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

Applying Techniques From Precision Medicine to Predict Challenging Behavior and Inform Clinical Resource Allocation

The identification of behavioral markers that predict the trajectory of behavior could guide the allocation of limited clinical resources to improve efficacy, efficiency, and safety. As a preliminary exploration of this possibility, we conducted a retrospective records review of incident reports for aggression displayed by residents at a secure juvenile detention center. Our purpose was to evaluate latency to first aggression as a candidate behavioral marker for predicting subsequent high-rate aggression. Our results indicate that latency to first aggression may be a high-quality predictor of subsequent high-rate aggression, and we identified specific cutoff scores that added high levels of predictive value. We use these data to demonstrate a process by which clinicians and researchers can identify predictor variables and use them to guide subsequent allocation of clinical resources. Practical, conceptual, and ethical considerations related to applications of this process as well as potential directions for future research in this area are discussed.

A Quantitative Systematic Literature Review of Combination Punishment Literature: Progress Over the Last Decade

This review evaluated single-case experimental design research that examined challenging behavior interventions utilizing punishment elements. Thirty articles published between 2013 and 2022 met study inclusion criteria. Study quality was also assessed. Through multiple levels of analysis (e.g., descriptive statistics, non-parametric statistics), we examined (a) participant and study trends, (b) differential outcomes related to temporal reinforcement approaches (antecedent, consequent, or combined reinforcement) applied alongside punishment element(s), (c) differential outcomes related to the punishment type (negative, positive) applied alongside reinforcement, and (d) effect sizes associated with study rigor across peer-reviewed and gray literature. Our results may tentatively suggest that, for certain situations, concurrently applying punishment with antecedent reinforcement approaches may coincide with significantly larger effect sizes compared to combined temporal reinforcement approaches, while positive punishment applied concurrently with reinforcement may coincide with larger but non-significant intervention effects. Most featured articles met rigor criteria, but larger effects were seen in peer-reviewed literature.

Validating social reinforcer classes for low-severity challenging behavior identified by sensitivity tests

Behavior analysts typically assess and treat challenging behavior after it occurs regularly and at high severity. Although effective, this reactive approach is quite costly and resource intensive. A growing literature supports an alternative preventive approach; the first step involves conducting sensitivity tests to screen the topographies and functions of low-severity behavior evoked by establishing operations commonly included in challenging behavior research (e.g., Fahmie et al., 2020). Despite the potential value of sensitivity tests, their correspondence with functional analyses has yet to be established. This study measured the correspondence between social reinforcer classes nominated by sensitivity tests and social reinforcer classes verified by traditional functional analysis outcomes of the same behaviors. Participants included 10 young autistic learners who were reported to exhibit low-severity challenging behavior. Data showed generally high correspondence between both assessment outcomes for challenging behavior but not for appropriate requests.

Different criteria affect prevalence of relapse of behavior targeted for treatment

Several studies have examined the prevalence of behavioral relapse among individuals with intellectual and developmental disabilities following common treatment challenges (context changes, schedule thinning). Most applied studies compare behavior during the treatment challenges with the maximum level of behavior from five preceding treatment sessions. This max-of-5 criterion could inadvertently capture behavior in transition during the preceding treatment phase, thereby underestimating the prevalence of relapse. In the current study, we reanalyzed existing clinical data with the max-of-5 criterion and an alternative criterion less likely to capture target behavior in transition-the mean of the last two sessions (mean-of-2 criterion) of the treatment phase. As hypothesized, the max-of-5 criterion produced lower prevalence estimates relative to the mean-of-2 criterion. We encourage researchers conducting these analyses to weigh different approaches to reporting prevalence data and discuss considerations for future areas of research and practice related to measurement of relapse.

On the prevalence and magnitude of resurgence during delay-and-denial tolerance teaching

Resurgence is the recurrence of target behavior (e.g., challenging behavior) during a worsening of reinforcement conditions (e.g., increases in response effort, decreases in alternative reinforcement). Previous studies have examined the prevalence and magnitude of resurgence during functional communication training implemented with discriminative stimuli. We conducted a systematic review of the literature to analyze the magnitude and prevalence of resurgence during delay-and-denial tolerance teaching. Similar to previous studies with discriminative stimuli, resurgence occurred for most participants and in about one third of transitions. When resurgence was present, challenging behavior increased to approximately 26% of baseline levels. Resurgence was less likely to occur during response-effort manipulations (i.e., complexity teaching, tolerance-response teaching) and was most likely to occur during increases in delays that ended following the passage of time rather than a response criterion. We discuss implications for treatment refinements and future treatment-relapse research.

Correspondence between preference for and efficacy of behavioral interventions: A systematic review

Understanding of the correspondence between intervention preference and efficacy is limited. We systematically reviewed 112 articles (457 cases) evaluating efficacy of and preference for behavioral interventions. We analyzed the percentage of cases for whom interventions were preferred and efficacious across broad (e.g., behavior reduction, performance, skill acquisition) and specific (e.g., noncontingent reinforcement, video modeling) intervention types. Authors reported one preferred intervention for most cases. Regarding efficacy, authors reported about half of cases as having one efficacious intervention and the other half having multiple equally efficacious interventions. The same intervention was preferred and efficacious for 74% of cases for whom authors reported one preferred and one efficacious intervention. Several specific interventions were generally preferred and efficacious across cases (e.g., digital stimuli, computer-based instruction, accumulated reinforcement, contingent reinforcement). We discuss clinical recommendations, the importance of assessing preference, and the need for research in developing protocols for assessing intervention preference.

A clinician's guide to performing a case series study

BACKGROUND

Whilst some guidance exists, the literature is relatively scarce on designing and reporting on case series studies for non-surgical techniques/interventions or interventions that may be considered outside the medical model. This commentary presents a set of thirteen design attributes and an adapted checklist for consideration by clinicians when considering a case series design focused on a non-surgical intervention.

Teaching trainees to implement functional communication training with multiple schedules: An evaluation of training effects and durability

We evaluated the effects of behavioral skills training on improving participant implementation of functional communication training with multiple schedules when working with a confederate. Behavioral skills training produced mastery-level responding for all six participants who required training, providing the first empirically supported training for this functional communication training approach. Next, we assessed durability during training challenges with (a) procedural changes to the original protocol, (b) a novel confederate with different discriminative stimuli and reinforcers, and (c) relapsed confederate destructive behavior. Training effects degraded at least once for all participants and in 62% of training challenges, although continuing to expose the participant to the challenging situations or providing postsession booster training resolved the degradation in most cases. We discuss these findings in relation to their clinical implications and directions for future research.

Examination of clinical variables affecting resurgence: A reanalysis of 46 applications

Despite the efficacy of behavioral interventions, resurgence of challenging behavior (e.g., aggression, self-injury) following successful treatment can still occur. Applied work has focused on identifying treatment-related variables thought to affect the occurrence and magnitude of resurgence. The current study describes the relation between several variables (i.e., phase duration, response rates in baseline and treatment, obtained rates of reinforcement, downshift in reinforcement step size) and resurgence in a retrospective consecutive controlled case series of 46 treatment applications for challenging behavior conducted in an inpatient setting. Only the downshift in reinforcement (e.g., schedule-thinning) step size was correlated with the magnitude of resurgence. These results are consistent with recent findings suggesting that treatment duration and other factors have inconsistent effects on resurgence of challenging behavior.

Application of a terminal schedule probe method to inform schedule thinning with multiple schedules

Multiple schedules are effective at decreasing challenging behavior and maintaining alternative behavior at acceptable levels. Currently, no conclusive guidance is available for empirically deriving multiple-schedule components (continuous reinforcement for alternative behavior and extinction for challenging behavior [discriminative stimulus] and extinction for both alternative and challenging behavior [delta stimulus]) during the schedule-thinning process. In the current investigation, we describe a terminal schedule probe method to determine delta stimulus starting points and strategies for subsequent schedule-thinning progressions to reach caregiver-informed terminal schedules. We review schedule-thinning outcomes for a clinical cohort using a consecutive controlled case series approach and report results for two groups: One group included applications of terminal probe thinning (n = 24), and the other involved traditional dense-to-lean thinning (n = 18). Outcomes suggest that the terminal schedule probe method produced effective treatments with less resurgence of challenging behavior and leaner, more feasible, multiple schedules.

Retrospective consecutive controlled case series of outcomes for functional analyses of severe destructive behavior

Functional analysis methods allow clinicians to determine the variable(s) that maintain destructive behavior. Previous reviews of functional analysis outcomes have included large samples of published and unpublished data sets (i.e., clinical samples). The purpose of this review was to conduct a large retrospective consecutive controlled case series of clinical functional analyses. We sought to identify the prevalence of differentiation, procedural modifications for undifferentiated and differentiated cases, and identified function(s) of destructive behavior. In addition, we extended the existing literature by determining whether functional analysis differentiation and function varied when single or multiple behavior topographies were consequated in the functional analysis. We discuss our findings considering previously published functional analysis reviews, provide avenues for future research, and offer suggestions for clinical practice.

Exploring factors that influence the efficacy of functional communication training

Understanding factors that influence the efficacy of functional communication training has both practical and conceptual benefits. The current study extended research in this area by exploring data from 95 consecutive applications of functional communication training with extinction across two independent clinics. We selected candidate predictor variables based on conceptual analysis, conducted preliminary exploratory analyses, and then selectively applied quantitative methods that are used in precision medicine to examine their accuracy and predictive utility. Treatment outcomes were better when challenging behavior was maintained by a single function than they were when it was maintained by multiple functions; however, these differences were most apparent among cases with an escape function. We also analyzed within-session responding to explore the potential influence of unprogrammed establishing operations on decrements in treatment efficacy. Our within-session measure only distinguished responders from nonresponders when escape was one of the multiple functions. Additional research is needed to validate these findings with an independent sample and to address a number of clinical conceptual issues.

Long-term effectiveness and generality of practical functional assessment and skill-based treatment

There are several considerations to address when conducting functional communication training for challenging behavior in a school setting, such as the need for schedule thinning and maintenance across staff and the need to establish a variety of appropriate classroom skills. There are several strategies for conducting schedule thinning following functional communication training and for transferring effects across people or settings. However, there are few examples of these processes in natural settings with relevant caregivers and with long-term maintenance of effects. We implemented a functional assessment and skill-based treatment process with six children with autism in a specialized school setting and extended treatment until challenging behavior was reduced to near-zero levels across multiple staff and settings. Follow-up data indicate that effects were still observed 1 year posttreatment and the use of crisis procedures (e.g., physical restraint) was eliminated for all participants.

Exploratory Time-Series Analysis of Consecutive Case Series Data: A Quality Improvement and Adherence Study of a Behavior Analytic Service Provider

Program evaluation is an essential practice for providers of behavior analytic services, as it helps providers understand the extent to which they are achieving their intended mission to the community they serve. A proposed method for conducting such evaluations, is through the use of a consecutive case series design, for which cases are sequentially gathered following the onset of a specific occurrence. Given the sequential nature in which data are collected within a consecutive case series, analytic techniques that adopt a time-series framework may be particularly advantageous. Although such methods are commonly used for program evaluation in medicine and economics, their application within the field of applied behavior analysis is largely absent. To serve as a model for providers undertaking evaluation efforts, I conducted a program evaluation of an outpatient severe behavior clinic, in which I employed quasi-experimental methods using an interrupted time-series analysis.

Rab4A-directed endosome traffic shapes pro-inflammatory mitochondrial metabolism in T cells via mitophagy, CD98 expression, and kynurenine-sensitive mTOR activation

Activation of the mechanistic target of rapamycin (mTOR) is a key metabolic checkpoint of pro-inflammatory T-cell development that contributes to the pathogenesis of autoimmune diseases, such as systemic lupus erythematosus (SLE), however, the underlying mechanisms remain poorly understood. Here, we identify a functional role for Rab4A-directed endosome traffic in CD98 receptor recycling, mTOR activation, and accumulation of mitochondria that connect metabolic pathways with immune cell lineage development and lupus pathogenesis. Based on integrated analyses of gene expression, receptor traffic, and stable isotope tracing of metabolic pathways, constitutively active Rab4AQ72L exerts cell type-specific control over metabolic networks, dominantly impacting CD98-dependent kynurenine production, mTOR activation, mitochondrial electron transport and flux through the tricarboxylic acid cycle and thus expands CD4+ and CD3+CD4-CD8- double-negative T cells over CD8+ T cells, enhancing B cell activation, plasma cell development, antinuclear and antiphospholipid autoantibody production, and glomerulonephritis in lupus-prone mice. Rab4A deletion in T cells and pharmacological mTOR blockade restrain CD98 expression, mitochondrial metabolism and lineage skewing and attenuate glomerulonephritis. This study identifies Rab4A-directed endosome traffic as a multilevel regulator of T cell lineage specification during lupus pathogenesis.

A concise review of the correspondence between the traditional functional analysis and alternative assessment formats

The functional assessment of challenging behavior (e.g., self-injurious behavior) has evolved over many years of research and practice. This concise review summarizes the positive predictive value, negative predictive value, accuracy, sensitivity, and specificity of common procedural adaptations reported to improve functional assessment safety and efficiency. We conclude with suggestions for clinicians and researchers.

A comparison of parental attention and preferred items during tummy time: A consecutive controlled case series evaluation

Tummy time is an activity for infants to practice their early motor skills. Although most pediatricians recommend tummy time, parents may avoid the procedures due to indices of infant discomfort during this period. This consecutive controlled case series evaluation compared the effects of preferred items selected from a preference assessment with those of parental attention on head evaluation and negative vocalizations during tummy time. In addition, we directly evaluated parental choice by inviting parents to select which tummy time treatment they wanted to implement. We found that both preferred items and parental attention effectively increased head elevation and decreased negative vocalizations during tummy time; however, parents tended to prefer the treatment that included the preferred item.

Examining patterns suggestive of acquisition during functional analyses: A consecutive controlled series of 116 cases

The functional analysis approach described by Iwata et al. (1982/1994) has been used widely to determine the variables evoking and maintaining challenging behavior. However, one potential concern with conducting functional analyses is that repeated exposure to contingencies may induce a novel functional relation. To examine the likelihood of these potential iatrogenic effects, we evaluated social test conditions of the functional analysis for 116 participants and searched for patterns of responding indicative of acquisition. Patterns suggestive of acquisition occurred in 13.70% of tangible reinforcement conditions; however, the prevalence was only slightly lower in the attention condition (8.75%). Much lower prevalence was observed for the escape condition (2.13%). When grouped by quotient score, a pattern of acquisition was just as likely to be observed in the attention condition as in the tangible condition. Additionally, patterns indicative of acquisition were no more likely to be observed with participants who emitted automatically reinforced challenging behavior.

Updated Recommendations for Reinforcement Schedule Thinning following Functional Communication Training

Schedule thinning is a necessary treatment procedure following the acquisition of a communication response during functional communication training. In this article, we update and extend the Hagopian et al. Behavior Analysis in Practice, 4, 4-16, (2011) review and recommendations on schedule-thinning procedures following functional communication training. Since their publication, substantial research has been published on the efficacy, efficiency, and social validity of schedule-thinning methods. We provide updated recommendations for schedule thinning based on contemporary literature that has been published since 2011, as well as discuss key areas for future research.

Further evidence of renewal in automatically maintained behavior

Renewal is a relapse phenomenon that refers to the recurrence of a previously reduced behavior following a change in stimulus conditions. Muething et al. (2022) examined the phenomenology of renewal among individuals with automatically maintained challenging behavior treated at an outpatient clinic. We replicated their findings by retrospectively examining renewal across various topographies of automatically maintained behavior treated at an inpatient hospital, and we extended their work by also examining differences across subtypes of automatically maintained self-injurious behavior. The prevalence of renewal was comparable to that observed by Muething et al., supporting the notion that automatically maintained challenging behavior is susceptible to relapse phenomena. Furthermore, renewal was twice as likely to occur for individuals with Subtype 2 versus Subtype 1 self-injurious behavior, providing additional evidence of behavioral differentiation between subtypes. Our findings suggest that even after apparent stability in treatment, practitioners should remain vigilant for the recurrence of automatically maintained behavior during generalization.

Understanding Individual Subject Differences through Large Behavioral Datasets: Analytical and Statistical Considerations

A core feature of behavior analysis is the single-subject design, in which each subject serves as its own control. This approach is powerful for identifying manipulations that are causal to behavioral changes but often fails to account for individual differences, particularly when coupled with a small sample size. It is more common for other subfields of psychology to use larger-N approaches; however, these designs also often fail to account for the individual by focusing on aggregate-level data only. Moving forward, it is important to study individual differences to identify subgroups of the population that may respond differently to interventions and to improve the generalizability and reproducibility of behavioral science. We propose that large-N datasets should be used in behavior analysis to better understand individual subject variability. First, we describe how individual differences have been historically treated and then outline practical reasons to study individual subject variability. Then, we describe various methods for analyzing large-N datasets while accounting for the individual, including correlational analyses, machine learning, mixed-effects models, clustering, and simulation. We provide relevant examples of these techniques from published behavioral literature and from a publicly available dataset compiled from five different rat experiments, which illustrates both group-level effects and heterogeneity across individual subjects. We encourage other behavior analysts to make use of the substantial advancements in online data sharing to compile large-N datasets and use statistical approaches to explore individual differences.

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.

Severe behavior problems in SYNGAP1-related disorder: A summary of 11 consecutive patients in a tertiary care specialty clinic

SYNGAP1-related disorder (SYNGAP1-RD) is a neurodevelopmental disorder that is commonly associated with epilepsy, autism spectrum disorder (ASD), and disruptive behaviors. In this study, behavior problems in 11 consecutive patients with SYNGAP1-RD are described and quantified based on a behavioral screening conducted within the context of a multi-disciplinary tertiary care specialty clinic visit. The behavioral phenotype was then compared to published samples of behavior problems in ASD and other genetic cause of epilepsy occurring in the context of neurodevelopmental disorders using results from the Aberrant Behavior Checklist-Community (ABC-C), an empirically derived outcome measure. We report common antecedent and consequent events surrounding problem behavior across individuals. Additionally, we report on the management approach of caregivers and the impact of problem behaviors on the family. Our results suggest a number of commonalities between behavioral profiles in SYNGAP1-RD with ASD and other genetic causes of developmental and epileptic encephalopathies, and also highlight severe behavior problems as a specific behavioral phenotype of SYNGAP1-RD.

Reflections and Critical Directions for Toilet Training in Applied Behavior Analysis

Achieving toileting independence is a critical skill that yields several benefits of pressing social, developmental, and health-related importance. The seminal behavioral approach to toilet training established the conceptualization of continence and framework for toileting research thereafter. Contemporary researchers continue to evaluate toilet training procedures that produce efficacious outcomes for young children that closely align with current applied behavior analysis (ABA) ethics and standards of practice. Despite the overall success of behavior-analytic toileting approaches, there are critical directions still worthy of consideration and investigation. In this paper, we acknowledge the seminal roots and many of the contemporary contributions. We also critically reflect on current practices while proposing necessary areas to advance behavior-analytic toilet training research.

Application of the evolutionary theory of behavior dynamics to severe challenging behavior

The evolutionary theory of behavior dynamics (ETBD) is a genetic algorithm that applies the Darwinian principles of evolutionary biology to model how behavior changes dynamically via selection by contingencies of reinforcement. The ETBD is a complexity theory where low-level rules of selection, reproduction, and mutation operate iteratively to animate "artificial organisms" that generate emergent outcomes. Numerous studies have demonstrated the ETBD can accurately model behavior of live animals in the laboratory, and it has been applied recently to model automatically maintained self-injury. The purpose of the current series of studies was to further extend the application of the ETBD to model additional functional classes of challenging behavior and clinical procedures. Outcomes obtained with artificial organisms generally corresponded well with outcomes observed with clinical cases sourced from consecutive controlled case series studies. Conceptual and methodological considerations on the application of the ETBD to model challenging behavior are discussed.

An evaluation of negative reinforcement to increase self-feeding and self-drinking for children with feeding disorders

Self-feeding with utensils represents an important step in a child's progression toward age-typical eating and emerges in the absence of intervention for most children. In contrast, children with feeding disorders may lack the skill or motivation to self-feed, which impedes progress toward age-typical eating. In the current study, experimenters used a multielement design to evaluate negative reinforcement in the form of meal termination to transition six participants with a feeding disorder from caregiver-fed to self-fed bites and drinks. Caregivers conducted meals in which they fed the participant or prompted them to self-feed. During self-fed meal-termination sessions, participants had the opportunity to end the meal contingent on self-feeding the presented bite(s) or drink(s). Self-feeding increased during meal-termination sessions for all participants. The experimenters discuss these results relative to their potential to inform interventions for children with feeding disorders that progress the child toward age-typical eating.

A replication and extension of the augmented competing stimulus assessment

Augmenting competing stimulus assessments by embedding tactics to increase stimulus engagement and disrupt challenging behavior can improve outcomes of treatments for automatically maintained self-injurious behavior, even for treatment-resistant subtypes. This study replicated and extended research on augmented competing stimulus assessments by reporting outcomes for 16 consecutively encountered cases with automatically maintained self-injurious behavior (19 total applications); six participants had treatment-responsive Subtype 1 and 10 had treatment-resistant Subtypes 2 or 3. Fewer high-competition stimuli were identified for individuals with treatment-resistant subtypes. When response-promotion and disruption tactics were applied and withdrawn, outcomes improved for six of eight applications. At least one high-competition stimulus was still effective when maintenance probes were conducted for a subset of participants. Ultimately, at least one high-competition stimulus was identified for each participant. Although augmenting tactics may not be necessary for all individuals, these findings provide additional support for their efficacy with treatment-resistant self-injurious behavior.

Simplified methods for identifying subtypes of automatically maintained self-injury

Subtypes of automatically maintained self-injurious behavior (SIB) have been defined based on response patterns observed during the functional analysis, which are thought to reflect each subtype's distinct mechanisms. Current practice for identifying subtypes involves using structured criteria to identify whether SIB is automatically maintained, followed by the application of additional criteria to identify the subtype. We describe a series of studies directed at simplifying these methods to facilitate wider application of the subtyping model in research and practice. In Studies 1 and 2, we demonstrate the accuracy of modified criteria using the level of differentiation of SIB across the play and no-interaction conditions at distinguishing between two subtypes (i.e., Subtypes 1 and 2). We then demonstrate visual analysis (without structured criteria) can accurately identify SIB as automatically maintained in Study 3, which can be used in combination with level of differentiation to enable application of the subtyping model in practice.

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.

A Systematic Review of Supervision Research Related to Board Certified Behavior Analysts

Supervision is paramount within applied behavior analysis. This is particularly true in the case of Board Certified Behavior Analysts® (BCBAs®) and trainees (i.e., those accruing hours and experience to become BCBAs). Given the importance of supervision in shaping future BCBAs (and subsequently the field of applied behavior analysis), researchers have emphasized supervision practices as they relate to BCBAs and trainees. However, what type of work is occurring in this area, such as empirical intervention studies or provision of supervisory recommendations through discussion-style articles, needs to be clarified. Therefore, we conducted the first and most comprehensive systematic review of supervision research related to BCBAs and trainees. Results indicated that most of the articles and work pertaining to BCBA supervision are discussion-style articles, with several survey studies and few empirical intervention studies. We discuss implications and areas for future supervision research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00805-0.

Efficacy of competing stimulus assessments: A summary of 35 consecutively encountered cases

Competing stimulus assessments (CSAs) are designed to identify stimuli that reduce challenging behavior through competition with its maintaining reinforcers. Recently, Haddock and Hagopian (2020) found that over 92% of CSAs described in published studies identified at least one high-competition stimulus (i.e., a stimulus correlated with at least an 80% reduction in challenging behavior). The current study describes the outcomes of CSAs in a retrospective consecutive controlled case series study of 35 cases (individuals) admitted to an inpatient setting. Findings on the limited relation between the level of stimulus engagement and reductions in challenging behavior were replicated; however, the efficacy of CSAs was lower (only 47% of CSAs were successful in identifying one or more high-competition stimuli). Discrepant findings across studies on the efficacy of CSAs are discussed in terms of differences in the sample participants and how outcomes are reported, which vary depending on the study's research questions.

Functional analysis of problem behavior: A 40-year review

Extensive reviews of functional analysis literature were conducted 10 (Beavers et al., 2013) and 20 (Hanley et al., 2003) years ago; we expanded this review to capture the vast and innovative functional analysis research that has occurred over the past decade. Our review produced 1,333 functional analysis outcomes from 326 studies on the functional analysis of problem behavior between June 2012 and May 2022. Some characteristics of functional analysis studies were similar across the current and previous two reviews (e.g., child participants, developmental disability diagnosis, use of line graphs depicting session means, differentiated response outcomes). Other characteristics deviated from the previous two reviews (e.g., increase in autistic representation, outpatient settings, use of supplementary assessments, the inclusion of tangible conditions, and multiple function outcomes; decrease in session durations). We update previously reported participant and methodological characteristics, summarize outcomes, comment on recent trends, and propose future directions in the functional analysis literature.

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.

Varying reinforcer dimensions during differential reinforcement without extinction: A translational model

Procedural arrangements of differential reinforcement of alternative behavior without extinction often involve presenting the same reinforcers for problem behavior and appropriate behavior, which is typically ineffective at reducing problem behavior and increasing an alternative response. However, manipulating reinforcement dimensions such that the contingencies favor the alternative response may improve treatment outcomes when using differential reinforcement of alternative behavior without extinction by increasing appropriate behavior and reducing problem behavior. We conducted this translational study with 32 college students completing a button-pressing task on a computer program in which they could engage in analogs to problem behavior and appropriate behavior. The effects of manipulating magnitude, immediacy, quality, and a combination of all three dimensions for the alternative response were evaluated. Overall, all dimension manipulations reduced the analog to problem behavior, with the largest reductions observed during the quality probe and the probe with all dimensions combined. These results support the notion that differential reinforcement of alternative behavior without extinction can be an effective form of treatment.

Further evaluation of treatment duration on the resurgence of destructive behavior

Translation of promising procedures for mitigating treatment relapse has received considerable attention recently from researchers across the basic-applied continuum. One procedure that has demonstrated mixed support involves increasing the duration of treatment as a strategy for blunting resurgence. In a recent translational study, Greer et al. (2020) failed to detect a mitigation effect of increased treatment duration on the resurgence of destructive behavior. However, design limitations may have been responsible. The present study corrected these limitations by (a) employing a sequential design to decrease the possibility of multiple-treatment interference, (b) evaluating more treatment durations, (c) arranging treatments of fixed durations, and (d) conducting treatments of more extreme duration in a different clinical sample. Despite these improvements in experimental rigor and the testing of more extreme boundary conditions, the present study also failed to detect a mitigation effect of increased treatment duration. Likely explanations are discussed.

A systematic review of the correspondence between descriptive assessment and functional analysis

Clinicians report that they often rely on descriptive assessments when developing behavior-reduction plans despite literature suggesting that functional analysis is the most rigorous assessment method. Further, research comparing the outcomes of descriptive assessments and functional analyses is mixed, with some studies showing low correspondence and others showing high correspondence. Such persistent use of descriptive assessments suggests that they may yield useful information despite inconsistent correspondence with functional analyses. A more fine-grained analysis of the relation between descriptive assessments and functional analyses may elucidate variables affecting their utility. We conducted a review of 48 studies that included descriptive assessments and functional analyses and evaluated several measures of correspondence between each pair of assessments. Results indicated that descriptive assessments had exact correspondence with functional analyses in 50% of comparisons. Results also suggested that descriptive assessments were more likely to accurately identify and predict the absence of a function relative to the presence of a function and that structured descriptive assessments were more likely to accurately predict functions.

Feasibility and Acceptability of a Compressed Caregiver Training Program to Treat Child Behavior Problems

In an effort to address some of the criticisms of Behavioral Parent Training programs (BPT; high attrition, reliance on caregiver report measures), the current study examined the feasibility, acceptability, and outcome of an intensive behavior treatment program (120-minute sessions for 5 days/week over the course of 2 weeks). Using a changing criterion single case experimental design, 12 children ( M child age = 4.9 years) and their primary caregivers completed the 2-week function-based intervention procedure designed to increase children’s frustration tolerance via a wait training procedure based on the principles of applied behavior analysis. Using both direct observation and standardized measures, results indicated that the treatment was effective in reducing childhood behavior problems, both within and between appointments (Cohen’s ds = 3.2 and 1.37, respectively). Preliminary evidence suggests that a compressed treatment package designed to train caregivers in function-based intervention strategies is feasible and acceptable.

A Retrospective Consecutive Controlled Case Series of Underspoon: A Modified-Bolus Placement to Address Behavior That Interfere With Swallowing

Children diagnosed with pediatric feeding disorder (PFD) or avoidant/restrictive food intake disorder (ARFID) may present with comorbid oral-motor delays that often contribute to their failure to consume an adequate volume and/or variety of foods. Once the food enters the mouth, these children may exhibit additional problematic behavior such as expulsion and packing that further averts oral intake. Previous research has evaluated the impact of modified-bolus placement methods, including flipped spoon and NUK® brush, in comparison to upright spoon on expulsion and packing. Whether responses are due to performance or skill deficits, researchers hypothesize that modified-bolus placement may assist with reducing the response effort associated with swallowing. This retrospective consecutive controlled case series assessed the clinical application of an additional modified-bolus placement method, underspoon, to increase food consumption and decrease problematic behavior that interfere with mouth clean for children with PFD or ARFID.

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.

A 20-year nationwide analysis of golf-associated eye injuries in the United States

PURPOSE

Existing knowledge regarding golf-associated eye injuries (GEIs) is sparse. The purpose of this study was to characterize the types of GEIs, examine the mechanisms of injury, describe the characteristics of GEI victims, and determine the incidence of GEIs during the 2002-2021 period using the National Electronic Injury Surveillance System (NEISS) database.

METHODS

Deidentified patient records were analyzed. Each GEI was assigned into a specific category of diagnosis, and the mechanism of injury was determined. National estimates were collected for each year, and simple linear regression modeling was used to determine trends over time. Furthermore, patient variables for sex, race, and age were analyzed.

RESULTS

The NEISS query provided a total of 379 GEIs for analysis. GEIs were most common in adult males, with a decreasing, although not statistically significant, trend during this period (β = -17.88, p = 0.110). Children were more likely to have a GEI caused by a golf club while adults were more likely to have one caused by the surrounding environment. Across all age groups, contusions and corneal abrasions were the most common GEIs, constituting 50.4% (190/377) of all eye injuries, followed by foreign body injuries (9%, 34/377) and then irritation/inflammation of the eye (8%, 30/377). The most common mechanism of injury among all players involved adverse interactions with the environment (37.7%, 142/377).

CONCLUSION

Contradictory to existing literature, we show that minor GEIs are more common than severe ones. Rather than golf clubs or balls, environmental elements are the leading cause of GEIs.

Development of Medication Administration Protocols for In-Home Pediatric Feeding Cases

Medication administration can be a significant issue in pediatric populations, and especially with patients with developmental disabilities and comorbid feeding disorders. Research has focused largely on consumption of solids rather than medication and liquids in pediatric feeding programs, with most studies being conducted within specialized hospital settings in the United States. No studies to our knowledge have detailed treatment evaluations for medication administration in pediatric feeding except for a few studies on pill swallowing. We report results of treatment protocols for medication administration using empirically-supported treatments in a short-term intensive home-based behavior-analytic program in Australia. Two males with autism spectrum and pediatric feeding disorders participated. We used a multiple baseline single-case experimental design for medication administration conducted concurrently with a treatment evaluation for solid foods. Consumption increased in number (9; supplements, laxatives, pain relievers), flavors (8; chocolate, blackcurrent and apple, strawberry, lemon-lime, orange, chocolate-vanilla, cherry, apple), forms (4; thin and thick liquids, chewables, gummies), and delivery methods (5; finger-fed, spoon, cup, medicine spoon, medicine cup) within the first treatment session. For one participant, we taught open cup drinking for a variety of liquids (milk, juices, medications). For both participants, we taught self-feeding with utensils for thick liquid medications. Treatment results were similar for solids and participants increased food variety to over 160 across food groups. All goals were met including training parents to maintain gains at home.

Radioiodine treatment of hyperthyroidism in cats: results of 165 cats treated by an individualised dosing algorithm in Spain

OBJECTIVES

Although radioiodine (131I) is the treatment of choice for feline hyperthyroidism, 131I-dosing protocols commonly induce iatrogenic hypothyroidism and expose azotaemia. A recently reported patient-specific 131I dosing algorithm minimised the risk of 131I-induced hypothyroidism and azotaemia, while maintaining high cure rates. The aim of the study was to report results of 131I treatment in a European population of hyperthyroid cats using this patient-specific dosing algorithm.

METHODS

This prospective case series (before-and-after study) evaluated 165 hyperthyroid cats referred for 131I treatment. All cats had serum concentrations of thyroxine (T4), triiodothyronine (T3) and thyroid-stimulating hormone (TSH) measured (off methimazole ⩾1 week). Thyroid volume and percentage uptake of 99mTc-pertechnetate (TcTU) were determined using thyroid scintigraphy. An initial 131I dose was calculated by averaging dose scores for T4/T3 concentrations, thyroid volume and TcTU; 70% of that composite dose was then administered. Twenty-four hours later, percentage 131I uptake was measured, and additional 131I administered as needed to deliver an adequate radiation dose to the thyroid tumour(s). Serum concentrations of T4, TSH and creatinine were determined 6-12 months later.

RESULTS

Median calculated 131I dose was 2.15 mCi (range 1.2-7.5), with only 51 (30.9%) receiving ⩾2.5 mCi. Of 165 cats, 124 (75.2%) became euthyroid, seven (4.2%) became overtly hypothyroid, 27 (16.4%) became subclinically hypothyroid and seven (4.2%) remained hyperthyroid. A higher proportion of overtly (85.7%) and subclinically (26.9%) hypothyroid cats developed azotaemia than euthyroid cats (13.6%; P = 0.0002). Hypothyroid cats were older (P = 0.016) and more likely to have detectable TSH concentrations (P = 0.025) and symmetrical bilateral distribution of 99mTc-pertechnetate uptake (P = 0.0002), whereas persistently hyperthyroid cats had higher severity scores (P = 0.012).

CONCLUSIONS AND RELEVANCE

Our results confirm that 131I dosing with this new algorithm results in high cure rates, with a lowered prevalence of 131I-induced overt hypothyroidism and azotaemia. Age, serum TSH concentrations, bilateral, symmetrical uptake and severity score help predict outcome.

Description and evaluation of a function-informed and mechanisms-based framework for treating challenging behavior

Individualization and iterative design are essential components of the assessment and treatment of challenging behavior. Currently, there are few validated frameworks for engaging in iterative processes. Due to the nature of single-case design, empirically rigorous evaluations of decision-tree processes are particularly prohibitive. Notwithstanding, evaluations are needed. In this paper we first describe a function-informed and mechanisms-based (FIMB) framework for selecting treatment components employed by a university-based practicum experience designed to expose pre-service practitioners to a valid treatment process for challenging behavior. Then, we share a completed retrospective consecutive case series across a 6-year period in which we conducted a technique analysis to identify which procedures were most commonly selected in the practicum, and the impact of those choices on client outcomes. The results suggest that the model can be highly effective for some, but not all, cases. Implications are discussed.

Quantification of behavioral data with effect sizes and statistical significance tests

This article describes the use of statistical significance tests and distance-based effect sizes with behavioral data from single case experimental designs (SCEDs). Such data often are interpreted only with visual analysis. However, a growing movement in the field is to quantify results to improve decision-making and communication across studies and sciences. The goal of the present study was to assess the agreement between visual analysis and various statistical tests. We recruited visual analysts to judge 160 pairwise data sets from published articles and compared these analyses to significance tests and effect sizes. One-tailed significance testing of Tau z and the percentage of pairwise differences in the predicted direction (PWD) generally agreed with each other, and complemented the effect sizes of Ratio of Distances (RD) and g. Visual analysis was somewhat unreliable and should be combined with statistical complements to maximize decision accuracy.

Revisiting the social validity of services rendered through a university-based practicum addressing challenging behavior

This paper represents the third in a three-part series intended to challenge the social validity of the services provided by a university-based practicum for addressing the challenging behavior of individuals with disabilities. In this paper, we surveyed referring stakeholders (e.g., parents, teachers) of past service recipients to explore the acceptability of the service model's goals, methods, and outcomes. We probed for tensions resultant from the model's threefold mission (service, training, and research) and explored how conflicts between these goals affected the quality of our services. Generally, results were favorable and appeared to support continued model implementation, but not without qualification. Emergent themes, areas for improvement, and future directions for intervention research are all discussed.

Exploring the validity of university-based practicum tailored to develop expertise in addressing challenging behavior

In theory, the principles, processes, and concepts of applied behavior analysis are universally applicable. In practice, clinicians commit their lives to serving specific populations in specific settings for which specialization is needed. The purpose of this 6-year retrospective consecutive case series was to describe and evaluate the quality and validity of a practicum experience tailored to develop specialized expertise in the assessment and treatment of challenging behavior for pre-service practitioners enrolled in a department of a special education program.

Transition States in Single-Case Experimental Designs: A Retrospective Consecutive-Controlled Case Series Investigation

Behavioral interventions to decrease problem behavior often involve the use of single-case experimental designs in which an individual's responding during a treatment condition is compared to responding during a control or baseline condition. It is possible that during the initial introduction of treatment, problem behavior continues to occur at baseline rates before behavior reduction is observed; this phenomenon is called a transition state. Evaluated the prevalence of transition states in the Journal of Applied Behavior Analysis and found that they occurred within 5.3% of the published literature. The current study replicated and extended Brogan et al. by evaluating the prevalence of transition states in unpublished clinical data of patients admitted to an inpatient hospital for the treatment of severe problem behavior. Using a retrospective consecutive-controlled case series, transition states were observed in 3% of cases for an average duration of 4.8 sessions. We discuss factors that may affect transitional behavior between phases and relevant implications for practice and research.

Conducting Translational Research in the Context of Patient Care

Although much has been written on the importance of translational research for bridging the continuum of basic science to clinical practice, few authors have described how such work can be carried out practically when working with patient populations in the context of ongoing clinical service delivery, where the priorities for patient care can sometimes conflict with the methods and goals of translational research. In this article, we explore some of the considerations for conducting this type of work while balancing clinical responsibilities that ensure high-quality patient care. We also discuss strategies we have found to jointly facilitate translational research and improve routine, clinical service delivery. A primary goal of this article is to encourage others working in applied settings to contribute to the increasingly important role that translational research plays in our science and practice by helping to better characterize and potentially lessen or remove barriers that may have impeded such investigations in the past.

Quantifying increases in problem behavior following downshifts in reinforcement: A retrospective analysis and replication

The recurrence of a previously eliminated or reduced behavior following a downshift in alternative reinforcement is referred to as resurgence. Resurgence as Choice (RaC) is a quantitative model of behavioral persistence that posits that resurgence is governed by the same behavioral principles that underlie choice behavior. Consistent with the predictions of RaC, extant basic research with animals indicates that resurgence increases as an exponential function of the size of the downshift in alternative reinforcement. Recently, Shahan and Greer (2021) extended this finding to resurgence of problem behavior during schedule thinning following functional communication training (FCT). They found that when resurgence occurred, it increased exponentially as a function of relative decrements in reinforcer availability during schedule thinning with compound schedules of reinforcement. The purpose of the current study was to directly replicate the analytic procedures described in Shahan and Greer to examine resurgence of problem behavior during schedule thinning following FCT using two novel clinical datasets. Our results closely replicate the findings from Shahan and Greer, providing additional support for the generality of resurgence during downshifts in alternative reinforcement in clinical contexts. These results also highlight the potential applicability of RaC for modeling resurgence of problem behavior during FCT schedule thinning.