Toward a functional analysis of self-injury

Cultural responsiveness in applied behavior analysis: Research and practice

The new Ethics Code for Behavior Analysts requires that certificants engage in training related to culturally responsive service delivery (BACB, 2020). There is limited work in the area of culturally responsive evidence-based practice within our field. Therefore, it is incumbent on researchers and practitioners to identify best practices for working with diverse populations. Hence, the purpose of this paper is three-fold: a) to review research within and outside the field of ABA related to culturally responsive assessment and treatment and provide practice recommendations, b) to examine the extent to which current practices in behavior assessment and treatment align with aspects of culturally responsive practices, and c) to inspire research in the areas of behavior assessment and treatment to identify best practices with regard to culturally responsive behavior analytic practices. The content of this paper is grounded in the framework described by Beaulieu and Jimenez-Gomez (2022).

Nonhuman primate abnormal behavior: Etiology, assessment, and treatment

Across captive settings, nonhuman primates may develop an array of abnormal behaviors including stereotypic and self-injurious behavior. Abnormal behavior can indicate a state of poor welfare, since it is often associated with a suboptimal environment. However, this may not always be the case as some behaviors can develop independently of any psychological distress, be triggered in environments known to promote welfare, and be part of an animal's coping mechanism. Furthermore, not all animals develop abnormal behavior, which has led researchers to assess risk factors that differentiate individuals in the display of these behaviors. Intrinsic risk factors that have been identified include the animal's species and genetics, age, sex, temperament, and clinical condition, while environmental risk factors include variables such as the animal's rearing, housing condition, husbandry procedures, and research experiences. To identify specific triggers and at-risk animals, the expression of abnormal behavior in captive nonhuman primates should be routinely addressed in a consistent manner by appropriately trained staff. Which behaviors to assess, what assessment methods to use, which primates to monitor, and the aims of data collection should all be identified before proceeding to an intervention and/or treatment. This article provides guidance for this process, by presenting an overview of known triggers and risk factors that should be considered, steps to design a comprehensive evaluation plan, and strategies that might be used for prevention or treatment. It also outlines the tools and processes for assessing and evaluating behavior in an appendix. This process will lead to a better understanding of abnormal behavior in captive primate colonies and ultimately to improved welfare.

Translating Quantitative Theories of Behavior into Improved Clinical Treatments for Problem Behavior

The most important advancement in the treatment of destructive behavior has been the development of the functional analysis, which is used to prescribe effective treatments like functional communication training. Although this approach can be highly effective, extinction bursts and forms of treatment relapse commonly occur when function-based treatments are implemented by caregivers in natural community settings. In recent years, researchers have increasingly applied quantitative theories of behavior like behavioral momentum theory (BMT) and the temporally weighted matching law (TWML) to understand, prevent, or mitigate extinction bursts and treatment relapse. In this paper, we describe BMT and TWML and selectively review the basic, translational, and applied research supporting and opposing each theory. Then, we describe how function-based treatments may be refined based on these theories to improve the effectiveness, generality, and durability of function-based treatments for individuals with autism spectrum and related disorders who display problem behavior.

Evaluation and Maintenance of Behavioral Interventions for 22q11.2 Deletion Syndrome

22q11.2-deletion syndrome is a genetic disorder caused by a small deletion of chromosome 22. This deletion often results in developmental delays, learning disabilities, medical conditions, and comorbid psychiatric conditions. Patients with 22q11.2DS may present with a variety of behavioral phenotypes including obsessiveness and rigidity, poor social skills, and anxiety. In some cases, the phenotype can consist of destructive and inappropriate behavior including harming self and others. Behavioral difficulties are reported as one of the most challenging aspects of 22q11.2-deletion syndrome for families of patients, however, few studies have examined behavioral interventions as a possible therapeutic treatment for this population. Using principles derived from operant-behavioral psychology, we conducted functional assessments to determine the environmental correlates of destructive and inappropriate behaviors in two adult men with 22q11.2-deletion syndrome. Subsequently, behavioral interventions based on differential reinforcement were incorporated into each participant's natural environment to eliminate these behaviors. Significant reductions in destructive and inappropriate behavior were observed with both participants and therapeutic gains were maintained at follow-up. We discuss the role of behavioral interventions in combination with appropriate psychotropic medication when addressing challenging behaviors in this population.

Utilizing Telehealth to Coach Parents to Implement Trial-Based Functional Analysis and Treatment

The trial-based functional analysis (TBFA) offers several advantages in natural settings, such as time efficiency and ecological validity. Previous studies have successfully trained or coached a variety of professionals and parents to conduct a TBFA utilizing in-person training procedures; however, no study has evaluated the effectiveness of telehealth coach or train others to implement a TBFA. Utilizing telehealth coaching, we coached three mothers of children with autism to conduct a TBFA in their home. The TBFA identified consequences maintaining challenging behavior for all three participants. Based on the results of the TBFA, we developed a functional communication training (FCT) intervention. Experimenters coached the mothers to implement the FCT intervention in their home. All interventions resulted in decreased challenging behavior and increased communication. The results suggest parents are capable of conducting a valid TBFA with telehealth coaching and support.

On the scope and characteristics of relapse when treating severe destructive behavior

Prior studies on treatment relapse have typically examined the prevalence of resurgence or renewal of target behavior (e.g., destructive behavior) in isolation. This study analyzed both types of relapse during 25 consecutive treatments involving functional communication training during worsening reinforcement conditions for alternative behavior (i.e., schedule thinning) or following context changes. We also examined disruption of alternative behavior (i.e., functional communication requests, compliance). Resurgence and renewal of destructive behavior occurred in 76% and 69% of treatments, respectively, and in approximately a third of changes in reinforcement or context. Relapse of destructive behavior predicted alternative-response disruption and vice versa; the co-occurrence of these two events always exceeded the background probabilities of either event occurring in isolation. General reductions in treatment efficacy occurred across changes in reinforcement or context, with no apparent decrease in likelihood in later transitions. We discuss implications of our findings with respect to future studies examining treatment durability.

Improving Juvenile Justice Settings by Decreasing Coercion: One Lab's Perspectives from Behind the Fence

In this article, we outline an emerging role for applied behavior analysis in juvenile justice by summarizing recent publications from our lab and discussing our procedures through the lens of coercion proposed by Goltz (2020). In particular, we focus on individual and group interventions that target a range of behaviors emitted by adolescents in a residential treatment facility. In general, individual interventions involve teaching adolescents to (1) respond appropriately to staff, (2) tolerate nonpreferred environmental conditions, and (3) control problematic sexual arousal. Likewise, group interventions involve low-effort manipulations that decrease disruptive behavior and increase appropriate behavior in settings with numerous adolescents. Thereafter, we describe behavioral interventions for staff working in juvenile justice. These staff-focused interventions aim to increase staff-initiated, positive interactions with students in order to change subsequent student behavior. In addition, we review our recent endeavors to assess and conceptualize other service providers' behavioral products (i.e., prescription practices) in a juvenile facility. Lastly, we discuss future directions of behavior-analytic intervention with juvenile-justice involved adolescents.

A Systematic Review of Direct Assessments to Evaluate Psychotropic Medication Effects for Children With Disabilities

To evaluate effects of psychotropic medication for children with disabilities, direct assessments may offer a valuable supplement to caregiver reports. Relative to indirect assessment, direct measures of behavior can increase objectivity and sensitivity, and some have potential to isolate distinct behavioral and learning processes. We conducted a systematic, narrative literature review to identify and describe the types and qualities of direct assessment methods that have been used to evaluate effects of non-stimulant psychotropic medication for children with disabilities. We identified 50 studies and 78 direct assessments, which we organized and described using seven assessment categories. Only one study met all three direct assessment quality indicators. We use our descriptive results to highlight research trends and gaps that warrant further study.

Ongoing, Explicit, and Direct Functional Assessment is a Necessary Component of ACT as Behavior Analysis: A Response to Tarbox et al. (2020)

Tarbox et al. (2020) offered preliminary functional analyses and practical guidelines for incorporating acceptance and commitment therapy (ACT) within the scope of practice of applied behavior analysis (ABA). Although we agree that this is a needed goal, the approach taken by the authors gives rise to important conceptual, ethical, and practical concerns that warrant further discussion. In particular, we propose that explicit functional assessment of behavior (FA) is necessary in any intervention said to be ABA, and we wonder about the apparent omission of explicit FA throughout the article. We question what we read as the authors' tacit assertion that the functions of verbal stimuli can be inferred based on behavioral topography, that the function of verbal behavior can likewise be inferred based on form, and that behavior-behavior relations are both causal and predictive of behavior, irrespective of context. Furthermore, we consider whether a number of procedures for functional assessment presented in the article under consideration are consistent with established ABA best practices. Finally, we discuss the extent to which ACT interventions absent explicit FA in ABA interventions introduces the possibility that the interventions may do harm, arguing that further discussion around competence and scope of ethical practice for behavior analysts who wish to incorporate ACT into their work is needed.

Persons With Intellectual and Developmental Disabilities in the Mental Health System: Part 1. Clinical Considerations

Individuals with intellectual and developmental disabilities (IDD) are at high risk of co-occurring mental health conditions, including major depressive disorder, bipolar disorder, anxiety disorders, psychotic illnesses, impulse control disorders, and others. Because of symptoms associated with these illnesses and with the disabilities themselves, these individuals are often served in a mental health service system framework. However, treatment for them in these settings has typically not been sufficiently nimble, knowledgeable, or adept. Most mental health professionals receive little training about the needs of this population, and system structures typically bifurcate care, when, in reality, conditions can be complex and overlapping. In this first of two articles on care for persons with IDD in the mental health system, the authors provide a clinical overview of these neurodevelopmental disorders and of mental health and other conditions that co-occur with IDD. Considerations and challenges for treating this population in the mental health system include early recognition of mental health conditions, which often requires caregiver and family input, as well as information from a variety of additional collateral sources; the importance of trauma-informed and person-centered care; the promotion of self-determination through use of decision supports; use of approaches such as applied behavior analysis to develop a frame to address challenging behaviors; and the need to properly assess and provide thoughtful pharmacologic intervention when appropriate. The ability of individuals with IDD to thrive in a wide range of community integration opportunities depends on many factors, and clinicians must understand and use the available approaches for treating them.

Acceptance and Commitment Training in Applied Behavior Analysis: Where Have You Been All My Life?

Examining behavior within the context of applied behavior analysis (ABA) from the perspective of acceptance and commitment training (ACTr), while understanding the role of relational framing and the transformation of stimulus function, can better equip behavior analysts to effectively address complex behavior that may be influenced by covert verbal behavior. This approach may lead to a more comprehensive analysis of behavior and result in more effective interventions for socially significant change. The aim of this article is to provide behavior analysts with information and guidance on using relational frame theory (RFT) and ACTr in behavior-analytic services. The article first provides a rationale for considering thoughts as behavior and outlines important components of RFT. Subsequently, the benefits of employing ACTr in ABA are highlighted, including brief descriptions and examples of the use of ACTr within ABA practice. The article highlights the importance of expanding the consideration of maintaining variables when attempting to address maladaptive covert verbal behavior and ultimately aims to encourage a greater number of behavior analysts to adopt RFT and ACTr practices in applied settings.

Positive behavioural support for children and young people with developmental disabilities in special education settings: A systematic review

Background

Positive behavioural support (PBS) can be effective in supporting children and young people (CYP) with developmental disabilities. This systematic review focused on describing the components and nine characteristics of PBS that have been used with CYP with developmental disabilities in special education settings, and the evidence for PBS effectiveness in these settings. Additionally, facilitators and barriers to PBS implementation, and experiences of stakeholders, were investigated.

Method

Systematic searches followed a registered protocol, and 30 studies were identified, narratively synthesised, and critically appraised.

Results

From the 30 studies included, 10 reported the presence of all 9 PBS characteristics, 17 reported on 8 PBS characteristics, and 3 reported on 7 characteristics. Overall, 28 studies demonstrated significant decreases in behaviours that challenge and increases in alternative behaviours, if increasing alternative behaviours was part of the interventions.

Conclusions

There was a lack of evidence on facilitators and barriers, and a lack of qualitative studies exploring experiences of stakeholders with PBS in special education settings. The available evidence suggested that not all studies reported on all PBS characteristics when describing the approach followed. In addition, available evidence suggested that most studies demonstrated effectiveness of PBS regarding the measured outcomes. Implications and future directions are discussed.

Behavioral Assessment and Treatment via Telehealth for Children with Autism: From Local to Global Clinical Applications

Functional analyses (FA) and functional communication training (FCT) are the most commonly used behavioral assessment and treatment approaches via telehealth for children with autism spectrum disorder (ASD) who display challenging behavior. The FA + FCT telehealth model has been shown to maintain treatment effectiveness (i.e., child behavioral outcomes and parent acceptability), as well as demonstrate treatment efficiency (i.e., cost savings). However, the majority of these studies have been conducted in the United States. Therefore, the purpose of this study was to evaluate the outcomes obtained with the telehealth FA + FCT model that included global applications. Descriptive statistics were used to analyze the results of the 199 participants who enrolled in the telehealth project across all project sites. The results showed that behavioral outcomes and parent acceptability maintained at similar levels to previous studies across all sites. Additionally, very few differences were found across project sites in relation to drop-out rates, visit cancellations, and technology issues. These results demonstrate the effectiveness of the FA + FCT telehealth model for addressing the challenging behavior needs of children with ASD globally and highlight areas in need of additional evaluation (e.g., drop-outs, cancellations) to determine the conditions under which telehealth could be best used.

A comparison of RIRD within chained and multiple schedules in the treatment of vocal stereotypy

Slaton and Hanley (2016) compared the effects of multiple and chained schedules on stereotypy and item engagement for 2 individuals who exhibited automatically maintained motor stereotypy. Contingent access to motor stereotypy (i.e., chained schedules) was more effective than time-based access (i.e., multiple schedules) at reducing motor stereotypy, increasing item engagement, and establishing stimulus control for both participants. We systematically replicated Slaton and Hanley with 2 participants by a) targeting vocal stereotypy, b) including response interruption and redirection as a treatment component across conditions, c) conducting sessions in the natural environment with teaching assistants as change agents, and d) conducting an analysis of the effective treatment component(s). Chained schedules were more effective for 1 participant, whereas both treatments were effective for the other participant. The component analysis showed that different components were necessary for effective treatment for each participant.

On the Reliability and Treatment Utility of the Practical Functional Assessment Process

Saini et al. (2019) urged caution with respect to the use of practical functional assessment (PFA) procedures to inform behavioral treatment when they found that responses to an open-ended caregiver interview were only somewhat reliable and showed moderate to weak correspondence with analog functional analyses. Because the practitioner's goal in conducting any functional assessment process is to inform the successful treatment of problem behavior, we replicated and extended Saini et al. by (a) evaluating the reliability of hypotheses gleaned from two independent PFA processes for each of four children, (b) conducting treatment informed by a randomly assigned PFA, and (c) determining the extent to which potentially different levels of reliability impacted the treatment utility of the PFA process. Results indicated that the reliability of the PFA process varied depending on the stringency with which it was evaluated. However, treatments developed from randomly determined PFA processes produced efficacious outcomes on problem behavior and targeted social skills that transferred to the context designed from the other PFA process in all evaluations, suggesting that the PFA has strong treatment utility despite parts of the process having ambiguous levels of reliability. We discuss implications for practitioners tasked with treating severe problem behavior.

An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol

BACKGROUND

Children and youth with autism spectrum disorder (ASD) may manifest self-injurious behaviors (SIB) that may become severe and refractory with limited pharmacologic or behavioral treatment options. Here, we present the protocol of a prospective, mixed-methods study to assess the safety and efficacy of deep brain stimulation (DBS) of the nucleus accumbens (NAcc) for children and youth with ASD and severe, refractory SIB.

METHODS

This is a prospective, single-center, single-cohort, open-label, non-randomized pilot trial of 6 patients. Participants will be recruited through specialized behavioral clinics with persistent severe and refractory SIB following standard and intensive interventions. Following NAcc-DBS, participants will be enrolled in the study for 12 months. The primary objectives of the study are safety and feasibility, assessed by rate of recruitment and identification of factors impacting adherence to follow-up and study protocol. Potential treatment efficacy will be assessed by changes in the Children's Yale-Brown Obsessive-Compulsive Scale in ASD (CYBOCS-ASD), the Behavior Problems Index (BPI), the Inventory of Statements about Self-Injury (ISAS) and the Repetitive Behavior Scale-Revised (RBS-R) questionnaires. Additional clinical outcomes will be assessed, including measures of participant and caregiver quality of life, actigraph measurements, and positron emission tomography (PET) changes following DBS.

DISCUSSION

This study will be the first to evaluate the effect of DBS of the NAcc on a pediatric population in a controlled, prospective trial. Secondary outcomes will improve the understanding of behavioral, neuro-imaging, and electrophysiologic changes in children with ASD and SIB treated with DBS. This trial will provide an estimated effect size of NAcc-DBS for severe refractory SIB in children with ASD in preparation for future comparative trials.

TRIAL REGISTRATION

Registration on ClinicalTrials.gov was completed on 12 June 2019 with the Identifier: NCT03982888 .

Analysis of unexpected disruptive effects of contingent food reinforcement on automatically maintained self-injury

Research has identified treatment-responsive and treatment-resistant subtypes of automatically maintained self-injurious behavior (ASIB) based on patterns of responding in the functional analysis (FA) reflecting its sensitivity to disruption by alternative reinforcement, and the presence of self-restraint. Rooker et al. (2019) unexpectedly observed reductions in treatment-resistant self-injury while participants performed an operant task. The current study further examined this in nine participants with treatment-resistant ASIB in an example of discovery-based research. An operant task engendering high rates of responding (switch-pressing) to produce food, reduced self-injury across all participants, and eliminated self-injury for some participants under certain schedules. Although this finding must be replicated and evaluated over longer time periods, it provides some evidence that alternative reinforcement can disrupt self-injury in these treatment-resistant subtypes under some conditions. Reinforcer and response competition are discussed as possible mechanisms underlying these disruptive effects, as are the potential implications of these findings regarding treatment.

A Neurobehavioral Continuum of Care for Individuals with Intellectual and Developmental Disabilities with Severe Problem Behavior

The Neurobehavioral Programs at Kennedy Krieger Institute constitute a comprehensive continuum of care designed to serve individuals with intellectual and developmental disabilities with co-occurring problem behavior. This continuum includes inpatient, intensive outpatient, outpatient, consultation, and follow-up services. The mission of these programs is to fully integrate patient care, research, training, and advocacy to achieve the best possible outcomes with patients, and to benefit the broader community of individuals with severe behavioral dysfunction. The primary treatment approach utilized across all programs is applied behavior analysis, however the inpatient unit also provides fully integrated interdisciplinary care. Factors driving the development and expansion of these programs are described, as are the processes and systems by which the mission objectives are achieved.

A retrospective analysis of stereotypy: Applicability of the behavioral subtyping model

Recent research on automatically reinforced self-injurious behavior (ASIB) has identified specific patterns of responding in functional analyses that correlate with intervention efficacy (Hagopian et al., 2015; Hagopian et al., 2017). Whereas research by Hagopian et al. (2015, 2017) points to an important development in the assessment and treatment of ASIB, it is unclear if the applicability extends to automatically reinforced noninjurious behaviors, including stereotypy. Therefore, the current study replicated the methods of Hagopian et al. (2017), extending this research to published cases of stereotypy and related behavior. The behavioral subtype for each case was identified, and where applicable, the subtype was compared to intervention outcome data. The categorization of data sets as either Subtype 1 or Subtype 2 did not correspond with specific treatment outcomes. Unlike the results of Hagopian et al. (2015, 2017), reinforcement-based interventions were not more likely to be effective for Subtype 1 stereotypy than for Subtype 2 stereotypy.

Functional Analysis and Successful Treatment of a Captive Rhesus Macaque's Disruptive Behavior

Functional analysis (FA) is a method developed and used by behavior analysts in human clinical settings to identify possible environmental variables that reinforce undesired behavior. FA is increasingly being applied to better understand the behavior of nonhuman animals. When training monkeys in a room with others, disruptive behavior displayed by neighboring monkeys can impede training progress. In the present study, a FA identified possible reinforcers of disruptive behavior (loud shaking of a toy) exhibited frequently (24% duration pre-treatment) by a rhesus macaque (Macaca mulatta) during in-room training sessions. The functional analysis identified that contingent delivery of foods was maintaining the disruptive behavior, with a mean percent duration of 57% in this condition. The implementation of a function-based treatment consisting of continuous access to a preferred food during in-room training sessions successfully decreased disruptive behavior by over 90% as measured during 15 subsequent sessions. This study advances the current literature applying functional analysis to nonhuman primates as a means of determining the reinforcers maintaining aberrant or undesirable behavior and applying effective treatments based on understanding this function.

Why Intellectual Disability Poses a Challenge to the Received View of Capacity and a Potential Response

While copious quantities of ink have been spilled on the topic of autonomy in the context of health care, little has been written about autonomy in relation to intellectual disability. After presenting the received account of capacity, we argue that it cannot account for the moral permissibility of limiting an individual with intellectual disability's access to diet soda. In cases of preventative medicine and intellectual disability, the philosophical motivation for the received account of capacity is incompatible with the actions it recommends. We consider and reject several potential solutions; then, drawing on applied behavior analysis and the phenomenon of automatic reinforcement, we propose our own solution. The article concludes by considering the broader implications of our discussion.

Behavioral Assessment and Treatment of Aerophagia

Aerophagia is characterized by excessive air swallowing and can have serious negative effects on one’s health. We present the assessment and treatment of a 16-year-old girl, Khloe, with developmental disabilities and aerophagia. The initial assessment indicated that aerophagia occurred primarily to access attention in a divided attention context; however, our function-based treatment did not result in a clinically significant reduction in problem behavior. We then conducted a second assessment that indicated that Khloe’s aerophagia indeed occurred primarily in a divided attention context, but that it persisted independent of social consequences. We concluded that the divided attention context served as a motivating variable for aerophagia. Our second treatment consisted of differential reinforcement of other behavior, noncontingent access to competing stimuli, and graduated exposure to contextual variables (i.e., people and divided attention) that occasioned aerophagia. The treatment was successful in reducing rates of aerophagia. We discuss implications for assessment and treatment, as well as recommendations for clinicians and students.

Procedures for determining and then modifying the extinction component of multiple schedules for destructive behavior

As a component of reinforcer schedule thinning following functional communication training, multiple schedules of reinforcement produce desirable rates and patterns of communication responses as an alternative response to destructive behavior. However, reinforcement schedule thinning is a gradual process that can take many sessions to obtain therapeutic goals. The desired outcome is that manding occurs only during signaled intervals of reinforcement with a sufficiently lean terminal schedule of reinforcement availability and low rates of destructive behavior. The purposes of this study were to (a) evaluate an assessment for informing the initial duration of extinction for alternative responding, (b) evaluate the utility of competing stimuli during extinction for alternative responding, and (c) assess a method for fading the availability of competing stimuli. With these procedures, all 4 participants experienced terminal schedules of reinforcement with rapid, robust reductions in destructive behavior soon after baseline. We discuss the implications and directions for future research.

Effects of Demand Complexity on Echolalia in Students With Autism

Echolalia is a linguistic phenomenon common in individuals with autism spectrum disorder. We examined the relationship between demand complexity and immediate echolalia in four students with an autism diagnosis in a university-based academic setting. Mastered and novel antecedent verbal demands that required an intraverbal response were systematically alternated using a multielement design to test whether participants' immediate echolalia was socially mediated. Results showed that immediate echolalia was more likely to occur during complex novel intraverbal tasks than in any other condition. Implications for function-based treatment strategies are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-020-00535-7.

Machine Learning for Supplementing Behavioral Assessment

The Questions About Behavioral Function (QABF) has a high degree of convergent validity, but there is still a lack of agreement between the results of the assessment and the results of experimental function analysis. Machine learning (ML) may improve the validity of assessments by using data to build a mathematical model for more accurate predictions. We used published QABF and subsequent functional analyses to train ML models to identify the function of behavior. With ML models, predictions can be made from indirect assessment results based on learning from results of past experimental functional analyses. In Experiment 1, we compared the results of five algorithms to the QABF criteria using a leave-one-out cross-validation approach. All five outperformed the QABF assessment on multilabel accuracy (i.e., percentage of predictions with the presence or absence of each function indicated correctly), but false negatives remained an issue. In Experiment 2, we augmented the data with 1,000 artificial samples to train and test an artificial neural network. The artificial network outperformed other models on all measures of accuracy. The results indicated that ML could be used to inform conditions that should be present in a functional analysis. Therefore, this study represents a proof-of-concept for the application of machine learning to functional assessment.

Neurodevelopmental atypisms in the context of joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes

Joint hypermobility (JHM), defined as an increased range of joint motion, is a frequent somatic trait in the general population but also the hallmark of many of the hereditary disorders of connective tissue. Ehlers-Danlos syndromes (EDS) belong to this group of diseases and are characterized by tissue fragility, skin abnormalities, and JHM. Between JHM and EDS, there are the so-called hypermobility spectrum disorders (HSD), which is an umbrella term referring to people with symptomatic JHM who do not fulfill criteria for a syndromic connective tissue disorder such as EDS. Among the variety of clinical correlates of JHM/HSD/EDS, neurodevelopmental atypisms are common although often not screened for and identified in the clinical setting. This article reviews the pertinent literature concerning neurodevelopmental conditions for which there is some evidence of an association with JHM/HSD/EDS. These include hyperactivity and attention deficit, learning, communication, and motor problems including tic disorders such as Tourette syndrome and autism spectrum disorders. Underlying mechanism hypotheses for such interconnections are also reviewed. The coexistence of connective tissue-altered conditions and neurodevelopmental atypisms increases disability in patients from an early age. Thus, increased awareness among clinicians and researchers is necessary to promote assessment, diagnosis, and develop management strategies to meet the specific needs of those affected.

Accuracy of caregiver identification of demands for children with escape-maintained challenging behavior

BACKGROUND

Although stimulus preference assessments are widely used to identify reinforcers and to inform positive reinforcement conditions in a functional analysis (FA), direct assessments of potential negative reinforcers are not as commonly employed. Demands are often selected from caregiver report alone.

AIMS

The purpose of the current study is to (a) replicate the Demand Assessment for Individuals with Severe Disabilities (DAISD) indirect assessment interview for caregivers to identify demands that may evoke challenging behavior; (b), compare the correspondence of the DAISD in relation to an established direct assessment, the demand latency assessment (DLA); and (c) evaluate if the demands that caregivers identify as the most aversive are more likely to evoke challenging behavior and identify an escape function in an FA than those demands caregivers identify as least aversive and replicate validation of the DLA.

METHODS AND PROCEDURES

This study evaluated caregiver accuracy at identifying demands most likely to evoke escape-maintained challenging behavior for four children with developmental disabilities. Caregiver-informed aversiveness hierarchies from the DAISD were compared to child-informed aversiveness hierarchies from the DLA. Functional analyses included separate escape conditions with DAISD and DLA most and least aversive demands.

OUTCOMES AND RESULTS

Although all caregivers identified at least eight demands, caregivers' accuracy with demand aversiveness was variable as indicated by (a) a false negative FA outcome for one of four participants with the caregiver-nominated most aversive demand; (b) higher rates of challenging behavior with the caregiver-nominated least aversive demand than most aversive for three of four participants; and (c) lack of a strong positive rank order correlation between caregiver- and child-hierarchies for all participants (range, -0.76 to .48). Compliance was not a strong predictive variable of challenging behavior with either assessment.

CONCLUSIONS AND IMPLICATIONS

Results indicate that the DAISD interview is useful at identifying multiple demands presented in the natural environment, but should be followed up with direct assessment to determine demand aversiveness rather than used for caregivers to rank demand aversiveness.

Training behavior analysts to conduct functional analyses using a remote group behavioral skills training package

Behavioral skills training (BST) is a well-established procedure used to train individuals how to perform a variety of complex skills. Previous research has used BST to train parents, teachers, and clinicians how to conduct a variety of clinical procedures, including functional analysis of problem behavior. Although this procedure has been demonstrated to be very effective, it can be time consuming and resource intensive. In the present study, 13 behavior analysts were trained to conduct functional analyses of problem behavior. All participants were employees of a multistate early intervention clinic. This staff training was conducted fully remotely, and trainers acted as child role-play partners. Participants experienced baseline, an instruction/discussion component, a post-instruction probe, group BST, and a post-BST probe. For 5 participants, in-situ probes were also conducted. All participants achieved mastery and in-situ errors were low.

Further comparison of isolated and synthesized contingencies in functional analyses

Recent research on functional analyses (FAs) has examined the extent to which problem behavior is maintained by single (isolated) or combined (synthesized) reinforcement contingencies. Outcomes of these analyses might differ depending on the sources of information that are used to inform contingencies included in test conditions. The purpose of the current study was to compare the outcomes of isolated FAs and synthesized contingency analyses (SCAs) with 3 participants. Conditions in both analyses were informed by interviews and both unstructured and structured observations. Problem behavior for all 3 participants was maintained by 1 or 2 isolated reinforcers. Results suggested false-positive SCA results for 2 participants. For 1 participant, a second isolated reinforcer was identified following the SCA, indicating the induction of a novel function. Implications for the use of isolated and synthesized consequences are discussed, as well as the predictive validity of the assessments that are used to inform them.

An evaluation of trial-based functional analyses of inappropriate mealtime behavior

Functional analyses allow clinicians to develop treatment targeting the variables maintaining a child's inappropriate mealtime behavior (Bachmeyer et al., 2019). Extended functional analyses can be inefficient, potentially delaying the onset of treatment. Researchers have suggested a trial-based functional analysis can increase assessment efficiency (Saini, Fisher, et al., 2019). This study compared trial-based functional analyses to extended functional analyses to determine the variables maintaining inappropriate mealtime behavior. We compared the efficiency and acceptability and evaluated treatments informed by the analyses. Exact correspondence between analyses was low (29%); however, most treatments indicated by the trial-based functional analyses (80%) resulted in improvements in the child's target behavior. The trial-based functional analysis required 71% less time than the extended functional analysis, and caregivers found analyses equally acceptable. Future researchers should continue refining trial-based functional analysis procedures to provide an efficient assessment that leads to efficacious treatment.

On the Efficacy of and Preference for Signaling Extinction in a Multiple Schedule

Previous basic research has shown that signaling the extinction component of a compound schedule can be aversive and nonpreferred. However, such discriminative stimuli are common when thinning schedules of reinforcement in practice, and they provide several advantages to clinicians. A limitation of previous applied studies on different arrangements of discriminative stimuli is that researchers have used identical stimuli to signal the availability of reinforcement across conditions that do and do not signal extinction, often doubling exposure to the stimulus signaling the availability of reinforcement. The present experiments corrected this limitation by comparing multiple-schedule arrangements that do and do not signal extinction when unique stimuli signal each component across conditions. Results from three participants indicated that both multiple-schedule arrangements were similarly efficacious when teaching the successive discrimination. However, response patterns differed when testing under a concurrent-operants arrangement, suggesting different patterns of preference across various multiple-schedule arrangements.

Prevalence of relapse of automatically maintained behavior resulting from context changes

Increases in behavior due to context changes are common and are known as instances of renewal. Clinically relevant examples from the literature highlighting renewal often include socially mediated problem behaviors. This report retrospectively analyzed data during context changes for individuals who engaged in problem behavior maintained by automatic reinforcement, to evaluate the prevalence of relapse. Problem behavior reemerged during changes both in the person implementing treatment (e.g., introducing a caregiver; 36%) and in the setting (e.g., introducing treatment in the home; 26%). Most prevalence studies report greatest relapse immediately following context changes but the highest level of relapse was observed after 5 sessions following person changes and no systematic pattern with setting changes. These patterns of relapse likely reflect differences in the function of settings and people relative to automatically reinforced behavior in the present study. Implications of relapse for treatments of problem behavior maintained by automatic reinforcement are discussed.

Assessing and Treating Anxiety in Individuals with Autism

Anxiety is a cluster of responses that can involve both operant and respondent behavior, which can be both public and/or private in nature, and occurs when an upcoming aversive stimulus is signaled. Despite the reported high comorbidity of autism and anxiety, there has been very limited research on how to directly assess and treat anxiety, especially with individuals who have limited communication skills. In Study 1, anxiety was assessed in five individuals with autism, ranging in age from 10 to 19 years old. Anxiety was assessed by measuring behavior during (1) a baseline (with no putative anxiety-provoking stimuli present), (2) signals for an upcoming aversive event, and (3) exposure to that aversive event. Anxiety presented in several different ways, as both conditioned activation and suppression, and both with and without problem behavior during the aversive event. In Study 2, individualized treatments involving differential reinforcement of alternative responses and stimulus fading were used to successfully reduce anxious responding in all four participants who displayed anxiety. These studies demonstrated a potentially useful means of assessing anxiety in individuals with autism which may not only help to measure anxious behavior and identify anxiety-provoking events, but may also lead to effective treatment.

Efficiency and preference for alternative activities during schedule thinning with functional communication training

Functional communication training is an effective treatment for decreasing socially reinforced destructive behavior (Carr & Durand, 1985). Clinicians frequently use multiple schedules to thin the reinforcement schedule (Hanley et al., 2001). Individuals are often taught to wait for functional reinforcers without alternative programmed stimuli. However, concurrently available items and activities are often accessible in the natural environment. In this study, we taught 4 participants a functional communication response to access functional reinforcers. We implemented a multiple schedule during schedule thinning, comparing a control condition (nothing available during S^Δ intervals) to separate conditions with items/activities (moderately preferred tangible items, attention, demands) noncontingently available during S^Δ intervals. After reaching the terminal schedule in one condition, therapists assessed participant preference across S^Δ conditions. For all participants, the terminal schedule was reached with alternative items and activities, and participant preference corresponded with the most efficient schedule thinning condition. Therapists also indicated preference for alternative items/activities.

Physician Perspectives on Severe Behavior and Restraint Use in a Hospital Setting for Patients with Autism Spectrum Disorder

Hospitals, with many features that can evoke severe behavior in patients with autism spectrum disorder (ASD), often use restraint as a behavior management strategy. Prior research on restraint in patients with ASD has primarily focused on children or specific departments. Twenty-five physicians and medical trainees from an urban teaching hospital participated in discussions about experiences managing severe behavior in patients with ASD across the lifespan. Twenty themes emerged from thematic analysis of participant transcripts. The five most salient themes included: lack of procedural knowledge with restraint implemented by other hospital professionals; alternative strategies to manage severe behavior; negative perceptions of restraint; helpful role of caregivers; and limited experience treating patients with ASD, and critical need for training in function-based management.

Increasing Access and Quality of Behavior-Analytic Services for the Latinx Population

Latinxs are the largest minority group in the United States, making up approximately 18% of the total population. Although there is a critical need for the behavioral health care system, including behavior analysts, to provide services to support the needs of the Latinx community, access to quality behavioral and mental health services continues to be lacking for the Black, Indigenous, and people of color populations. This article highlights some of the cultural and language factors that should be considered by behavior-analytic providers who have a shared responsibility to make culturally and linguistically appropriate services available to this population. Additionally, recommendations for systemic action across service providers, professional organizations, behavior-analytic training programs, and researchers are suggested to address these barriers. Recommendations for bringing about this systemic change are suggested across three domains: (a) increasing diversity in the behavior-analytic workforce, (b) enhancing training in cultural- and language-related issues, and (c) conducting research on cultural and language adaptations to behavior-analytic evidence-based treatments.

Functional analysis and treatment of aggression exhibited by cats toward humans during petting

Human-directed aggression is a common problem that can often result in rehoming or relinquishing the cat as well as injuries and infections for the human. Functional analyses (FAs) have been used to determine the cause of problem behavior by human and nonhuman animals, and treatments developed based on FA results have been proven effective. This study applied this methodology to assess and treat human-directed aggression exhibited by 3 cats during petting. Results suggested that aggression during petting for all 3 cats was maintained by social-negative reinforcement (escape from petting), and differential reinforcement of other behavior plus within-session stimulus fading (escape contingent on the absence of aggression following a specified number of pets that systematically increased as aggression remained low) was effective in decreasing aggression for all 3 cats. All 3 cats were available for adoption through a rescue organization during the study, and all of the cats were adopted after completing treatment.

Exploring Quality in the Applied Behavior Analysis Service Delivery Industry

As the applied behavior analysis (ABA) service industry (“the industry”) continues to rapidly expand, it faces three major problems. First, ABA service delivery quality (ASDQ) is undefined in ABA research and the industry. Second, we cannot rely exclusively on professional organizations that oversee licensure and certification to control ABA service delivery quality because they do not have control over the relevant contingencies. Third, without objective indicators of ABA service delivery quality, it is difficult for ABA organizations to distinguish the quality of their services from competitors. In this article, first we explain the need for more critical discussion of ASDQ in the field at large, briefly describe a sample of common views of quality in ABA research and the industry, and identify some of their limitations. Then we define ASDQ and present a cohesive theoretical framework which brings ASDQ within the scope of our science so that we might take a more empirical approach to understanding and strengthening ASDQ. Next, we explain how organizations can use culturo-behavioral science to understand their organization’s cultural practices in terms of cultural selection and use the evidence-based practice of ABA at the organizational level to evaluate the extent to which methods targeting change initiatives result in high ASDQ. Lastly, in a call to action we provide ABA service delivery organizations with six steps they can take now to pursue high ASDQ by applying concepts from culturo-behavioral science and total quality management.

Shining a Light on the Challenging Behaviors of Adolescents with Comorbid Diagnoses: Use of Pictorial Concurrent Operant Preference Assessment

Currently, there are no published studies that have used the concurrent operant preference assessment procedure to identify functions of challenging behaviors displayed by individuals with comorbid diagnoses. Four participants (aged 11–16 years) with comorbid diagnoses who displayed multiple challenging behaviors were referred to this study. We modified the standard concurrent operant preference assessment and used the new modified version, the pictorial concurrent operant preference assessment, to identify the functions of the challenging behaviors. Utilizing the triangulation mixed-methods design, we compared the indirect functional behavioral assessment (FBA) and the direct FBA with the pictorial concurrent operant preference assessment. The results obtained successfully demonstrated the concordance among these assessments in identifying the behavioral function for each participant. The results further showed that (1) the preferences served the same functional effects on both the challenging behaviors and the adaptive behaviors and (2) the pictorial concurrent operant preference assessment can be used independently to identify potential behavioral function and to specify the reinforcing potency of each behavioral function. The significance of the study results, limitations of this study, and directions for future research and clinical practice are discussed.