The Myth of Attention-Seeking Behavior: Supporting Health and Wellness in People with Autism Spectrum Disorders and Intellectual Disabilities

As a behavioural consultant, one of the most common phrases used in referral information is that the individual is engaging in a series of behaviors “just to get attention”. Attention has been postulated as a motivation for behavior by the most widely used behavioral assessments such as the Motivation Assessment Scale, the Functional Assessment Screening Tool and others. This article will present the concept that people do not want attention, rather they want the things attention brings, such as safety, affection, acceptance and other needs. In a sense, attention is the means to an end, and not the end itself. A conceptualization for identifying the reinforcers sought by people using behavior to get the attention of others is presented within the context of a single case study.


Introduction
The Motivation Assessment Scale [1] is one of the most widely used assessments of its type, and categorizes behavior within four different possible motivational cues: sensory, escape, motivation, and tangible. Other assessments such as the Questions about Behavioural Function [2] use similar categories, and include attention as one of the functions of behavior. As a behavioral consultant for over 30 years, the most frequent statement for why additional consultation services are sought is that the person is seeking attention from others through their behavior, in ways that have been difficult for people to understand and/or explain. One referral, written jointly by a psychologist and psychiatrist, said: "Over a period of several years, this young woman was admitted to hospital seven times. She presents as a highly social young adult who has struggled to develop appropriate social skills and boundaries. By far the large majority of inappropriate behavior is observed to be attention seeking by behavioral function. That is, she uses both appropriate and inappropriate behavior to gain the attention of adults around her. Attention seeking through the use of negative behavior is exacerbated when there are many peers in the environment and she feels she has to compete with them for attention, as well as by the actions of adults who attempt to correct or limit her inappropriate behavior through direct confrontation, which tends to escalate the situation." [3] The fact that this referral was written jointly by a psychologist and occupational therapist is an excellent example of translational science and partnership [4]. This collaborative approach is slowly becoming more normative within human service systems. However, the statement that the function of the behavior is to gain attention is incomplete. Identifying what people want, and the conditions or settings in which people experience needs is the focus of structural behavior assessment [5] and provides a unique framework from which to support the person using a series of behaviors to attain their own goals.
After interviewing the person several times and conducting a trauma screen, this person did not want attention, she wanted the affirmation of adults and the acceptance of her peers. Rather than attention, the actual motivators of behavior are affirmation, acceptance, acknowledgement, appreciation and achievement [6] along with the need for safety [7].
In her book on Cooperative Discipline, Linda Albert writes about A+ relationships in schools-Affirmation, Acknowledgement, Acceptance, Appreciation, and Attention. Building on her work, it appears that attention is the doorway through which people invite us into their lives, using the attention from others to seek what they need. For people whose lives were stable and characterized by words like "loved" and "safe" and "predictable" their needs for the identified motivators are met by an intrinsic sense of worth and value which come from having their needs for attaching relationships, social relationships, and achievement being met in multiple environments. These Positive Childhood Experiences of individuals result in stability and long term positive mental health [8]. For many of us, however, who have been exposed to four or more Adverse Childhood Experiences (ACE's) our childhood and/or adolescence and early adulthood were not as loving and safe and predictable [9].
A Google search on how to address attention getting behavior results in literally hundreds of books, articles, websites and workshops on how to stop these behaviors [10]. Many reinforce the perception that "all they want" is attention. Many rightly focus on the frustration we may feel in working with someone who is "attention seeking" because it can be tiring and frustrating working with some-B. Bowen one who constantly seeks attention.
Looking at the list of "A" words-affirmation, acknowledgement, acceptance, and appreciation, the common factor amongst these needs is relational in nature. David Pitonyak [11] and others have written, in one form or another, on the idea that "Loneliness is the only real disability." Loneliness is often reinforced by a human service system that is underfunded, overworked, and which in many forms seeks to control rather than serve, lead rather than follow the lead of the people we serve. The systemic factors that inadvertently support loneliness are explained in the idea of transitioning from a model of services to a model of supports and individualizing the many processes that together form the human service system [12]. An additional factor in the lack of affirmation, acknowledgement, acceptance and appreciation is the turnover rate of direct support professionals in some areas and organizations is over 60%, making relationships almost impossible [13].

Case Study
Needs that are unmet become setting events for future behavioral interaction [14] One way of identifying unmet needs is the Matrix of Needs [15] which provides a framework within which needs can be identified individually and understood within a developmental structure. Using this case as an example, the individual in question is a young woman in her early 20's who has been attending a community college in the United States. In her courses in bookkeeping and accounting, she has been labeled as a person who constantly seeks out the attention of teachers, clerical staff, and administrators. Due to her diagnosis of autism spectrum disorder (ASD) she often misinterprets social cues and struggles with classwork not related to mathematics Figure 1.
1) Safety: In the Matrix of Needs model, safety does not have a separately identified position within the matrix. Rather, safety is seen as an all-encompassing need, and is a structural need rather than a process need as are the other identified needs. The perception of safety starts with how human beings process incoming stimuli, using a complex array of inputs that flow upwards from the peripheral nervous system (PNS) into the brain, or central nervous system (CNS). Neurons which direct the flow of sensory inputs upwards are termed afferent, while neurons which direct sensory outputs which become behavior are termed efferent.
It is well-established that people with ASD have significant differences in how sensory inputs are processed. People with ASD often miss or mis-interpret visual and auditory information from their environments, which increase stress and can be interpreted as a threat to their safety [16].
In this individual, she used behaviors that appeared to be attention seeking to clarify her auditory perceptions as she had difficulty processing what she heard in class. She also had difficulty understanding visually based information such as facial expressions and body language. While the focus of the college was on an B. Bowen environment that was physically safe and free from bullying, she perceived the environment to be unsafe as she could not understand much of the social interaction in classroom settings with resultant feelings of anxiety. Likewise, office environments in which she was able to volunteer were highly reliant on auditory processing which worked against her and limited her ability to both interact with others and comprehend their communications.
2) Attaching Relationships: This individual comes from a stable family environment, with two siblings, one older and one younger. She reported no exposure to any abuse or neglect within her home setting, and had an ACE score of 1, with an exposure to bullying within her school. This need was presumed to have been met based both selfreports, previous assessments and observations of the interactions between the individuals and their family members.
3) Subsistence: All of this individual's subsistence needs appear to be fully met. There is no history of any eating disorder, chronic illness, or sleep disorder. She is within expected ranges for weight given her height and age. times she appears to have more difficulty processing auditory than visual inputs. This is consistent with research findings which indicate that people with ASD may utilize parts of the brain usually devoted to visual processing in order to process auditory inputs [17]. As a result of limitations in auditory processing, this individual and others repeatedly ask for clarification, which may appear to be attention-seeking behavior from the perspective of a non-autistic staff person in a teaching, clerical, or administrative role.

5) Social Relationships:
Because of the limitations in processing auditory and visual communications, people with ASD have significant difficulty in social relationships, which is one of the diagnostic indicators of ASD. This individual had no social relationships with peers at her college, and after college felt isolated. As indicated previously, loneliness is one of the primary challenges facing people with any diagnostic label in the mental health and/or developmental disabilities category.

6) Achievement:
In tasks that required little or no social interaction or communication, such as the creation of spreadsheets or data entry, this individual excelled. Unfortunately, most positions in bookkeeping and accounting require some degree of social interaction. Because of her ASD and resultant social limitations, this individual had significant difficulties with people when she had volunteer experiences during her college coursework. She had the diploma that said she had the so-called "hard skills" in accounting and bookkeeping, but lacked the "soft skills" which are increasingly necessary in a socially interconnected workplace. 7) Plan of Supports: Using The Matrix of Needs as a way to assess her needs, the primary impediment to success appeared to be the ways in which this individual processed auditory information. This was directly related the ways in which her neurosensory system processed incoming stimuli and her resultant communication deficits, which also affected her ability to socially interact with peers, and gain a sense of affirmation from her peers and achievement in her work.
When the needs for safety, attaching relationships, subsistence, communication, achievement and social relationships are met, the visual model in Figure 2 provides an understanding that the individual has a stable foundation upon which other needs can be met. As the needs for subsistence and attaching relationships had been met, the focus of the plan of supports focused on perceptions of social safety through increased skills in receptive communication, which would then lead to increases in her ability to develop social relationships and develop opportunities to achieve in a work environment.
The local community theater was approached, and agreed to let this individual sit in on rehearsals, and then talk with selected actors and the director to explain why certain words, facial expressions, and body language were used to convey information and emotion to the audience. She began to watch selected television shows and films to study the ways in which people communicated expressively, and to compare her perceptions to those of others. Working with the individual being supported, a volunteer position was created in a small office in which she was able to perform bookkeeping tasks. The tasks were broken down through a task-analysis with visual models to clearly explain the required steps of each task along with written information. The supervisor was trained in understanding ASD and the need for affirmation that her work was adequate, along with the acceptance of her peers. Weekly de-briefing was instituted to support her to process her interactions, and after 12 weeks the debriefing ended as she no longer needed this level of support.

Conclusions
The individual began to apply for positions in small organizations and eventually procured a position as a bookkeeper in a credit processing center. While her ASD continues to be a formidable barrier for her, by focusing on communication skills and structuring the auditory and visual inputs in the workplace, her behavioral outputs became more aligned with the social expectations of her work environment.
What had been labeled as attention-seeking behaviors were reframed to perceive her behaviors as efforts to gain a sense of affirmation from supervisors and professors, and acceptance from her peers. In seeking to provide supports to people with ASD and other limitations, the term "attention-seeking" must be seen as a way to gain acceptance, affirmation, acknowledgement, and appreciation rather than just attention. The Matrix of Needs can provide a framework to assess the degree to which needs are met within the life of the individual and determine the necessary steps to support the individuals to receive affirmation from others, acknowledgement that they are present and are not invisible, acceptance from peers and appreciation for not only what they do but who they are.

Human Subjects and Research
No studies involving human beings or animals were conducted in the writing of this article. Case studies have been anonymized.

Conflicts of Interest
There are no conflicts of interest experienced by the author. There was no payment by any organization in the writing of this article.