tailored to Charles’ wants and needs to better his quality of life and to ensure safety. All the hard furniture was removed from the home and replaced with soft, cushioned seating such as a giant love sac, a vibrating chair, and vibrating floor mats. PDS crafted specialized tables that were installed within the walls that would fold down so that this was to be only available when being utilized. This made sure that any surfaces that Charles may use to engage in self-injury would not be readily accessible. A soft, cloth sensory swing was placed in his living room for engagement to prevent boredom which could trigger further SIB. The floors of the home were modified with the addition of two-inch padding underneath the carpet throughout the entire home, excluding the bathroom. In the bathroom, the floors were covered with water resistant padding to further ensure Charles’ safety. Padding was also placed on the walls and ceilings. A specialized, padded wardrobe was built into the wall. Additional outdoor sensory activities were installed, including a swing set, blow-up sensory toys, and interactive games. Staff received extensive medical and behavioral training, including how to utilize items within Charles’ sensory diet to reduce occasions of self-injury.  PDS decided the best course of action was to hire more staff and require additional training and certifications to improve the quality of supports within the home. Behavioral technicians were hired for every shift, the staff within the home were required to become certified through the National Association of Dual Diagnosis, and a master’s level behavior specialist was hired to be the home manager for in-home behavioral supports. To further empower Charles and improve his quality of life, there was a transition from Picture Exchange Communication System (PECS) to Proloquo. Proloquo is a symbol-supported, Augmentative and Alternative Communication (AAC) app used by individuals with limited or no speech to communicate. It provides a voice for non-verbal users by allowing them to tap symbols and words on a device, which are then spoken by natural-sounding text-to-speech voices. PDS felt the transition from PECS to Proloquo was necessary to give Charles power and his own voice. PDS collaborated with Temple University’s College of Education and Human Development team for additional staff training on implementation of Proloquo and how to best assist staff when working with Charles to improve communication skills and further lessen the likelihood of SIB due to a communication deficit.

Conclusion

A collaborative team of cultivated specialists created a “wish list” home and environment for Charles, focused on safety and a specialized sensory diet. Team meetings were held weekly while designing the plan and weekly meetings have continued since the plan was implemented. Updates to the plan are made as needed, keeping the team informed of any changes deemed necessary to ensure everyone is on the same page and gives the best support possible. Taking a person-centered approach in addressing Charles’ needs and safety proved to be integral in the overall success of the environmental modifications. His environment was designed to his specific wants and needs. Charles now navigates his own home and property with precision because of the environmental modifications that were implemented. His overall quality of life and safety has been maximized. There are endless possibilities when the proper, specialized environmental modifications are put into place.

References

1.   Autism Learning Partners (2025), Debunking 8 Common Stereotypes. Debunking 8 Common Stereotypes of Autism.

2. Key Autism Services (2025), Understanding Self-Injurious Behaviors in Autism: Focus on Head Banging. Heading Banging Autism