Meta-analysis of noncontingent reinforcement effects on problem behavior

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

OBJECTIVE

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period.

STUDY DESIGN

In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors.

RESULTS

Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall.

CONCLUSIONS

Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Additional Comments on the Use of Contingent Electric Skin Shock

Prior to the ABAI member vote to decide between two alternative position statements on contingent electric skin shock (CESS), the current authors helped draft a consensus statement supporting the abolition of CESS. In this commentary, we provide additional, supporting information for that consensus statement by (1) showing that the extant literature does not support the supposition that CESS is more efficacious than less-intrusive interventions; (2) providing data showing that implementing interventions that are less intrusive than CESS does not lead to overreliance on the use of physical or mechanical restraint to control destructive behavior; and (3) discussing the ethical and public relations issues that arise when behavior analysts use painful skin shock to reduce destructive behavior in persons with autism or intellectual disability.

Deep brain stimulation for autism spectrum disorder

Deep brain stimulation (DBS) is a medical treatment that aims to obtain therapeutic effects by applying chronic electrical impulses in specific brain structures and neurological circuits. Over the years, DBS has been studied for the treatment of many psychiatric disorders. Scientific research on the use of DBS in people with autism has focused this interest mainly on treatment-resistant obsessive-compulsive disorder, drug-resistant epilepsy, self-injurious behaviors (SIB), and aggressive behaviors toward the self. Autism spectrum disorder (ASD) includes a group of developmental disabilities characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills and the presence of repetitive and stereotyped behaviors as well as restricted interests. People with autism often have numerous medical and psychiatric comorbidities that worsen the quality of life of patients and their caregivers. Obsessive-compulsive symptoms can be found in up to 81.3% of people with autism. They are often severe, refractory to treatment, and particularly difficult to treat. SIB has a high prevalence in severely retarded individuals and is often associated with autism. Drug treatment of both autism and SIB presents a therapeutic challenge. To describe the current state of the art regarding the efficacy of DBS in people with ASD, a literature search was conducted for relevant studies using the PubMed database. Thirteen studies have been considered in this paper. Up to date, DBS has been used for the stimulation of the nucleus accumbens, globus pallidus internus, anterior limb of the internal capsule, ventral anterior limb of the internal capsule, basolateral amygdala, ventral capsule and ventral striatum, medial forebrain bundle, and posterior hypothalamus. In the total sample of 16 patients, 4 were adolescents, and 12 were adults. All patients had symptoms resistant to multiple drug therapy. Many patients taken into consideration by the studies showed clinical improvements as evidenced by the scores of the psychopathological scales used. In some cases, clinical improvements have varied over time, which may require further investigation. Among the new therapeutic perspectives, DBS could be a valid option. However, further, and more in-depth research is needed in this field.

A Multilevel Meta-analysis of Single-Case Research on Interventions for Internalizing Disorders in Children and Adolescents

The effectiveness of interventions for internalizing disorders in children and adolescents was studied using a review and meta-analysis of published single-case research. Databases and other resources were searched for quantitative single-case studies in youth with anxiety, depressive, and posttraumatic stress disorders. Raw data from individual cases were aggregated and analyzed by means of multilevel meta-analytic models. Outcome variables were symptom severity assessed across baseline and treatment phases of the studies, and diagnostic status at post- and follow-up treatment. Single-case studies were rated for quality. We identified 71 studies including 321 cases (M^age = 10.66 years; 55% female). The mean quality of the studies was rated as below average, although there were considerable differences between the studies. Overall, positive within-person changes during the treatment phase in comparison to the baseline phase were found. In addition, positive changes in the diagnostic status were observed at post- and follow-up treatment. Yet high variability in treatment effects was found between cases and studies. This meta-analysis harvests the knowledge from published single-case research in youth-internalizing disorders and illustrates how within-person information from single-case studies can be summarized to explore the generalizability of the results from this type of research. The results emphasize the importance of keeping account of individual variability in providing and investigating youth interventions.

Barriers to Accessing Effective Treatments for Destructive Behavior

The field of applied behavior analysis has developed and refined a comprehensive methodology for the assessment and successful treatment of destructive behavior: An individualized approach emphasizes (a) function of responding (or its cause) over its form; (b) objective and reliable measurement of behavior; (c) systematic procedures and their application; (d) rigorous, single-case experimental designs; and (e) determinations of successful intervention judged by improvements in the same individual's performance. Outcomes of this approach are often dramatic and reliably surpass those obtained by alternative means. However, significant barriers limit the accessibility of this proven therapy. Too few intensive behavioral intervention units, diagnosis- and age-dependent insurance authorization and reimbursement practices, long waitlists and slow approval processes, and the possibility of treatment relapse represent a few such barriers. This article describes these barriers and suggests some potential solutions.

Behavioural and cognitive-behavioural interventions for outwardly directed aggressive behaviour in people with intellectual disabilities

BACKGROUND

Outwardly directed aggressive behaviour in people with intellectual disabilities is a significant issue that may lead to poor quality of life, social exclusion and inpatient psychiatric admissions. Cognitive and behavioural approaches have been developed to manage aggressive behaviour but the effectiveness of these interventions on reducing aggressive behaviour and other outcomes are unclear. This is the third update of this review and adds nine new studies, resulting in a total of 15 studies in this review.

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly directed aggressive behaviour compared to usual care, wait-list controls or no treatment in people with intellectual disability. We also evaluated enhanced interventions compared to non-enhanced interventions.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was March 2022. We revised the search terms to include positive behaviour support (PBS).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of children and adults with intellectual disability of any duration, setting and any eligible comparator.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were change in 1. aggressive behaviour, 2. ability to control anger, and 3. adaptive functioning, and 4.

ADVERSE EFFECTS

Our secondary outcomes were change in 5. mental state, 6. medication, 7. care needs and 8. quality of life, and 9. frequency of service utilisation and 10. user satisfaction data. We used GRADE to assess certainty of evidence for each outcome. We expressed treatment effects as mean differences (MD) or odds ratios (OR), with 95% confidence intervals (CI). Where possible, we pooled data using a fixed-effect model.

MAIN RESULTS

This updated version comprises nine new studies giving 15 included studies and 921 participants. The update also adds new interventions including parent training (two studies), mindfulness-based positive behaviour support (MBPBS) (two studies), reciprocal imitation training (RIT; one study) and dialectical behavioural therapy (DBT; one study). It also adds two new studies on PBS. Most studies were based in the community (14 studies), and one was in an inpatient forensic service. Eleven studies involved adults only. The remaining studies involved children (one study), children and adolescents (one study), adolescents (one study), and adolescents and adults (one study). One study included boys with fragile X syndrome. Six studies were conducted in the UK, seven in the USA, one in Canada and one in Germany. Only five studies described sources of funding. Four studies compared anger management based on cognitive behaviour therapy to a wait-list or no treatment control group (n = 263); two studies compared PBS with treatment as usual (TAU) (n = 308); two studies compared carer training on mindfulness and PBS with PBS only (n = 128); two studies involving parent training on behavioural approaches compared to wait-list control or TAU (n = 99); one study of mindfulness to a wait-list control (n = 34); one study of adapted dialectal behavioural therapy compared to wait-list control (n = 21); one study of RIT compared to an active control (n = 20) and one study of modified relaxation compared to an active control group (n = 12). There was moderate-certainty evidence that anger management may improve severity of aggressive behaviour post-treatment (MD -3.50, 95% CI -6.21 to -0.79; P = 0.01; 1 study, 158 participants); very low-certainty evidence that it might improve self-reported ability to control anger (MD -8.38, 95% CI -14.05 to -2.71; P = 0.004, I2 = 2%; 3 studies, 212 participants), adaptive functioning (MD -21.73, 95% CI -36.44 to -7.02; P = 0.004; 1 study, 28 participants) and psychiatric symptoms (MD -0.48, 95% CI -0.79 to -0.17; P = 0.002; 1 study, 28 participants) post-treatment; and very low-certainty evidence that it does not improve quality of life post-treatment (MD -5.60, 95% CI -18.11 to 6.91; P = 0.38; 1 study, 129 participants) or reduce service utilisation and costs at 10 months (MD 102.99 British pounds, 95% CI -117.16 to 323.14; P = 0.36; 1 study, 133 participants). There was moderate-certainty evidence that PBS may reduce aggressive behaviour post-treatment (MD -7.78, 95% CI -15.23 to -0.32; P = 0.04, I2 = 0%; 2 studies, 275 participants) and low-certainty evidence that it probably does not reduce aggressive behaviour at 12 months (MD -5.20, 95% CI -13.27 to 2.87; P = 0.21; 1 study, 225 participants). There was low-certainty evidence that PBS does not improve mental state post-treatment (OR 1.44, 95% CI 0.83 to 2.49; P = 1.21; 1 study, 214 participants) and very low-certainty evidence that it might not reduce service utilisation at 12 months (MD -448.00 British pounds, 95% CI -1660.83 to 764.83; P = 0.47; 1 study, 225 participants). There was very low-certainty evidence that mindfulness may reduce incidents of physical aggression (MD -2.80, 95% CI -4.37 to -1.23; P < 0.001; 1 study; 34 participants) and low-certainty evidence that MBPBS may reduce incidents of aggression post-treatment (MD -10.27, 95% CI -14.86 to -5.67; P < 0.001, I2 = 87%; 2 studies, 128 participants). Reasons for downgrading the certainty of evidence were risk of bias (particularly selection and performance bias); imprecision (results from single, often small studies, wide CIs, and CIs crossing the null effect); and inconsistency (statistical heterogeneity).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that cognitive-behavioural approaches such as anger management and PBS may reduce outwardly directed aggressive behaviour in the short term but there is less certainty about the evidence in the medium and long term, particularly in relation to other outcomes such as quality of life. There is some evidence to suggest that combining more than one intervention may have cumulative benefits. Most studies were small and there is a need for larger, robust randomised controlled trials, particularly for interventions where the certainty of evidence is very low. More trials are needed that focus on children and whether psychological interventions lead to reductions in the use of psychotropic medications.

Basic and applied research on extinction bursts

Discontinuation of the contingency between a response and its reinforcer sometimes produces a temporary increase in the response before its rate decreases, a phenomenon called the extinction burst. Prior clinical and basic studies on the prevalence of the extinction burst provide highly disparate estimates. Existing theories on the extinction burst fail to account for the dynamic nature of this phenomenon, and the basic behavioral processes that control response bursting remain poorly understood. In this paper, we first review the basic and applied literature on the extinction burst. We then describe a recent refinement of the concatenated matching law called the temporally weighted matching law that appears to resolve the above-mentioned issues regarding the extinction burst. We present illustrative translational data based conceptually on the model. Finally, we discuss specific recommendations derived from the temporally weighted matching law regarding procedures clinicians could implement to potentially mitigate or prevent extinction bursts.

Bridging the gap between laboratory and applied research on response-independent schedules

In 1948, Skinner described the behavior of pigeons under response-independent schedules as "superstitious," and proposed that the responses were reinforced by contiguous, adventitious food deliveries. Subsequently, response-independent schedules have been of interest to both basic and applied researchers, first to understand the mechanisms involved, and later, as "noncontingent reinforcement" (NCR) to reduce undesirable behavior. However, the potential superstitious effects produced by these schedules have been challenged, with some researchers arguing that antecedent variables play a significant role. This paper examines the evidence for adventitious reinforcement from both laboratory and applied research, the results of which suggest that antecedent, nonoperant functions may be important in fully understanding the effects of NCR. We propose an applied-basic research synthesis, in which attention to potential nonoperant functions could provide a more complete understanding of response-independent schedules. We conclude with a summary of the applied implications of the nonoperant functions of NCR schedules.

Interpreting treatment effect size from single case experimental design data: a preliminary analysis of differential effects of treatments designed to increase or decrease behaviour

BACKGROUND

Estimates of treatment effect size from single case experimental design (SCED) data may be impacted by the direction for treatment effects (i.e. ascending or descending slope for the dependent variable). Estimating effect sizes for treatments designed to decrease behaviour are potentially more restricted because the intended direction for treatment is zero (i.e. an absolute basal). Conversely, effect sizes for interventions that increase behaviour are less restricted due to a relatively unconstrained ceiling from a pure measurement standpoint (i.e. no absolute ceiling). That is, treatments that increase behaviour have a broader range of possible effect size values as the ceiling is only limited by demand characteristics and the learners' skills and motivation to exhibit the behaviour.

METHOD

The current study represents a preliminary analysis of the mean and range of SCED effect sizes for treatments designed to either increase or decrease target behaviour. A within-case Cohen's d measure that was developed for SCED data was used to estimate treatment effect sizes.

RESULTS

Results indicated that the mean and range of effect size values for treatments that increased behaviour were significantly greater compared with treatments that decreased behaviour.

CONCLUSIONS

Results are discussed in terms of developing standards, or best practices, specific to interpreting effect size values and meeting quality control requirements for inclusion of the data set in future SCED meta-analytic studies estimating treatment effect size. Specifically, preliminary results suggest that benchmarks for low, medium and high SCED effect size values need to be developed separately for treatments that increase or decrease levels of the dependent variable.

Parents Are People Too: Implementing Empirically Based Strategies During Daily Interactions

The outcomes of the COVID-19 pandemic have resulted in decision-making related to in-person versus remote behavior-analytic service delivery. For those service providers who shifted from delivering in-person therapy to remote consultation, parents have presumably, at least at times, assumed a role similar to a registered behavior technician (RBT). We suggest that behavior analysts recommend two empirically based strategies to parents that they could incorporate into their daily lives during service disruptions: environmental enrichment and differential reinforcement of alternative behavior. We provide examples of naturally occurring contexts during which parents could integrate these procedures: (1) self-care or daily living activities, (2) physical activity, and (3) preferred learning activities. We support selecting these strategies and their application during exemplar contexts under the premise that they do not result in additional time expenditure, afford parents opportunities to complete essential (household, work-related, or personal) tasks, and still result in therapeutic gains.

Reducing Stereotypies for a Student With Deafblindness

Introduction: Little is known about the effects of specific behavioral strategies to reduce stereotypy and self-injury for learners with sensory impairments and additional disabilities. Method: A single-subject, multi-treatment withdrawal design was used to test the isolated and combined effects of physical prompting to engage in object manipulation of preferred items, contingent reinforcement, and response blocking on target hand-related stereotypy and object manipulation for one 9-year-old boy with deafblindness and additional disabilities. Results: A functional relation was observed to show that hand-related stereotypy decreased due to prompting and reinforcement of object manipulation. Adding response blocking had inconsistent positive effects on stereotypy, and a functional relation was not observed. Prompting alone did not appear to increase object manipulation until contingent reinforcement was added, and response blocking did not appear to have an additive effect to increase object manipulation. Discussion: Results contradict findings of the replicated study and indicate need for further research, including research carried out in natural environments. Implications for Practitioners: Practitioners can use this research to justify the application of differential reinforcement of incompatible behavior using functional activities that result in meaningful reinforcement for students.

Optimal number of baseline sessions before changing phases within single-case experimental designs

Recommendations vary considerably for the minimum or optimal number of baseline sessions to conduct within single-case experimental design clinical analyses or research studies. We examined the optimal number of baseline sessions that produced minimal bias. First, we examined the relation between the number of baseline sessions and the degree of bias in calculating estimates of treatment effect size. As the number of baseline sessions increased, the bias in effect size estimates decreased, r = -0.36, p < 0.001. s, we examined what would be the minimum number of baseline sessions associated with varying levels of bias. Bias of approximately ten percent was associated with four to five baseline sessions. Bias of about five percent was associated with six to seven baseline sessions. Third, we examined the relation between standard deviation and varying levels of bias. As the number of baseline sessions increases, the standard deviation for the phase decreased, r = -0.89, p < 0.001. Fourth, we examined what value of standard deviation in the baseline phase was associated with equal to or more than five versus ten percent bias. When considering five or ten percent bias, the optimal level of standard deviation was 0.59 or less.

Meta-analyses and effect sizes in applied behavior analysis: A review and discussion

For more than four decades, researchers have used meta-analyses to synthesize data from multiple experimental studies often to draw conclusions that are not supported by individual studies. More recently, single-case experimental design (SCED) researchers have adopted meta-analysis techniques to answer research questions with data gleaned from SCED experiments. Meta-analyses enable researchers to answer questions regarding intervention efficacy, generality, and condition boundaries. Here we discuss meta-analysis techniques, the rationale for their adaptation with SCED studies, and current indices used to quantify the effect of SCED data in applied behavior analysis.

Examining the correlation between symptoms of obsessive compulsive disorder and autism spectrum disorder in a community-based sample of adults

We examined the association between obsessive compulsive disorder (OCD) and autism spectrum disorder (ASD) symptoms among a community-based sample of adults (n = 217) that completed an OCD and ASD screening instrument. Approximately 39% of the sample that met the ASD screener cutoff criteria also met the screener cutoff criteria for OCD. The correlation between overall OCD symptoms (i.e., obsessions and compulsions) and ASD symptoms was small but statistically significant for the entire sample of participants. Similarly, obsession and compulsion subscales showed almost identical results for correlation with ASD symptoms (i.e., small but statistically significant) for the entire sample. These results suggest that levels of compulsions and obsessions are equally correlated with ASD symptoms, and neither elevated compulsions nor obsessions differentially predicted the severity of ASD symptoms in a community-based sample of adults. However, when the analysis was restricted to only the participants that met screening criteria cutoff score for ASD, statistically significant results occurred with only elevated compulsions accurately predicting severity of ASD symptoms. These results suggest that compulsive behavior appears to be a good candidate for targeting intervention resources for individuals with characteristics of ASD given the mounting data suggesting that compulsions are more common than obsessions.

Functional Analysis and Noncontingent Reinforcement With Extinction in the Treatment of Perseverative Speech

The present study evaluated the effectiveness of noncontingent reinforcement combined with extinction in the treatment of perseverative speech of an 11-year-old boy with autism spectrum disorder. Following a functional analysis that suggested perseverative speech was maintained by attention, treatment was introduced and consisted of delivering attention on a fixed-time schedule and placing perseverative speech on extinction. The intervention resulted in a 98.5% decrease in perseverative speech, which maintained over a 28-month period.

Research Designs and Literature in the Field of Visual Impairment: What Informs Our Practices?

Introduction:

This descriptive study identified types of articles published and research designs used in targeted special education journals. Articles in visual impairment (i.e., low vision or blindness) published between 2012 and 2017 were examined to determine what literature informed the field during the 6-year period.

Method:

A total of 4,850 articles from 37 journals were reviewed. Initially, all articles published from 2012 through 2014 in targeted disability journals across categories related to the Individuals with Disabilities Education Act (IDEA) were reviewed. Subsequently, articles published from 2015 through 2017 in six key journals in visual impairment and deafblindness were reviewed. Each article in every volume of selected journals in the 6-year period was coded for type, research design, and target population.

Results:

The majority of research designs implemented with IDEA-eligible individuals with visual impairments were quantitative, specifically regression analyses, comparative, and single-case research designs (hereafter, single-case designs). Studies targeting non-IDEA eligible participants nearly doubled those targeting children with visual impairments. Less than one third of studies identified were intervention studies. Single-case designs were the most commonly used designs for intervention studies, and few reported effect size. The overall small number of studies with children with visual impairments indicate an increased need for experimental studies to identify evidence-based practices.

Discussion:

A greater number of empirical than nonempirical articles was identified in visual impairment, possibly indicating increased investigation of practices and interventions. This trend aligns with the current focus on using evidence and data to support practice and policy. Further research should evaluate quality of studies.

Implications for practitioners:

It is important to be familiar with the body of research informing the field of visual impairment to understand the evidence underlying its practices and policies. It is recommended that increased numbers of high-quality intervention studies be conducted to identify evidence-based practices.

The Relevance of Operant Behavior in Conceptualizing the Psychological Well-Being of Captive Animals

The term "psychological well-being" is used in reference to husbandry with animals in human care settings such as research, agriculture, and zoos. This article seeks to clarify and conceptualize the term based upon two approaches that draw from several bodies of literature: the experimental analysis of behavior, experimental psychology, animal welfare and husbandry, farm animal behavior, zoo husbandry, and ethology. One approach focuses on the presence of problem behavior such as stereotypies, depressive-like behavior, and aggression, and emphasizes the conditions under which aberrant behavior in animals under human care occurs. The second approach examines what might be considered wellness by emphasizing opportunities to engage with its environment, or the absence of such opportunities, even if problematic behavior is not exhibited. Here, access to an interactive environment is relatively limited so opportunities for operant (voluntary) behavior could be considered. Designing for operant behavior provides opportunities for variability in both behavior and outcomes. Operant behavior also provides control over the environment, a characteristic that has been a core assumption of well-being. The importance of interactions with one's environment is especially evident in observations that animals prefer opportunities to work for items necessary for sustenance, such as food, over having them delivered freely. These considerations raise the importance of operant behavior to psychological well-being, especially as benefits to animals under human care.

Behavioral Approaches to Assessment and Early Intervention for Severe Problem Behavior in Intellectual and Developmental Disabilities

This article summarizes the literature on prevalence and establishment of severe problem behavior in individuals with intellectual and developmental disabilities, empirical support for applied behavior analysis, and evidence-based behavioral assessment and treatment procedures. Early intervention and prevention approaches and the role of the pediatrician with regard to surveillance, early intervention, and coordination of care are discussed.

Treatment Burst Data Points and Single Case Design Studies: A Bayesian N-of-1 Analysis for Estimating Treatment Effect Size

Single-case experimental designs (SCED) evaluate treatment effects for each participant, but it is difficult to aggregate and quantify treatment effects across SCED participants receiving the same type of treatment. We applied Bayesian analytic procedures to SCED data aggregated across participants that have previously only been applied to large-N and group design studies of treatment effect sizes. For the current study, we defined transient elevated treatment data points as (1) above the range of the last five baseline sessions during the first three sessions of treatment (i.e., extinction burst); (2) within or above the range of baseline after the first three treatment sessions (i.e., recurrence burst); or (3) thinning phase data points above the last three prethinning treatment data points (i.e., thinning burst). Results indicated that the treatment effect sizes remained large regardless of controlling for transient elevated treatment data points. Finally, we examined the effects of reinforcer schedule thinning on estimates of treatment effect size. Results indicated a moderate negative impact of schedule thinning on treatment effect size with a 16% decrease in effect size. Recommendations for research and practice are provided, and the utility of using Bayesian analysis in single-case experimental designs is discussed.

Using e-learning modules to teach ongoing-visual inspection of functional analyses

Despite the effectiveness of function-based treatments, most clinicians do not conduct functional analyses (FA). The time required to conduct an FA is a major barrier preventing their use. One way to increase FA efficiency is to discontinue the analysis as soon as it has produced clear results. Saini et al. (2018) evaluated a structured procedure for ongoing-visual inspection of FAs and found that it produced accurate interpretations while averaging 40% fewer sessions than author interpretation. This study evaluated the efficacy of an e-learning module for training registered behavior technicians (RBTs) to implement ongoing visual inspection of FAs. Following training, 5 of the 6 participants showed mastery of ongoing visual inspection, and the final participant did so with the addition of supplemental procedures. We discuss how this training may increase the efficiency of FAs by teaching individuals who are less experienced in FA methodology when to seek supervision from a supervising Board Certified Behavior Analyst® (BCBA).

The Key Role of Purine Metabolism in the Folate-Dependent Phenotype of Autism Spectrum Disorders: An In Silico Analysis

Folate deficiency in the critical developmental period has been repeatedly associated with an increased risk of Autism spectrum disorders (ASD), but the key pathophysiological mechanism has not yet been identified. In this work, we focused on identifying genes whose defect has similar consequences to folate depletion in the metabolic network. Within the Flux Balance Analysis (FBA) framework, we developed a method of blocked metabolites that allowed us to define the metabolic consequences of various gene defects and folate depletion. We identified six genes (GART, PFAS, PPAT, PAICS, ATIC, and ADSL) whose blocking results in nearly the same effect in the metabolic network as folate depletion. All of these genes form the purine biosynthetic pathway. We found that, just like folate depletion, the blockade of any of the six genes mentioned above results in a blockage of purine metabolism. We hypothesize that this can lead to decreased adenosine triphosphate (ATP) and subsequently, an S-adenosyl methionine (SAM) pool in neurons in the case of rapid cell division. Based on our results, we consider the methylation defect to be a potential cause of ASD, due to the depletion of purine, and consequently S-adenosyl methionine (SAM), biosynthesis.

The consecutive controlled case series: Design, data-analytics, and reporting methods supporting the study of generality

Single-case experimental designs (SCEDs) have proven invaluable in research and practice because they are optimal for asking many experimental questions relevant to the analysis of behavior. The consecutive controlled case series (CCCS) is a type of study in which a SCED is employed in a series of consecutively encountered cases that undergo a common procedure or share a common characteristic. Additional design elements, data-analytic, and reporting methods enable researchers to ask experimental questions relevant to the study of generality of procedures and processes. The current paper discusses the CCCS methodologies, including the retrospective, prospective, and randomized CCCS. These methodologies can be applied to examine the generality of clinical procedures (including their general efficacy, the limits of their generality, and variables that may mediate generality); study the epidemiology and phenomenology of clinical problems; and compare the efficacy of 2 clinical procedures within a randomized controlled trial combining SCEDs with randomized group designs.

Toward Actionable Practice Parameters for "Dual Diagnosis": Principles of Assessment and Management for Co-Occurring Psychiatric and Intellectual/Developmental Disability

PURPOSE OF REVIEW

Although treatment algorithms and parameters for best practice are readily available for all major syndromes of psychiatric impairment, the occurrence of psychiatric syndromes in individuals with intellectual and developmental disability (IDD) invokes serious contextual challenges for interpretation of symptoms, diagnosis, and optimization of treatment, both for clinicians and for the service sectors in which care and support of individuals with IDD are delivered. Recognizing that there exist very few definitive resources for best practice under the circumstance of this form of "dual diagnosis," the Missouri Department of Mental Health convened an expert panel to conduct a focused review and synthesis of the relevant scientific literature from which to develop guidance in the form of decision support to clinicians. This article summarizes the findings for three of the most common and impairing clusters of psychiatric symptoms that co-occur with IDD-aggression, depression, and addictions.

RECENT FINDINGS

Individuals with IDD are at high risk for the development of psychiatric symptoms (PS), which often manifest uniquely in IDD and for which evidence for effective intervention is steadily accruing. Interventions that are commonly implemented in the IDD service sector (e.g., functional communication training and positive behavioral support planning) are capable of mitigating severe behavioral impairment, yet rarely invoked when dual diagnosis patients are seen in the psychiatric service sector. Conversely, state-of-the-art interventions for traumatic stress, pharmacotherapy, and psychotherapy have proven capable of improving behavioral impairments in IDD but are typically restricted to the psychiatric service sector, where there exist significant barriers to access for patients with IDD, including limitations imposed by diagnostic eligibility and practitioner experience. Bridging these gaps in knowledge and clinical capacity across the respective IDD and PS service sectors should be of very high priority in strategizing the care and support of IDD patients with serious co-occurring psychiatric conditions.

Evaluating preference for and reinforcing efficacy of a therapy dog to increase verbal statements

The purpose of this study was to evaluate preference for and reinforcing efficacy of a therapy dog to increase verbal statements across different contingencies. Five children with autism spectrum disorder ages 3-8 years participated. Alternating treatments and reversal designs were used to compare conditions in which (a) a therapy dog was not present, (b) access to a therapy dog was noncontingent, (c) access to a therapy dog was contingent on interacting with a therapist, and (d) access to another preferred item was contingent on interacting with a therapist. Results varied across participants. Noncontingent access to the therapy dog slightly increased verbal statements for 1 participant. Contingent access to the therapy dog increased social interactions for 2 participants; however, this was the most effective intervention for only 1 participant. Practitioners should be aware that some clients may be better suited for interventions including therapy dogs than others.

Using Principles from Applied Behaviour Analysis to Address an Undesired Behaviour: Functional Analysis and Treatment of Jumping Up in Companion Dogs

The aim of this study was to investigate the feasibility and effectiveness of procedures successfully used in human related applied behaviour analysis practices to the field of clinical animal behaviour. Experiment 1 involved functional analyses to identify the reinforcement contingencies maintaining jumping up behaviour in five dogs. Experiment 2 comprised teaching dog owners a noncontingent reinforcement intervention (i.e., time-based reinforcement) via behavioural skills training. Single-case experimental methods were implemented in both experiments. The results of Experiment 1 showed that access to a tangible (dogs D01, D02, D03, and D04) and owner attention (dog D05) were reliably maintaining the jumping up behaviour. Experiment 2 demonstrated that noncontingent reinforcement effectively reduced jumping in three out of four dogs (Tau -0.59, CI 90% [-1-0.15], p = 0.026, Tau -1, CI 90% [-1--0.55], p = 0.0003, and Tau -0.32, CI 90% [-0.76-0.11], p = 0.22 for dyads D01, D02, and D05, respectively), and that behavioural skills training was successful in teaching owners to perform a dog training intervention with high fidelity. Although the results are promising, more canine-related research into functional analysis and noncontingent reinforcement, as well as implementation of behavioural skills training with animal caregivers, is needed.

Functional analysis and treatment of self-injurious feather plucking in a black vulture (Coragyps atratus)

The etiology and maintenance of self-injurious feather plucking (FP) have been attributed to biological and environmental processes, yet a definitive solution has not been found. The current study investigated the application of a functional analysis and function-based treatment to reduce the FP of a black vulture (Coragyps atratus). FP was found to be maintained by positive reinforcement in the form of contingent attention. A treatment consisting of noncontingent reinforcement decreased FP, and levels of FP remained low during schedule thinning. The current study further demonstrates the validity of function-based assessment and treatment with captive animals.

Applying Standards of Effectiveness to Noncontingent Reinforcement: A Systematic Literature Review

Noncontingent reinforcement is a time-based schedule of reinforcement that has been shown to decrease problem behavior. Although the intervention is considered well established, there exist concerns that much of the supporting research has been conducted under highly controlled experimental conditions that may lack ecological validity. That is, although the efficacy has been demonstrated, the effectiveness in less controlled settings has not. To evaluate this concern, we analyzed research on noncontingent reinforcement between 1993 and 2017. Standards of evidence for effectiveness were adapted from prevention science and applied to noncontingent reinforcement literature. We specifically focused on generalizability across populations and settings, the conditions under which the intervention was applied, specific treatment parameters, opportunity cost, and social validity. Our results indicate several areas where evidence of noncontingent reinforcement effectiveness in applied settings is limited. We identify these limitations and provide a range of recommendations for future research to promote more widespread dissemination of the procedure.

A review of environmental enrichment as treatment for problem behavior maintained by automatic reinforcement

We reviewed studies that used environmental enrichment as treatment for problem behavior maintained by automatic reinforcement. A search of behavior analytic journals produced 71 publications with a total of 265 applications of environmental enrichment used alone or in conjunction with alternative behavior manipulations (e.g., prompting, reinforcement) and problem behavior manipulations (e.g., blocking, restraint). Environmental enrichment, as a sole intervention, was efficacious in 41% of the sample. Alternative behavior manipulations, problem behavior manipulations, and a combination of both improved the overall efficacy of environmental enrichment. We discuss factors that may influence the efficacy of environmental enrichment, current trends in research on this topic, and implications for both practitioners and researchers.

Evaluating the effects of discriminability on behavioral persistence during and following time-based reinforcement

With four children with autism we evaluated a refinement to time-based reinforcement designed to reduce response persistence when we simultaneously introduced time-based reinforcement and extinction. We further evaluated whether this refinement mitigated response recurrence when all reinforcer deliveries ceased during an extinction-only disruptor phase. The refinement involved increasing the saliency of the contingency change from contingent reinforcement (during baseline) to time-based reinforcement by delivering different colored reinforcers during time-based reinforcement. Behavioral momentum theory predicts that increasing the discriminability of the change from variable-interval to variable-time reinforcement should lead to faster reductions in responding. We present data on four participants, three of whom displayed response patterns consistent with the predictions of behavioral momentum theory during time-based reinforcement. However, the participants showed more varied patterns of recurrent behavior during extinction. We discuss these results within a translational research framework focusing on strategies used to mitigate treatment relapse for severe destructive behavior, as time-based reinforcement is one of the most commonly prescribed interventions for destructive behavior displayed by individuals with intellectual and developmental disabilities.

Using caregiver report on the impact of challenging behavior exhibited by children with autism spectrum disorder to guide treatment development and outcomes

Objectives: Evaluations of treatments using applied behavior analysis (ABA) for challenging behavior have relied mostly on direct behavioral observation. While observation is crucial, qualitative information can also be beneficial. In this study, we describe methods for using qualitative information in ABA treatments for challenging behavior. Method: Three participants were undergoing treatment for challenging behavior. Information was collected through caregiver interviews at the start and end of the admission. Directed content analysis identified themes in the interviews and we compared treatment outcomes using qualitative and quantitative measures. Results: Three themes emerged: description, frequency, and impact of the behavior. Quantitative and qualitative measures both suggested successful interventions for two participants. For the third, direct observation suggested treatment was effective while caregiver report did not. Conclusion: Incorporation of qualitative information into outcomes allowed for a more comprehensive view of treatment success and guided assessment and treatment decisions. Treatments based on applied behavior analysis (ABA) are commonly studied for the treatment of challenging behavior, but these studies rely mostly on direct behavioral observation. While observation is crucial, qualitative information is also useful in ensuring meaningful results. In this study, we describe a method of collecting, analyzing, and using qualitative information collected from caregivers and compare qualitative to quantitative outcomes.

Treatment of severe problem behaviour in children with autism spectrum disorder and intellectual disabilities

Children with autism spectrum disorder (ASD) and intellectual disabilities (ID) present with problem behaviour at rates disproportionately higher than their typically-developing peers. Problem behaviour, such as self-injury, aggression, pica, disruption, and elopement result in a diminished quality-of-life for the individual and family. Applied behaviour analysis has a well-established research base, detailing a number of assessment and treatment methods designed to address behaviour problems in children with ASD and ID. Although the variables that lead to the emergence of problem behaviour are not precisely known, those that are currently responsible for the maintenance of these problems can be identified via functional behaviour assessment, which is designed to identify events that occasion problem behaviour, consequences that maintain it, as well as other environmental factors that exert influence on the behaviour. Corresponding function-based treatment is implemented when environmental determinants are identified, with the aim of decreasing or eliminating problem behaviour, as well as teaching the individual to engage in more appropriate, alternative behaviour. In some cases, when problem behaviour is under the control of both environmental and biological variables, including psychiatric conditions, combining behavioural and pharmacological interventions is viewed as optimal, although there is limited empirical support for integrating these approaches.

Prevention of the development of problem behavior: A laboratory model

Few studies have isolated the preventive efficacy of common behavioral strategies like noncontingent reinforcement (NCR) and differential reinforcement of alternative behavior (DRA). The purpose of the current study was to develop and evaluate a laboratory model of these two problem behavior prevention strategies. Undergraduate students participated in a computer simulation, in which clicks to a designated area of the computer screen were analogous to the emergence of problem behavior. The responding of participants in a control group, who experienced a percentile schedule used to mimic the shaping of problem behavior, was compared to that of participants in two experimental groups, each with a history of either DRA or NCR. Between-subjects group comparisons showed that both intervention strategies were equally effective in the prevention of our analog to problem behavior when compared to the control group. The strengths and limitations of a laboratory model for prevention are discussed in light of recent applied work in this area.

Resurgence as Choice

Resurgence is typically defined as an increase in a previously extinguished target behavior when a more recently reinforced alternative behavior is later extinguished. Some treatments of the phenomenon have suggested that it might also extend to circumstances where either the historic or more recently reinforced behavior is reduced by other non-extinction related means (e.g., punishment, decreases in reinforcement rate, satiation, etc.). Here we present a theory of resurgence suggesting that the phenomenon results from the same basic processes governing choice. In its most general form, the theory suggests that resurgence results from changes in the allocation of target behavior driven by changes in the values of the target and alternative options across time. Specifically, resurgence occurs when there is an increase in the relative value of an historically effective target option as a result of a subsequent devaluation of a more recently effective alternative option. We develop a more specific quantitative model of how extinction of the target and alternative responses in a typical resurgence paradigm might produce such changes in relative value across time using a temporal weighting rule. The example model does a good job in accounting for the effects of reinforcement rate and related manipulations on resurgence in simple schedules where Behavioral Momentum Theory has failed. We also discuss how the general theory might be extended to other parameters of reinforcement (e.g., magnitude, quality), other means to suppress target or alternative behavior (e.g., satiation, punishment, differential reinforcement of other behavior), and other factors (e.g., non- contingent versus contingent alternative reinforcement, serial alternative reinforcement, and multiple schedules).

Predicting the Effects of Interventions: A Tutorial on the Disequilibrium Model

The disequilibrium approach to reinforcement and punishment, derived from the probability-differential hypothesis and response deprivation hypothesis, provides a number of potentially useful mathematical models for practitioners. The disequilibrium approach and its accompanying models have proven effective in the prediction and control of behavior, yet they have not been fully espoused and integrated into clinical practice. The purpose of this tutorial is to detail the disequilibrium approach and adapt its mathematical models for use as a tool in applied settings. The disequilibrium models specify how to arrange contingencies and predict the effects of those contingencies. We aggregate these models, and provide them as a single tool, in the form of a Microsoft Excel® spreadsheet that calculates the direction and magnitude of behavior change based on baseline measures and a practitioner's choice of intervention parameters. How practitioners take baseline measures and select intervention parameters in accordance with disequilibrium models is explicated. The proposed tool can be accessed and downloaded for use at https://osf.io/knf7x/.

Self-injurious behaviour in people with intellectual disability and autism spectrum disorder

PURPOSE OF REVIEW

This review summarises the recent trends in research in the field of self-injurious behaviour in people with intellectual disability and autism spectrum disorder.

RECENT FINDINGS

New data on incidence, persistence and severity add to studies of prevalence to indicate the large scale of the clinical need. A number of person characteristics have been repeatedly identified in prevalence and cohort studies that: can be considered as risk markers (e.g. stereotyped behaviour, autism spectrum disorder) and indicate possible causal mechanisms (e.g. sleep disorder, anxiety). Studies have started to integrate traditional operant learning paradigms with known person characteristics and reviews and meta-analyses of applied behaviour analytic procedures can now inform practice.

SUMMARY

Despite these positive developments interventions and appropriate support falls far short of the required need. Expansions in applied research are warranted to develop and evaluate innovative service delivery models that can translate knowledge of risk markers and operant learning paradigms into widespread, low cost routine clinical practice. Alongside this, further pure research is needed to elucidate the direction of causality of implicated risk factors, in order to understand and intervene more effectively in self-injury.

Behavior analytic approaches to problem behavior in intellectual disabilities

PURPOSE OF REVIEW

The purpose of the current review is to summarize recent behavior analytic research on problem behavior in individuals with intellectual disabilities. We have focused our review on studies published from 2013 to 2015, but also included earlier studies that were relevant.

RECENT FINDINGS

Behavior analytic research on problem behavior continues to focus on the use and refinement of functional behavioral assessment procedures and function-based interventions. During the review period, a number of studies reported on procedures aimed at making functional analysis procedures more time efficient. Behavioral interventions continue to evolve, and there were several larger scale clinical studies reporting on multiple individuals. There was increased attention on the part of behavioral researchers to develop statistical methods for analysis of within subject data and continued efforts to aggregate findings across studies through evaluative reviews and meta-analyses.

SUMMARY

Findings support continued utility of functional analysis for guiding individualized interventions and for classifying problem behavior. Modifications designed to make functional analysis more efficient relative to the standard method of functional analysis were reported; however, these require further validation. Larger scale studies on behavioral assessment and treatment procedures provided additional empirical support for effectiveness of these approaches and their sustainability outside controlled clinical settings.

Functional analysis and treatment of problem behavior exhibited by children with fragile X syndrome

The efficacy of function-based interventions for the treatment of severe problem behavior exhibited by individuals with intellectual and developmental disabilities (IDD) is well established. However, few studies have reported on behavioral interventions in fragile X syndrome (FXS) specifically. The present study is a consecutive case-series analysis that reports on functional analysis and treatment of problem behavior of nine children with FXS. Assessment findings were consistent with previous research indicating that among individuals with FXS, problem behavior is more commonly maintained by escape from demands and access to tangible items, relative to the broader population of individuals with IDD. Functional analysis-based behavioral interventions resulted in a mean reduction in problem behavior of 95.2% across the nine participants. Additionally, generalization of treatment effects from controlled clinical settings to home, school, and community was demonstrated. The current findings suggest that function-based behavioral interventions shown to be effective with the broader population of individuals with IDD are also effective for individuals with FXS. Our results in combination with those of previous studies describing functional analysis outcomes provide additional evidence for a unique functional behavioral phenotype for severe problem behavior in individuals with FXS. Implications of study findings for early intervention and prevention of problem behavior in children with FXS are discussed.