Complex Factors Associated with Disruptive Medical Professional Behavior: Retrospective Analysis of the Colorado Physician Health Program Data.

Anesthesiologists Recovering From Chemical Dependency: Can They Safely Return to the Operating Room?

To the Editor: The survey study by Dr DesRoches and colleagues reported data regarding physicians’ experiences with impaired colleagues. Although the authors concluded that a large number of practicing physicians do not support the current process of self-regulation, we believe that the discussion lacked consideration of relevant issues that would put these results into more meaningful context. The association between a state’s malpractice environment and likelihood of reporting an impaired colleague could represent cause or effect. Malpractice claims may be lower in states in which more impaired physicians are reported because such physicians could access the help they need before any patients are harmed. Thus, the quality of the state’s physician health program (PHP) may have a more meaningful effect on the reporting climate within a state. PHPs were implemented to help physicians access treatment while maintaining public safety. There are no national standards for PHPs, so the structure, size, and quality of the programs vary. For example, some PHPs mandate disciplinary action by the state board of medicine, whereas others allow physicians to obtain treatment confidentially and without punitive action (eg, Florida, Alabama). In addition, some states recently lost a PHP (California) or do not have a PHP (Georgia). In an observational study of 904 substance-impaired physicians enrolled in 16 PHPs, there was a 78% recovery rate. The survey used by DesRoches et al did not specifically ask participants about reporting colleagues to a PHP, which may reflect a need for increased awareness of such programs. Given that perceived lack of anonymity and efficacy were identified by the authors as possible barriers to reporting an impaired colleague, state PHPs may provide a valuable resource to impaired physicians and colleagues who are ethically charged with reporting them. It seems likely that rates of reporting an impaired colleague would be higher in states with a high-quality PHP. It is also notable that participants practicing less than 10 years were most likely to agree that physicians should report all impaired or incompetent colleagues (71%) and had the highest rates of actually reporting them (79%). These results may reflect increased education regarding this topic, with medical schools recently focusing more attention on patient safety, medical errors, duty-hour limits, and physician impairment. Continuing medical education regarding physician impairment may enhance knowledge, confidence, and ethical responsibility among physicians already in practice. Lisa J. Merlo, PhD, MPE lmerlo@ufl.edu McKnight Brain Institute University of Florida College of Medicine Gainesville Karl M. Altenburger, MD Professionals Resource Network Inc of Florida Fernandina Beach Mark S. Gold, MD McKnight Brain Institute University of Florida College of Medicine

During the past year, the College of Physicians and Surgeons of Ontario (CPSO) has focused much of its attention on a physician who has long eluded regulatory action, even though his behavior may have posed a risk to patient care and created chaos in his workplace for a number of years.This physician may be clinically competent; indeed, he may be technically superior. However, no one wants to refer patients to him. No one wants to assist him in surgery. He is the one who screams at nurses, belittles medical students and makes criticisms that go beyond the bounds of fair professional comment. However, he is not always loud. He can be the passive physician who will not answer the pager while on call, who does not show up at meetings and will not help find solutions to departmental problems. Indeed, this physician is not always male, but more often than not that seems to be the case.Currently, there are clear processes to deal with physicians who commit fraud, sexually abuse a patient, need their clinical skills upgraded, need assistance with issues such as patient communication or record keeping and those who need assistance in dealing with substance abuse.The disruptive physician, however, does not necessarily fall into these categories. As a result, his bad behavior can continue for years without apparent redress.There is now, however, a waning tolerance for doctors who behave badly. Too much time and effort is spent responding to the morale problems caused by the disruptive physician. More importantly, there is a better understanding of the potential harm that disruptive behavior can pose to patient safety.As the regulator for the medical profession in Ontario, it is the CPSO’s responsibility to take action. That is why we are taking the lead in developing a program that deals with these physicians. Our first step was to organize a brainstorming session and invite everyone who has a role to play: the health-care profession regulators, the hospitals, the medical schools, the medical associations and the administrators of the physician health program. We spent the day discussing the problem from all angles to ensure that we had a shared understanding of the situation. We agreed that our focus should not entirely be upon individual disruptive doctors, but also upon the interaction between their behavior and the situation in which it occurs. An analysis of disruptive behaviors, and programs that are designed to deal with them, must always include a dimension-like “setting” to account for this interaction. Behavior that is acceptable in the locker room is not acceptable in the operating room. The setting defines appropriate behavior.We also devoted a good portion of the session listening to presentations from experts in the field of disruptive physician behavior. The day ended with resolve to draft a definitive statement that would make it clear that disruptive behavior is unacceptable and will not be tolerated.The participants at this session were also divided into four working groups, each one charged with a unique assignment. The expectation is that when the project reconvenes later this year, each group will have developed thoughtful approaches for responding to disruptive behavior on one of the following levels: community/institutional, educational, physician health and regulatory. We can then, as a group, identify the key strategies that need to be developed for dealing with this very complex problem in whatever environment it arises, be it during medical school, or within a community practice or hospital.It is worth pointing out that one incident report does not a disruptive physician make. Doctors, being fallible human beings who work in very stressful environments, will likely have the occasional angry outburst. This is not the behavior upon which we are focused. Rather, we focused upon multiple reports from a variety of such sources as nursing staff, physician colleagues or family members of patients.A literature search and report commissioned by the CPSO and conducted by the Canadian Policy Research Network (CPRN) found that disruptive behavior affects everyone involved in the health care environment and is detrimental for all involved in the delivery of health care services. It can undermine practice morale, heighten turnover in practice, diminish productivity and increase the risk of substandard or ineffective care.Indeed, almost all the material reviewed cited the general impact disruptive behavior could have on patient care. Specific concerns listed were: upsetting patients or undermining the patient’s confidence in the care being received; upsetting the staff enough that they refuse to continue working with the physician; delaying needed care as other physicians attempt to refer patients elsewhere; and increased risk of harming patients — distracting the physician or the staff enough that an actual error is made in the delivery of care.Perhaps not surprisingly, it is often medical students who bear the brunt of a physician’s ire. Half of all medical students report experiencing some form of abuse during training, including being yelled at and belittled. Interestingly, those writing about disruptive behavior make the point that these behaviors may have been learned, even role-modeled, during medical school and residency training. Then, upon entering independent practice, these physicians simply behave in a way they have seen reinforced during their training period.Traditionally, the health care professions have not been very good at dealing with disruptive doctors. It is not surprising. Most people prefer to avoid conflict and physicians are no different in this regard. Physicians often feel a sense of “breaking ranks” when reporting a colleague. Chiefs of staff may not want to suspend a doctor who is technically competent, especially in areas already suffering from physician shortages. Nurses may worry that their concerns will not be taken seriously and they will only further anger the doctor if they report an incident. Concerns over burden of proof and liability have become increasingly important as the nature of the health care environment becomes increasingly litigious.Hospital administrators feel acutely uncomfortable dealing with the issue of disruptive physicians. Indeed, one researcher stated, “confronting a disruptive physician is the most dreaded task a physician executive faces.”The CPSO recognizes that there will be obstacles to effecting the kind of cultural change that we envision. However, this is not a problem from which we can afford to shy away. As a regulator, the safe delivery of patient care is our top priority and all our actions in this new initiative will be fundamentally aimed at enhancing patient care and improving the processes for delivering that care. If a physician’s behavior has the potential to jeopardize the well-being of patients, then we need to address it quickly and effectively.

To the Editor: The survey study by Dr DesRoches and colleagues reported data regarding physicians’ experiences with impaired colleagues. Although the authors concluded that a large number of practicing physicians do not support the current process of self-regulation, we believe that the discussion lacked consideration of relevant issues that would put these results into more meaningful context. The association between a state’s malpractice environment and likelihood of reporting an impaired colleague could represent cause or effect. Malpractice claims may be lower in states in which more impaired physicians are reported because such physicians could access the help they need before any patients are harmed. Thus, the quality of the state’s physician health program (PHP) may have a more meaningful effect on the reporting climate within a state. PHPs were implemented to help physicians access treatment while maintaining public safety. There are no national standards for PHPs, so the structure, size, and quality of the programs vary. For example, some PHPs mandate disciplinary action by the state board of medicine, whereas others allow physicians to obtain treatment confidentially and without punitive action (eg, Florida, Alabama). In addition, some states recently lost a PHP (California) or do not have a PHP (Georgia). In an observational study of 904 substance-impaired physicians enrolled in 16 PHPs, there was a 78% recovery rate. The survey used by DesRoches et al did not specifically ask participants about reporting colleagues to a PHP, which may reflect a need for increased awareness of such programs. Given that perceived lack of anonymity and efficacy were identified by the authors as possible barriers to reporting an impaired colleague, state PHPs may provide a valuable resource to impaired physicians and colleagues who are ethically charged with reporting them. It seems likely that rates of reporting an impaired colleague would be higher in states with a high-quality PHP. It is also notable that participants practicing less than 10 years were most likely to agree that physicians should report all impaired or incompetent colleagues (71%) and had the highest rates of actually reporting them (79%). These results may reflect increased education regarding this topic, with medical schools recently focusing more attention on patient safety, medical errors, duty-hour limits, and physician impairment. Continuing medical education regarding physician impairment may enhance knowledge, confidence, and ethical responsibility among physicians already in practice. Lisa J. Merlo, PhD, MPE lmerlo@ufl.edu McKnight Brain Institute University of Florida College of Medicine Gainesville Karl M. Altenburger, MD Professionals Resource Network Inc of Florida Fernandina Beach Mark S. Gold, MD McKnight Brain Institute University of Florida College of Medicine

Background: Risk assessment of future disruptive and violent acts is of great importance to public protection and care in the medical setting. The VA Puget Sound, Seattle, is utilizing clinical forensic risk evaluations in its assessments of veterans with disruptive Patient Record Flags or at elevated risk for violent behavior. Aim: To assess and compare provider knowledge, experience, and satisfaction with the clinical forensic risk assessment through the facility's Disruptive Behavior Evaluation Clinic. Method: A pilot internet-based survey was constructed to evaluate provider characteristics, experience, and satisfaction with a new Disruptive Behavior Evaluation Clinic. Members of the hospital's Disruptive Behavior Committee and mental health service lines were asked about their familiarity and confidence in the consultative service. Results: Forty-four providers responded. Of these, 23 providers were familiar with the Disruptive Behavior Evaluation Clinic and its clinical forensic risk assessments. All members of the facility's Disruptive Behavior Committee were familiar with the risk assessments. Members of the Disruptive Behavior Committee as well as clinical providers from the mental health service lines ranked highly the utility of the detailed risk assessments and risk management recommendations. Conclusions: The provider satisfaction survey provided evidence for the overall satisfaction with the use of clinical forensic risk assessments in VA facilities for assessment and management of persons with Patient Record Flags and other indicators of elevated risk of disruptive or violent behavior at one VA hospital.

State Physician Health Programs (PHPs) assess, support, and monitor physicians with mental, behavioral, medical, and substance abuse problems. Since their formation in the 1970s, PHPs have offered support groups following the 12-step model for recovery from substance use disorders (SUDs). However, few programs have developed support groups for physicians without SUDs. This study at the Massachusetts PHP (Physician Health Services Inc.) represents the first effort to survey physician attitudes concerning a unique support group that goes beyond classic addiction models. The group was initiated because of the observation that physicians with problems other than SUDs did not fit easily into the 12-step framework. It was hypothesized that such a group would be effective in helping participants control workplace stress, improve professional and personal relationships, and manage medical and psychiatric difficulties. With a response rate of 43% (85 respondents), the survey identified a strong overall impact of the Physician Health Services Inc. support group, identifying positive effects in all areas of personal and professional life: family and friends, wellness, professional relationships, and career. Respondents identified the role of the facilitator as particularly important, underscoring the facilitator's capacity to welcome participants, manage interactions, set limits, and maintain a supportive emotional tone. The implications for physician health extend from supporting a broader application of this model to using a skilled facilitator to manage groups intended to reduce the stress and burnout of present-day medical practice. The results encourage PHPs, hospitals, medical practices, and physician groups to consider implementing facilitated support groups as an additional tool for maintaining physician health.

To the Editor: Alcohol and drugs can precipitate aggressive behavior in susceptible individuals. In this study, we examined whether histories of alcohol and/or drug problems would relate to disruptive behaviors in the medical setting. Method. Participants were men and women aged 18 years or older being seen for non-emergent medical care at a resident-provider internal medicine outpatient clinic. We excluded individuals with compromising symptoms of a severity that would preclude the ability to successfully complete a survey. Of the 441 individuals approached, 401 (90.9%) agreed to participate. Of these, 394 completed relevant study measures (64.5% female; age range, 18–92 years [mean = 53.38, SD = 16.23]; 89.6% white). All but 7.6% had graduated from high school; 26.5% had a bachelor’s degree. During clinic hours, one of the authors approached consecutive incoming patients, informally assessed exclusion criteria, and then invited candidates to participate by completing a survey, which took about 10 minutes. Following queries about demographic information, we then asked, “Have you ever had a problem with alcohol?” and “Have you ever had a problem with drugs?” (ie, elemental inquiries that mirror typical clinician queries in the clinical setting), with yes/no response options. We then asked respondents about engagement in any of 17 disruptive behaviors in the medical setting, eg, yelled or screamed at medical personnel, cursed at medical personnel, verbally threatened medical personnel, stormed out of an appointment (the author-developed Disruptive Behaviors Survey, as it was presented to participants, is available at www.MindingtheMind.com/disruptivebehaviors.pdf). This project was approved by 2 institutional review boards. Participants were informed on the survey cover page that completion of materials constituted informed consent. Results. Of the 394 respondents, 38 (9.6%) indicated having had a problem with alcohol and 29 (7.4%) a problem with drugs (16 respondents for alcohol but not drugs; 7 respondents for drugs but not alcohol; and 22 respondents for both alcohol and drugs). The number of endorsed disruptive behaviors ranged from 0 to 11, with 49.0% of respondents endorsing at least 1 behavior (9.1% endorsed 1 behavior; 20.3%, 2 behaviors; 10.4%, 3 behaviors; 5.6%, 4 behaviors; and 3.6%, 5 or more behaviors). To ensure that statistical outliers did not exert an undue influence on analyses, we truncated the total number of disruptive behaviors at 5. Respondents who indicated a history of alcohol problems reported a statistically significantly greater number of disruptive behaviors in the medical setting (mean = 1.71, SD = 1.83) than respondents who did not indicate a history (mean = 1.16, SD = 1.42) (F1,392 = 4.91, P < .05). Similarly, respondents who indicated a history of drug problems reported a statistically significantly greater number of disruptive behaviors in the medical setting (mean = 2.03, SD = 1.76) than respondents who did not indicate a history (mean = 1.15, SD = 1.43) (F1,392 = 10.06, P < .01). The potential limitations of this study include the self-report nature of the data and imprecise definition of “alcohol problem” or “drug problem.” However, this is the first study to our knowledge to examine relationships between alcohol and/or drug problems and disruptive behaviors in the medical setting. Findings suggest that medical personnel be alert to the potential risks of treating individuals with past and/or current alcohol and/or drug problems.

There is increasing focus on physician burnout, psychiatric problems, and substance use disorders. Costs of recovery for physicians enrolled in Physician Health Programs (PHPs) remain unexamined with little known regarding funding resources. We sought to elucidate perceived costs of recovery from impairing conditions and highlight resources for financial strain. This survey study was distributed by the Federation of State Physician Health Organizations via e-mail to 50 PHPs in 2021. Questions assessed perceptions of costs and ability to pay for recommended evaluation, treatment, and monitoring. Questions also assessed limitation of engagement due to financial concerns, and availability of financial resources. Complete responses were received from 40 of 50 eligible PHPs. The majority (78%) of responding PHPs assessed ability to pay at initial intake evaluation. There is notable financial strain on physicians, particularly those earliest in training, to pay for services. PHPs are vital to physicians, especially physicians-in-training, as "safe haven programs."Methods to financially assist through PHPs included fee deferrals, sliding scale fees, and fee forgiveness. Health insurance, medical schools, and hospitals were able to provide additional assistance. Because burnout, mental health, and substance use disorders are high stakes amongst physicians, it is critical that access toPHPs is available, destigmatized, and affordable.Our paper focuses specifically on the financial cost of recovery, the financial burden placed on PHP participants, a topic lacking in the literature, and highlights remedies and vulnerable populations.

Participation in physician health programs (PHPs) is associated with positive outcomes for healthcare professionals (HCPs) with potentially-impairing conditions, but more information is needed about PHP completer experiences. The present study explored program completers' perceptions of their involvement with one state PHP. A PHP staff member with no monitoring role conducted exit interviews via telephone with all individuals who completed the program between January 2019 and September 2023 (n = 666). Deidentified interview responses were examined using quantitative descriptive analysis and thematic analysis. The HCPs who completed PHP participation were generally satisfied with the program. Three major themes emerged: (1) PHP offers valuable support; (2) Helpful components of the PHP; and (3) Challenges encountered during PHP monitoring. The HCPs generally expressed appreciation for the PHP, with many describing a bittersweet journey. Components of the program identified as helpful included peer support, availability and expertise of case managers, accountability, advocacy and support offered by the program, and mental healthcare. Key challenges faced by program completers included the financial burden, feeling overwhelmed by program requirements, and perceived stigma and negative treatment related to their PHP involvement. Many PHP completers perceive PHP support as critical to improving their recovery outcomes. Additional resources may be needed to relieve the perceived financial burden of PHP participation, mitigate disruption to daily life/responsibilities, and reduce emotional distress following referral to PHP. This is a large qualitative study of the perspectives and experiences of PHP completers.

The decision to enter the field of anesthesia after recovery from substance abuse has been a controversy in the anesthesiology community. The incidence of abuse has been estimated at 1% of faculty members and 1.6% of residents in training programs.1 This incidence is similar to that reported by Ward et al.2 for the decade between 1970 and 1980. Unfortunately, death or near-death is often the event which identifies the physician as a substance abuser.1 The traditional view has been that recovery from substance abuse by anesthesiologists, particularly those who abuse opioids, is poor. Menk et al.3 demonstrated that only one third of residents who abuse opioids successfully reenter the specialty of anesthesia. Collins et al.4 reported that only 46% of residents who returned to training ultimately completed the program. Fry5 reported that only 15% of residents were successful in their effort to reenter the specialty of anesthesia. All of these studies are accompanied by frequent death during relapse that range from 9% to 31%. These dismal statistics have led many in the anesthesia community to call for either redirection of rehabilitated residents into lower-risk specialties or, more drastically, for the anesthesia leadership to adopt a "one strike, you're out" policy.6 Drs. Skipper, Campbell, and DuPont7 are to be congratulated on providing a major ray of hope with their article in this issue of the journal. They offer encouraging evidence in an area where the literature is highly pessimistic for the impaired anesthesiologist. Their 70% success rate for physicians treated at state Physician's Health Programs (PHPs) demonstrates that recovery is possible and even likely. Despite this finding, several aspects of their paper must be addressed. The article reveals that only 16 of 42 PHPs participated in the study. The primary reasons for nonparticipation were lack of resources and/or regulatory impediments. The outcome rate for programs not participating is unknown, but it is unlikely that programs which declined to participate based on "lack of resources" would have outcomes as good as those that have more resources. In 2007, the California State Auditor evaluated the Medical Board of California's Physician Diversion Program and determined that standards were not being met. On July 26, 2007, the Medical Board voted to close the program. There are no universal or federal standards for all programs and thus outcomes may vary by state. In all likelihood, well funded and organized programs have the resources to produce better results. The American Medical Association Council on Mental Health recognized that treatment rather than discipline should be the goal for the impaired physician. By 1980, nearly all state medical societies had authorized or implemented a physician treatment program. Well funded and organized programs have developed better treatment models over the years. The Oregon experience revealed that 75% of those who were treated were either stable or improved during an 8-yr follow-up.8 The Massachusetts Medical Society's Physician Health Service reported a 75% success rate as defined as "continuous or complete abstinence from any use of alcohol or drugs for a minimum of 3 years."9 The prior surveys by Menk et al. and Collins et al. that document poor outcomes do not address what would have happened if the individuals had been referred to a physician's health service. They did not report whether a contract had been signed or whether the physician was compliant with a monitoring program, all keys to successful recovery. The major flaw in comparing the data from Menk et al. and Collins et al. to the current data is that residents were the primary subjects in the earlier papers, and yet this very population was appropriately excluded from the current report because of small numbers. Extreme caution must be taken when generalizing the current results using board-certified anesthesiologists and applying those results to residents. A resident must still negotiate the stressful period of training. After residency, the nascent graduate then has many more years of actual anesthesia practice and exposure to the same substances to which he or she became addicted. Finally, the trainee may not have developed the professional support system that an older anesthesiologist has. Anesthesiologists are frequently described as being overrepresented in PHPs.9,10 The assumption is often made that this is due to a higher rate of substance abuse disorders among anesthesiologists. There is clearly a frequent incidence of death among substance-abusing anesthesiologists likely because of the high potency and low therapeutic windows of such drugs, including opioids, propofol, and volatile anesthetics.11,12 We may classify any use of occupational drugs as substance abuse or misuse because of our fear of death to the individual. Nearly 20% of training programs have reported a pretreatment fatality.4 The authors compare multiple variables between anesthesiologists and other physicians in an attempt to find differences. They found that anesthesiologists in treatment programs are more likely to abuse opioids and have a higher incidence of IV drug abuse, yet they have a lower incidence of a positive drug screen while undergoing treatment. When a large number of variables is compared among groups, it becomes increasingly likely that some difference will occur because of chance alone. In particular, with a significance value set to P < 0.05, we expect about 1 in 20 test items to be "abnormal" even when there is no true difference between groups. Fortunately, the main findings just mentioned were significant with P values <0.01 and thus likely represent trustworthy findings. Importantly, some of the measured variables may covary. Take, for example, the finding that anesthesiologists are more likely to use narcotics and that they are also more likely to use IV drugs. These findings are unlikely to be independent of each other and thus may represent a single difference between anesthesiologists and nonanesthesia physicians. Questions remain as to the overall likelihood of recovery for an anesthesiologist who has engaged in substance abuse. It is clear that trained anesthesiologists who enter well-funded and supported PHPs and sign a contract including intensive monitoring have a high likelihood of recovery and return to successful practice. We are indebted to Skipper et al.7 for showing that a positive outcome can be obtained. More research is needed regarding the success of treatment of residents and fellows who develop such disorders. A simple "one strike, you're out" policy when applied to all providers does not take into account these new data by Skipper et al. Their data focused only on anesthesiologists in practice. If addicted anesthesia residents are referred to the same types of physician health service programs as studied by Skipper et al. and complete a full course of treatment, they may enjoy the same positive outcomes. We believe that residents in anesthesia without coexisting psychiatric disorders, polysubstance abuse, and a family history of substance abuse and who complete a PHP should be considered for reentry into the specialty in consultation with the resident's addictionologist and psychiatrist.

The Physician as Patient: A Clinical Handbook for Mental Health Professionalsby Michael F. Myers, M.D., and Glen O. Gabbard, M.D. Arlington, Va, American Psychiatric Publishing, 2008, 252 pp., $46.00.

Managing disruptive behaviors in the health care setting: focus on obstetrics services

‘Safe Haven’ Integral to Physician Wellness

Fetal alcohol spectrum disorders (FASD) are often characterized by disruptive behavior problems and there are few effective interventions available. GoFAR is a novel, 3-part intervention designed to improve self-regulation and adaptive living skills of children with FASD by improving metacognitive control of emotions and arousal. The intervention has 3 components: (i) GoFAR: a "serious game" designed to teach a metacognitive control strategy in a computer game environment; (ii) parent training on child behavioral regulation; and (iii) Behavior Analog Therapy (BAT) sessions, a practical application of the metacognitive learning methodology by parent and child in the context of learning adaptive skills. The learning strategy (FAR) teaches the child to Focus and make a plan, Act out the plan, and Reflect back on the plan. Thirty families were randomized to 3 groups: (i) GoFAR (n = 10); (ii) FACELAND (n = 10); or (iii) CONTROL (n = 10). The 2 intervention groups, GoFAR and FACELAND, used computer games to instruct children. Both groups also received 5 sessions of parent training followed by 5 sessions of joint parent/child therapy (BAT). Assessment of disruptive behavior, including frequency of temper tantrums, frustration tolerance, impulsivity, destructiveness, aggression, and maintaining attention were carried out before enrollment at Mid-Treatment, when game play and parent training were completed, and finally, after completing the BAT sessions. Parental report of disruptive behavior overall was significantly reduced in the GoFAR group after the first components, game play and parent training, and after the BAT sessions in the FACELAND group with no changes in the CONTROL group over time. The GoFAR(®) game was well received by children and effective in teaching the required skills. Mastering the FAR metacognitive strategy was associated with a reduction in disruptive behaviors in children with FASD suggesting that effective interventions can improve outcomes for this high-risk group.

Abstract&#x0D; Autistic students experience barriers to behavior, communication, and social interaction. Based on a preliminary study, it was found that autistic students did not respond to people around them, were often alone, and rarely played. The purpose of this study was to describe the pattern of disruptive behavior in autistic students. Subject selection is done by means of identification of children with special needs and assessment of disruptive behavior. The research design is a qualitative case study with a descriptive method. Data were collected by observation and interviews. Observations were used to observe verbally and physically disruptive behavior the teacher's role in overcoming disruptive behavior, as well as the impact of disruptive behavior on autistic students. Interviews were used to get answers orally to classmates and class teachers, principals, parents, neighbors. The data were analyzed using componential analysis which analyzed more specifically the focus of the research. The results of the study showed that autistic students' verbally disruptive forms of behavior such as making fun of and calling with bad names. The forms of behavior that physically interfere with autistic students are attacking, pulling the headscarf, pulling hair, and pulling friends' hands. The teacher plays an authoritative role in overcoming the disruptive behavior raised by autistic students. The impact of disruptive behavior on the person being bullied is feeling uncomfortable and angry. The impact of behavior on autistic students themselves is being attacked and ostracized. It is recommended for teachers to provide assertiveness, collaborate with behavioral therapists and competent experts.&#x0D; Keywords: Disturbing behavior; the role of the teacher; impact; autistic students.&#x0D;