A multilevel meta-analysis of single-case and small-n research on interventions for reducing challenging behavior in persons with intellectual disabilities

Effect of stress-based interventions on the quality of life of people with an intellectual disability and their caregivers

PURPOSE

People with intellectual disabilities often show challenging behaviour, which can manifest itself in self-harm or aggression towards others. Real-time monitoring of stress in clients with challenging behaviour can help caregivers to promptly deploy interventions to prevent escalations, ultimately to improve the quality of life of client and caregiver. This study aimed to assess the impact of real-time stress monitoring with HUME, and the subsequent interventions deployed by the care team, on stress levels and quality of life.

MATERIALS AND METHODS

Real-time stress monitoring was used in 41 clients with intellectual disabilities in a long-term care setting over a period of six months. Stress levels were determined at the start and during the deployment of the stress monitoring system. The quality of life of the client and caregiver was measured with the Outcome Rating Scale at the start and at three months of use.

RESULTS

The results showed that the HUME-based interventions resulted in a stress reduction. The perceived quality of life was higher after three months for both the clients and caregivers. Furthermore, interventions to provide proximity were found to be most effective in reducing stress and increasing the client's quality of life.

CONCLUSIONS

The study demonstrates that real-time stress monitoring with the HUME and the following interventions were effective. There was less stress in clients with an intellectual disability and an increase in the perceived quality of life. Future larger and randomized controlled studies are needed to confirm these findings.

Characteristics of Moderators in Meta-Analyses of Single-Case Experimental Design Studies

Hierarchical linear modeling (HLM) has been recommended as a meta-analytic technique for the quantitative synthesis of single-case experimental design (SCED) studies. The HLM approach is flexible and can model a variety of different SCED data complexities, such as intervention heterogeneity. A major advantage of using HLM is that participant and-or study characteristics can be incorporated in the model in an attempt to explain intervention heterogeneity. The inclusion of moderators in the context of meta-analysis of SCED studies did not yet receive attention and is in need of methodological research. Prior to extending methodological work validating the hierarchical linear model including moderators at the different levels, an overview of characteristics of moderators typically encountered in the field is needed. This will inform design conditions to be embedded in future methodological studies and ensure that these conditions are realistic and representative for the field of SCED meta-analyses. This study presents the results of systematic review of SCED meta-analyses, with the particular focus on moderator characteristic. The initial search yielded a total of 910 articles and book chapters. After excluding duplicate studies and non peer-reviewed studies, 658 unique peer-reviewed studies were maintained and screened by two independent researchers. Sixty articles met the inclusion criteria and were eligible for data retrieval. The results of the analysis of moderator characteristics retrieved from these 60 meta-analyses are presented. The first part of the results section contains an overview of moderator characteristics per moderator level (within-participant level, participant level, and study level), including the types of moderators, the ratio of the number of moderators relative to the number of units at that level, the measurement scale, and the degree of missing data. The second part of the results section focuses on the metric used to quantify moderator effectiveness and the analysis approach. Based on the results of the systematic review, recommendations are given for conditions to be included in future methodological work.

Predicting Problematic Behavior in Autism Spectrum Disorder Using Medical History and Environmental Data

Autism spectrum disorder (ASD), characterized by social, communication, and behavioral abnormalities, affects 1 in 36 children according to the CDC. Several co-occurring conditions are often associated with ASD, including sleep and immune disorders and gastrointestinal (GI) problems. ASD is also associated with sensory sensitivities. Some individuals with ASD exhibit episodes of challenging behaviors that can endanger themselves or others, including aggression and self-injurious behavior (SIB). In this work, we explored the use of artificial intelligence models to predict behavior episodes based on past data of co-occurring conditions and environmental factors for 80 individuals in a residential setting. We found that our models predict occurrences of behavior and non-behavior with accuracies as high as 90% for some individuals, and that environmental, as well as gastrointestinal, factors are notable predictors across the population examined. While more work is needed to examine the underlying connections between the factors and the behaviors, having reasonably accurate predictions for behaviors has the potential to improve the quality of life of some individuals with ASD.

Non-pharmacological and pharmacological interventions for the reduction or prevention of topographies of behaviours that challenge in people with intellectual disabilities: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

People with intellectual disability show a high prevalence of behaviours that challenge. Clinical guidelines recommend that such behaviour should first be treated with non-pharmacological interventions, but research suggests off-label pharmaceuticals are commonly used. We aimed to evaluate the efficacy of non-pharmacological and pharmacological interventions for topographies of behaviours that challenge drawn from randomised controlled trials (RCTs).

METHODS

In this systematic review and meta-analysis, we searched PsycINFO, MEDLINE, Embase, CINAHL, and CENTRAL databases for RCT studies assessing an intervention (pharmacological or non-pharmacological) for behaviours that challenge (self-injury behaviour, aggression, destruction of property, irritability, and a composite overall measure) in participants with intellectual disability. The primary aim was to assess the efficacy of non-pharmacological and pharmacological interventions on behaviours that challenge. Secondary aims were to evaluate how effects varied over time and whether intervention, methodological, and participant characteristics moderate efficacy. We extracted standard mean difference (SMD) effect sizes (Cohen's d) from eligible studies and meta-analysed the data using a series of random effects models and subgroup analyses. This study was registered with PROSPERO 2021, CRD4202124997.

FINDINGS

Of 11 912 reports identified, 82 studies were included. 42 (51%) studies assessed non-pharmacological interventions and 40 (49%) assessed pharmacological interventions. Across all studies, 4637 people with intellectual disability aged 1-84 years (mean age 17·2 years) were included. 2873 (68·2%) were male, 1339 (28·9%) were female, and for 425 (9·2%) individuals, data on gender were not available. Data on ethnicity were unavailable. Small intervention effects were found for overall behaviours that challenge at post-intervention (SMD -0·422, 95% CI -0·565 to -0·279), overall behaviours that challenge at follow-up (-0·324, -0·551 to -0·097), self-injury behaviour at post-intervention (-0·238, -0·453 to -0·023), aggression at post-intervention (-0·438, -0·566 to -0·309), and irritability at post-intervention (-0·255, -0·484 to -0·026). No significant differences between non-pharmacological and pharmacological interventions were found for any topography of behaviours that challenge (all p>0·05).

INTERPRETATION

A broad range of interventions for behaviours that challenge are efficacious with small effect sizes for people with intellectual disability. These findings highlight the importance of precision in the measurement of behaviours that challenge, and when operationalising intervention components and dosages.

FUNDING

Cerebra.

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.

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.

Participant characteristics predicting communication outcomes in AAC implementation for individuals with ASD and IDD: a systematic review and meta-analysis

This meta-analysis examined communication outcomes in single-case design studies of augmentative and alternative communication (AAC) interventions and their relationship to participant characteristics. Variables addressed included chronological age, pre-intervention communication mode, productive repertoire, and pre-intervention imitation skills. Investigators identified 114 single-case design studies that implemented AAC interventions with school-aged individuals with autism spectrum disorder and/or intellectual disability. Two complementary effect size indices, Tau(AB) and the log response ratio, were applied to synthesize findings. Both indices showed positive effects on average, but also exhibited a high degree of heterogeneity. Moderator analyses detected few differences in effectiveness when comparing across diagnoses, age, the number and type of communication modes, participant's productive repertoires, and imitation skills to intervention. A PRISMA-compliant abstract is available: https://bit.ly/30BzbLv.

Mental health problems in children with intellectual disability

Intellectual disability ranks in the top ten causes of disease burden globally and is the top cause in children younger than 5 years. 2-3% of children have an intellectual disability, and about 15% of children present with differences consistent with an intellectual disability (ie, global developmental delay and borderline intellectual functioning). In this Review, we discuss the prevalence of mental health problems, interventions to address these, and issues of access to treatment and services. Where possible, we take a global perspective, given most children with intellectual disability live in low-income and middle-income countries. Approximately 40% of children with intellectual disability present with a diagnosable mental disorder, a rate that is at least double that in children without intellectual disability. Most risk factors for poor mental health and barriers to accessing support are not unique to people with intellectual disability. With proportionate universalism as the guiding principle for reducing poor mental health at scale, we discuss four directions for addressing the mental health inequity in intellectual disability.

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

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

The Effects of Data-based Instruction (DBI) for Students with Learning Difficulties in Korea: A Single-subject Meta-analysis

Data-based instruction (DBI) is an ongoing process to utilize students' data for determining when and how to intensify intervention. It is an educational approach that is suggested as effective to enhance achievements of struggling learners, particularly for those who did not respond to intensive intervention in usual ways. In Korea, DBI was introduced and applied for students with learning difficulties especially since 2000 when the first Korea curriculum-based measurement (CBM) was developed as the name of Basic Academic Skills Assessment. Despite a number of studies accumulated since then, there has been a lack of research that examined the level of evidence-based practice (EBP) of DBI research. Thus, the present study sought to synthesize the DBI research so far in Korea by analyzing the effectiveness of DBI for school-aged students with learning difficulties via meta-analysis and evaluating the quality of the research. In this study, a total of 32 single-subject design studies were used. Multilevel meta-analysis revealed that the mean effect size of DBI was statistically significant (B = 1.34) and there was significant variance across participants in effect sizes. The results from the conditional model showed that exceptionality type, the number of sessions, and the length of each session were significantly accountable for the variability of effect sizes. In addition, the results of the qualitative analysis revealed the acceptable quality of the overall DBI research with some limitations. Based on these findings, implications and study limitations were discussed.

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.

A systematic review of behaviour analytic interventions for young children with intellectual disabilities

BACKGROUND

According to several comprehensive systematic and narrative reviews, interventions based on applied behaviour analysis principles, or behaviour analytic interventions, are considered evidence based for children with autism spectrum disorder (ASD). However, no comprehensive review of the literature related to behaviour analytic interventions for children with intellectual disability (ID) currently exists.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration ID: CRD42018099317), the purpose of this study was to conduct a systematic review of the relevant published literature on the use of behaviour analytic interventions to develop skills in young children (0-8 years) with ID (and without ASD). A preliminary search of the literature identified 1209 potential studies published between January 2000 and April 2020. The review process resulted in 48 articles consisting of 49 studies (i.e. one paper contained two studies) that met the inclusion criteria. Most used single-case research designs. Studies were evaluated on five dimensions of methodological quality based on the Scientific Merit Rating Scale developed by the National Autism Center (NAC). The NAC definitions were also used for the quantity and quality of research evidence required for interventions to be considered established or emerging.

RESULTS

There were a number of limitations to the quality of the body of research. Nevertheless, various behaviour analytic interventions met criteria for being established interventions when used for targeting communication, adaptive and pre-academic skills in young children with ID. Behaviour analytic interventions targeting academic skills met criteria for emerging interventions.

CONCLUSIONS

Although the current literature is limited, results indicate that behaviour analytic interventions may be effectively used to support skill development in children with ID.

The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders

PURPOSE/BACKGROUND

Individuals with autism spectrum disorders present with social communication deficits and a rigid adherence to sameness. Along with these symptoms, many individuals also present with severe challenging behaviors that place themselves as well as their families and communities at risk for injury. For these individuals, new and effective treatments are acutely needed. Propranolol has been used worldwide for over 50 years. Its primary indication is for hypertension, but there is evidence that, at higher doses, propranolol inhibits rage and anger through its effects on the central nervous system. This effect has been demonstrated in a variety of neuropsychiatric disorders.

METHODS/PROCEDURES

Here, we present 46 retrospective analyses of clinical cases that were followed by a psychiatrist. Propranolol was prescribed as an add-on to the patients' existing medications. The doses ranged from 120 to 960 mg per day (mean = 462 mg).

FINDINGS/RESULTS

Thirty-nine (85%) of 46 patients were found to be much improved or very much improved on the physician-rated Clinical Global Impression Improvement scale. There were few side effects noted, with only 2 subjects unable to tolerate the propranolol.

IMPLICATIONS/CONCLUSIONS

It appears that high-dose propranolol can be given safely with minimal adverse cardiovascular problems, provided that close clinical monitoring is maintained. A more rigorous clinical trial is needed to elucidate and verify its clinical utility, clinical practice parameters, and the effects of propranolol as a monotherapy versus as an add-on to the patient's existing medication regimen.

Non-pharmacological interventions for challenging behaviours of adults with intellectual disabilities: A meta-analysis

BACKGROUND

Non-pharmacological interventions are recommended for the treatment of challenging behaviours in individuals with intellectual disabilities by clinical guidelines. However, evidence for their effectiveness is ambiguous. The aim of the current meta-analysis is to update the existing evidence, to investigate long-term outcome, and to examine whether intervention type, delivery mode, and study design were associated with differences in effectiveness.

METHOD

An electronic search was conducted using the databases Medline, Eric, PsychINFO and Cinahl. Studies with experimental or quasi-experimental designs were included. We performed an overall random-effect meta-analysis and subgroup analyses.

RESULTS

We found a significant moderate overall effect of non-pharmacological interventions on challenging behaviours (d = 0.573, 95% CI [0.352-0.795]), and this effect appears to be longlasting. Interventions combining mindfulness and behavioural techniques showed to be more effective than other interventions. However, this result should be interpreted with care due to possible overestimation of the subgroup analysis. No differences in effectiveness were found across assessment times, delivery modes or study designs.

CONCLUSIONS

Non-pharmacological interventions appear to be moderately effective on the short and long term in reducing challenging behaviours in adults with intellectual disabilities.

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.

Residents' and resident representatives' perspectives on the influence of the organisational environment on challenging behaviour

BACKGROUND

This study explored the perspectives of residents of residential disability service organisations and resident representatives on the influence of the organisational environment on challenging behaviour in people with intellectual disabilities (ID).

METHOD

Sixteen residents and representatives from four specialised Dutch disability service organisations were interviewed. Data were analysed using a grounded theory approach, with a sensitising frame based on Bronfenbrenner's ecological theory.

RESULTS

Some organisational factors (e.g. staff turnover, insufficient finances) can have negative effects on interactions among residents and staff and family members, resulting in more challenging behaviour, but other organisational factors (e.g. shared vision, values and expectations, competent staff) can positively influence staffs' attitudes and actions, which in turn helps to manage challenging behaviour in people with ID.

CONCLUSIONS

Residents' and representatives' perspectives provide a better understanding of the positive and negative influences of the organisational environment on challenging behaviour in people with ID.

A randomization test wrapper for synthesizing single-case experiments using multilevel models: A Monte Carlo simulation study

Multilevel models (MLMs) have been proposed in single-case research, to synthesize data from a group of cases in a multiple-baseline design (MBD). A limitation of this approach is that MLMs require several statistical assumptions that are often violated in single-case research. In this article we propose a solution to this limitation by presenting a randomization test (RT) wrapper for MLMs that offers a nonparametric way to evaluate treatment effects, without making distributional assumptions or an assumption of random sampling. We present the rationale underlying the proposed technique and validate its performance (with respect to Type I error rate and power) as compared to parametric statistical inference in MLMs, in the context of evaluating the average treatment effect across cases in an MBD. We performed a simulation study that manipulated the numbers of cases and of observations per case in a dataset, the data variability between cases, the distributional characteristics of the data, the level of autocorrelation, and the size of the treatment effect in the data. The results showed that the power of the RT wrapper is superior to the power of parametric tests based on F distributions for MBDs with fewer than five cases, and that the Type I error rate of the RT wrapper is controlled for bimodal data, whereas this is not the case for traditional MLMs.

Using a Functional Analysis Followed by Differential Reinforcement and Extinction to Reduce Challenging Behaviors in Children With Smith-Magenis Syndrome

Smith-Magenis syndrome (SMS) is a genetic disorder, commonly caused by a 17p11.2 deletion, affecting the Retinoic Acid Induced 1 gene. It affects approximately 1 in 25,000 individuals, with over 90% engaging in challenging behaviors. Function-based treatments, using the principles of applied behavior analysis, have consistently been shown to decrease challenging behaviors exhibited by individuals with developmental delays. However, additional research is needed to determine the effects of these interventions with specific diagnostic subsets, including SMS. The current study identified the function of challenging behavior for 2 children with SMS and found a function-based treatment, consisting of differential reinforcement and extinction, reduced challenging behavior for both.

Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key

PURPOSE OF REVIEW

Self-injurious behaviour (SIB) is a devastating condition frequently encountered in autism spectrum disorders (ASDs) that can lead to dangerous tissue injury and profound psychosocial difficulty. An increasing number of reports over the past decade have demonstrated the swift and well tolerated resolution of intractable SIB with electroconvulsive therapy (ECT) when psychopharmacological and behavioural interventions are ineffective. The current article provides a review of the salient literature, including the conceptualization of repetitive self-injury along the catatonia spectrum, and further clarifies the critical distinction between ECT and contingent electric shock.

RECENT FINDINGS

We searched electronically for literature regarding ECT for self-injurious behaviour from 1982 to present, as the first known report was published in 1982. Eleven reports were identified that presented ECT in the resolution of self-injury in autistic or intellectually disabled patients, and another five reports discussed such in typically developing individuals. These reports and related literature present such self-injury along the spectrum of agitated catatonia, with subsequent implications for ECT.

SUMMARY

Intractable self-injury remains a significant challenge in ASDs, especially when patients do not respond adequately to behavioural and psychopharmacological interventions. ECT is well tolerated and efficacious treatment for catatonia, and can confer marked reduction in SIB along the agitated catatonia spectrum.

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.

One by One: Accumulating Evidence by using Meta-Analytical Procedures for Single-Case Experiments

This paper presents a unilevel and multilevel approach for the analysis and meta-analysis of single-case experiments (SCEs). We propose a definition of SCEs and derive the specific features of SCEs’ data that have to be taken into account when analysing and meta-analysing SCEs. We discuss multilevel models of increasing complexity and propose alternative and complementary techniques based on probability combining and randomisation test wrapping. The proposed techniques are demonstrated with real-life data and corresponding R code.

Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability

BACKGROUND

A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control-measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction?

METHOD

A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined.

RESULTS

The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour.

IMPLICATIONS

This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.

Correlates of direct care staffs' attitudes towards aggression of persons with intellectual disabilities

BACKGROUND AND AIM

To explain direct care staff's attitudes (responsive or rejecting) towards aggression of clients with intellectual disability (ID), data were collected about client characteristics as well as individual and team characteristics of 475 direct care staff members, working in 71 teams.

METHOD AND RESULTS

Multilevel analyses revealed that a positive team climate was positively associated with both a rejecting and responsive attitude towards aggression. Senior staff members and females showed a less responsive attitude towards aggression, whereas a relatively high percentage of females in a team and a positive attitude towards external professionals were associated with a more responsive attitude towards aggression. Unexpectedly, staff who experienced less verbal and/or physical aggressive incidents of their clients with ID showed a more rejecting attitude towards aggression. Finally, characteristics of the clients with ID accounted for the largest part of the variance in the attitude towards aggression of direct care staff, in particular psychiatric diagnoses.

CONCLUSIONS AND IMPLICATIONS

Further research is necessary in order to understand how team processes affect the attitude towards aggression of direct care staff. Further it is recommended to provide direct care staff with knowledge about mental disorders in clients with ID.

The Generality of Interview-Informed Functional Analyses: Systematic Replications in School and Home

Behavioral interventions preceded by a functional analysis have been proven efficacious in treating severe problem behavior associated with autism. There is, however, a lack of research showing socially validated outcomes when assessment and treatment procedures are conducted by ecologically relevant individuals in typical settings. In this study, interview-informed functional analyses and skill-based treatments (Hanley et al. in J Appl Behav Anal 47:16-36, 2014) were applied by a teacher and home-based provider in the classroom and home of two children with autism. The function-based treatments resulted in socially validated reductions in severe problem behavior (self-injury, aggression, property destruction). Furthermore, skills lacking in baseline-functional communication, denial and delay tolerance, and compliance with adult instructions-occurred with regularity following intervention. The generality and costs of the process are discussed.

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.

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

BACKGROUND

Outwardly-directed aggressive behaviour is a significant part of problem behaviours presented by people with intellectual disabilities. Prevalence rates of up to 50% have been reported in the literature, depending on the population sampled. Such behaviours often run a long-term course and are a major cause of social exclusion. This is an update of a previously published systematic review (see Hassiotis 2004; Hassiotis 2008).

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly-directed aggressive behaviour in people with intellectual disabilities when compared to standard intervention or wait-list controls.

SEARCH METHODS

In April 2014 we searched CENTRAL, Ovid MEDLINE, Embase, and eight other databases. We also searched two trials registers, checked reference lists, and handsearched relevant journals to identify any additional trials.

SELECTION CRITERIA

We included studies if more than four participants (children or adults) were allocated by random or quasi-random methods to either intervention, standard treatment, or wait-list control groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies and extracted and assessed the quality of the data.

MAIN RESULTS

We deemed six studies (309 participants), based on adult populations with intellectual disabilities, suitable for inclusion in the current version of this review. These studies examined a range of cognitive-behavioural therapy (CBT) approaches: anger management (three studies (n = 235); one individual therapy and two group-based); relaxation (one study; n = 12), mindfulness based on meditation (one study; n = 34), problem solving and assertiveness training (one study; n = 28). We were unable to include any studies using behavioural interventions. There were no studies of children.Only one study reported moderate quality of evidence for outcomes of interest as assessed by the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We judged the evidence for the remaining studies to be of very low to low quality. Most studies were at risk of bias in two or more domains: one study did not randomly allocate participants and in two studies the process of randomisation was unclear; in one study there was no allocation concealment and in three studies this was unclear; blinding of assessors did not occur in three studies; incomplete outcome data were presented in one study and unclear in two studies; there was selective reporting in one study; and other biases were present in one study and unclear in four studies.Three of the six studies showed some benefit of the intervention on improving anger ratings. We did not conduct a meta-analysis, as we considered the studies too heterogeneous to combine (e.g. due to differences in the types of participants, sample size interventions, and outcome measures).Follow-up data for anger ratings for both the treatment and control groups were available for two studies. Only one of these studies (n = 161) had adequate long-term data (10 months), which found some benefit of treatment at follow-up (continued improvement in anger coping skills as rated by key workers; moderate-quality evidence).Two studies (n = 192) reported some evidence that the intervention reduces the number of incidents of aggression and one study (n = 28) reported evidence that the intervention improved mental health symptoms.One study investigated the effects of the intervention on quality of life and cost of health and social care utilisation. This study provided moderate-quality evidence, which suggests that compared to no treatment, behavioural or cognitive-behavioural interventions do not improve quality of life at 16 weeks (n = 129) or at 10 months follow-up (n = 140), or reduce the cost of health service utilisation (n = 133).Only one study (n = 28) assessed adaptive functioning. It reported evidence that assertiveness and problem-solving training improved adaptive behaviour.No studies reported data on adverse events.

AUTHORS' CONCLUSIONS

The existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited. There is a paucity of methodologically sound clinical trials and a lack of long-term follow-up data. Given the impact of such behaviours on the individual and his or her support workers, effective interventions are essential. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.

Comparison of behavior analytic and eclectic early interventions for young children with autism after three years

In a previous study, we compared the effects of just over one year of intensive behavior analytic intervention (IBT) provided to 29 young children diagnosed with autism with two eclectic (i.e., mixed-method) interventions (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005). One eclectic intervention (autism programming; AP) was designed specifically for children with autism and was intensive in that it was delivered for an average of 25-30 h per week (n = 16). The other eclectic intervention (generic programming; GP) was delivered to 16 children with a variety of diagnoses and needs for an average of 15-17 h per week. This paper reports outcomes for children in all three groups after two additional years of intervention. With few exceptions, the benefits of IBT documented in our first study were sustained throughout Years 2 and 3. At their final assessment, children who received IBT were more than twice as likely to score in the normal range on measures of cognitive, language, and adaptive functioning than were children who received either form of eclectic intervention. Significantly more children in the IBT group than in the other two groups had IQ, language, and adaptive behavior test scores that increased by at least one standard deviation from intake to final assessment. Although the largest improvements for children in the IBT group generally occurred during Year 1, many children in that group whose scores were below the normal range after the first year of intervention attained scores in the normal range of functioning with one or two years of additional intervention. In contrast, children in the two eclectic treatment groups were unlikely to attain scores in the normal range after the first year of intervention, and many of those who had scores in the normal range in the first year fell out of the normal range in subsequent years. There were no consistent differences in outcomes at Years 2 and 3 between the two groups who received eclectic interventions. These results provide further evidence that intensive behavior analytic intervention delivered at an early age is more likely to produce substantial improvements in young children with autism than common eclectic interventions, even when the latter are intensive.

Efficacy of behavioral interventions for reducing problem behavior in persons with autism: an updated quantitative synthesis of single-subject research

Problem or challenging behaviors are highly prevalent among persons with autism and bring along major risks for the individual with autism and his/her family. In order to reduce the problem behavior, several behavioral interventions are used. We conducted a quantitative synthesis of single-subject studies to examine the efficacy of behavioral interventions for reducing problem behavior in persons with autism. Two hundred and thirteen studies representing 358 persons with autism met the inclusion criteria and were included in the statistical analyses. Overall, we found that behavioral interventions were on average effective in reducing problem behavior in individuals with autism, but some interventions were significantly more effective than others. The results further showed that the use of positive (nonaversive) behavioral interventions was increasing over time. The behavioral interventions were on average equally effective regardless of the type of problem behavior that was targeted. Interventions preceded by a functional analysis reduced problem behavior significantly more than interventions not preceded by a functional analysis. Finally, treatment and experimental characteristics, but not participant characteristics, were statistically significant moderators of the behavioral treatment effectiveness.

A Review of Intervention Programs to Prevent and Treat Behavioral Problems in Young Children with Developmental Disabilities

Children with developmental disabilities are at higher risk for internalizing and externalizing behavioral problems than children in the general population. Effective prevention and treatment programs are necessary to reduce the burden of behavioral problems in this population. The current review identified 17 controlled trials of nine intervention programs for young children with developmental disabilities, with parent training the most common type of intervention in this population. Nearly all studies demonstrated medium to large intervention effects on child behavior post-intervention. Preliminary evidence suggests interventions developed for the general population can be effective for children with developmental disabilities and their families. A greater emphasis on the prevention of behavior problems in young children with developmental disabilities prior to the onset of significant symptoms or clinical disorders is needed. Multi-component interventions may be more efficacious for child behavior problems and yield greater benefits for parent and family adjustment. Recommendations for future research directions are provided.

Psychosocial interventions for reducing vocal challenging behavior in persons with autistic disorder: a multilevel meta-analysis of single-case experiments

Vocal challenging behavior (VCB) forms a common problem in individuals with autistic disorder. Since VCB is associated with negative outcomes for the individual and his or her environment, it is important to know how to manage this type of CB. To evaluate the effectiveness of several psychosocial interventions applied to decrease VCB in individuals with autistic disorder, we conducted a meta-analysis of single-case experiments (SCEs). Fifty-two SCEs, including 74 participants, were combined using a multilevel meta-analysis. The overall treatment effect was large and statistically significant. However, the effect varied significantly over the included studies and participants. Examining this variance, evidence was found for a moderator effect of VCB type and intervention type, with, on average, the largest effects for interventions used to reduce VCB including stereotypical VCB and for interventions containing both antecedent and consequence components. Age, gender, primary treatment setting, publication year, and study quality did not significantly moderate the intervention effect.

Prevention and early intervention for behaviour problems in children with developmental disabilities

PURPOSE OF REVIEW

To review the recent evidence regarding early intervention and prevention studies for children with developmental disabilities and behaviour problems from 2011 to 2013. Recent advances in the field are discussed and important areas for future research are highlighted.

RECENT FINDINGS

Recent reviews and studies highlight the utility of antecedent interventions and skills training interventions for reducing behaviour problems. There is preliminary evidence for the effectiveness of parent training interventions when delivered in minimally sufficient formats or in clinical settings. Two recent studies have demonstrated the utility of behavioural interventions for children with genetic causes of disability.

SUMMARY

Various forms of behavioural and parent training interventions are effective at reducing the behaviour problems in children with developmental disabilities. However, research on prevention and early intervention continues to be relatively scarce. Further large-scale dissemination studies and effectiveness studies in clinical or applied settings are needed.