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

A novel model of care for paediatric patients with developmental disabilities and associated behaviours of concern

AIM

Children and adolescents with autism spectrum disorder and/or intellectual disability often present to emergency departments with behaviours of concern: irritability, aggression and self-injurious behaviour. The objective of this study was to design, implement and evaluate a new model of care to support these patients and their families following presentation to reduce the need for re-presentation.

METHODS

We designed and evaluated a new model of care for these patients, comprising consultations with a developmental paediatrician and a child psychiatrist, referral to a specialist behavioural service and 6 weeks of care coordination by a clinical nurse consultant. Using a quality improvement framework, iterative improvements were made to the model via a series of plan-do-study-act cycles. Re-presentation rates were compared with a control group of patients who presented with behaviours of concern but were not recruited into the study. Participating families and treating clinicians were surveyed at 2 and 6 weeks post-enrolment to gather qualitative feedback about their experience of the model.

RESULTS

A total of 31 families participated in the study. Three- and 6-month re-presentation rates were 48.7% and 36.3% lower than the control group. Qualitative evaluation of the model by both families and clinicians was positive. The model was feasible and acceptable. Families reported feeling heard and understood, and that the intervention was helpful and provided a positive path forwards.

CONCLUSIONS

The findings suggest that a simple model of care can be successfully implemented and provide meaningful benefits for families of children with behaviours of concern, including reduced crisis-oriented help-seeking.

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.

Mental and Behavioral Health, and Crisis Services for People with Intellectual and Developmental Disabilities in Medicaid Home- and Community-Based Services

People with intellectual and developmental disabilities (IDD) often have higher rates of comorbid mental health conditions compared to the general population. Yet, many people with IDD also have unmet needs for mental and behavioral health services. The aim of this study was to examine how states provided mental and behavior health, and crisis services to people with IDD in their Home- and Community-Based Services (HCBS) programs, the largest funding mechanism for Long-Term Services and Supports (LTSS) for people with IDD in the United States. We analyzed fiscal year (2021) Medicaid HCBS waivers for people with IDD from across the United States to examine if and how they provided mental and behavior health, and crisis services. States projected spending $968.9 million for mental and behavior health, and crisis services for 190,299 people with IDD. Applied behavior analysis services were provided at greater rates than positive behavior supports and other forms of behavior interventions. While most states provided mental and behavior health, and crisis services in their waivers, there were vast inconsistencies in how they did so, across states, waivers, and services. HCBS are a crucial safety net to ensure people with IDD, especially those who also have mental health disabilities, can live and thrive in their communities.

Factors Associated With Prolonged Mental Health Admissions at US Children's Hospitals

BACKGROUND AND OBJECTIVES

Mental health (MH) hospitalizations at medical hospitals are associated with longer length of stay (LOS) compared with non-MH hospitalizations, but patient factors and costs associated with prolonged MH hospitalizations are unknown. The objective of this paper is to assess patient clinical and demographic factors associated with prolonged MH hospitalizations and describe variation in MH LOS across US children's hospitals.

METHODS

We studied children aged 5 to 20 years hospitalized with a primary MH diagnosis during 2021 and 2022 across 46 children's hospitals using the Pediatric Health Information System database. Generalized estimating equations, clustered on hospital, tested associations between patient characteristics with prolonged MH hospitalization, defined as those in the 95th percentile or above (>14 days).

RESULTS

Among 42 654 primary MH hospitalizations, most were aged 14 to 18 (62.4%), female (68.5%), and non-Hispanic white (53.8%). The most common primary MH diagnoses were suicide/self-injury (37.4%), depressive disorders (16.6%), and eating disorders (10.9%). The median (interquartile range) LOS was 2 days (1-5), but 2169 (5.1%) experienced a hospitalization >14 days. In adjusted analyses, race and ethnicity, category of MH diagnosis, and increasing medical and MH complexity were associated with prolonged hospitalization.

CONCLUSIONS

Our results emphasize several diagnoses and clinical descriptors for targeted interventions, such as behavioral and inpatient MH resources and discharge planning. Expanded investment in both community and inpatient MH supports have the potential to improve health equity and reduce prolonged MH hospitalizations.

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.

Registered Behavior Technicians' Training Experiences for Severe Problem Behavior: A Survey

Registered Behavior Technicians (RBTs) are the primary paraprofessionals who deliver applied behavior analysis (ABA) services to individuals with autism spectrum disorder (ASD) under supervision of a Board Certified Behavior Analyst (BCBA). Effective training and supervision for RBTs providing ABA services is critical, especially for technicians working with children who exhibit severe behaviors. Recent research has assessed the needs of BCBAs working with individuals who exhibit severe problem behavior (Colombo et al., 2021). However, no research exists to identify the needs and ongoing training offered to the RBTs who provide ABA services to clients who exhibit severe problem behavior. Thus, the purpose of the current study was to survey RBTs for their initial training experiences and ongoing supports offered when working with clients who exhibit severe problem behavior. Results indicated that some RBTs reported appropriate initial and ongoing training, however, 13% reported receiving no initial training and 29% reported receiving no ongoing training when working with clients who engaged in severe problem behavior. In addition, 75% of RBTs reported sustaining an injury themselves and 36% reported their client sustained some type of injury. Suggestions for improvement for training RBTs working with this population and directions for future research are discussed.

Developing a psychoeducational programme for caregivers of people with intellectual disability

Background

In the Western Cape, South Africa, a significant number of individuals with intellectual disabilities are cared for by caregivers who receive little or no compensation, education or support. Despite the unique challenges faced by these caregivers, no psychoeducational programmes have been implemented for this particular population.

Objectives

The study aimed to examine the factors contributing to caregiver distress and develop a solution in the form of a psychoeducational programme for caregivers.

Methods

A mixed-methods research approach was employed. The qualitative phase involved exploratory research to gather fundamental information and gain new insights into caregiver distress. The quantitative phase utilised a 'one-group pre-test, post-test design' with a Likert-scale questionnaire to enable meaningful interpretations and comparisons of the psychoeducational programme's impact and value. The paired t-test was employed to determine significant differences between pre-test and post-test results.

Results

The statistical findings demonstrated a significant increase in knowledge, with 99% of respondents indicating a positive impact in reducing caregiver distress and 85% feeling better equipped to care for individuals with intellectual disabilities.

Conclusion

The psychoeducational programme developed in this study had a positive effect on reducing caregiver distress.

Contribution

This knowledge provides valuable insights for healthcare professionals in designing relevant intervention programmes, offering support and providing resources not only for individuals with intellectual disabilities but also for their caregivers.

Community-based care for autistic youth: community providers' reported use of treatment practices in the United States

Introduction

To illustrate the landscape of community-based care for autistic youth in the United States, we identified transdisciplinary psychosocial intervention practice sets that community providers report utilizing to care for this population, and examined characteristics associated with provider-reported utilization.

Methods

The Usual Care for Autism Study (UCAS) Survey assessed provider demographics and provider-reported use of transdisciplinary practices for common ASD co-occurring problems: social difficulties, externalizing behaviors, and anxiety. Community practitioners (N = 701) from allied health, behavioral, education, medical, mental health and other disciplines who treat or work with autistic youth (7-22 years) participated.

Results

Exploratory factor analysis yielded four factors: Consequence-Based Strategies (CBS), Cognitive-Behavioral and Therapy Strategies (CBTS), Antecedent-Based Strategies (ABS), and Teaching Strategies (TS). Providers across disciplines reported utilizing ABS more often than other sets. Providers from behavioral disciplines, with less than 4-year or Master degrees, or with more experience reported the most use of ABS, CBS and CBTS. Medical and behavioral providers reported the most use of TS. Setting and child characteristics were associated with practice set use, indicating variability by disability and client socioeconomic status.

Discussion

Findings reflect the complexity and inconsistency of the service landscape for autistic youth across the U.S. Only by understanding the service landscape and predictors of practice utilization, can researchers, policymakers, provider groups, and the autistic community facilitate effective implementation strategy development and use to ultimately improve community-based care.

A multidimensional investigation of the relationship between skin-mediated somatosensory signals, emotion regulation and behavior problems in autistic children

Introduction

Autistic children may have abnormal sensory perception, emotion dysregulation and behavior problems. The aim of this cross-sectional study was to explore the relationship between skin-mediated somatosensory signals and emotion/behavior difficulties in autistic children and adolescents, in comparison typically developing peers (TDP).

Methods

Thirty-eight autistic children and adolescents and 34 TDP completed a multidimensional assessment consisting of the measurement of somatosensory thresholds of touch, pain and temperature, a task on emotion knowledge and parent-reported questionnaires on sensory reactivity, emotion regulation and behavior.

Results

Autistic children had higher pain sensitivity, less sensory reactive behaviors and more behavior problems than their TDP. In contrast to TDP, several somatosensory thresholds of autistic children correlated with emotion regulation and behavior problems.

Discussion

Sensory dysfunction may affect the development of emotional processing and behavior in autistic children and adolescents. This knowledge can lay the foundation for future studies on co-occurring alterations in corresponding neural networks and for the implementation of early interventions, including sensory rehabilitation therapy, for promoting regulated behaviors in autistic children and adolescents.

Report of the ABAI Task Force on Contingent Electric Skin Shock

As a task force appointed by the Executive Council of the Association for Behavior Analysis International (ABAI), we investigated the clinical use of contingent electric skin shock (CESS) in behavior analytic treatments for severe problem behavior. We studied how CESS is used in contemporary behavior analysis, reinforcement-based alternatives to CESS, and current ethical and professional guidelines for applied behavior analysts. We recommended that ABAI uphold clients' right to receive CESS when it is restricted to extreme cases and used under rigorous professional and legal oversight. Our recommendation was rejected by a vote of the full members of ABAI, who instead endorsed an alternative recommendation, developed by members of the Executive Council, that opposed the use of CESS under any condition. Here we present for the record our report and initial recommendations, the formal statement that was rejected by the members of ABAI, and the statement that was endorsed.

Medicinal Cannabis for Paediatric Developmental, Behavioural and Mental Health Disorders

Parents of children with developmental, behavioural and mental health disorders are increasingly asking whether medicinal cannabis might be a therapeutic option for their child. This paper presents the current evidence for medicinal cannabis in this population. Preliminary evidence from open-label studies suggests the potential for medicinal cannabis to ameliorate some symptoms in children with autism spectrum disorder. However, only one double-blind placebo-controlled trial has been completed, with inconclusive findings. Synthetic, transdermal cannabidiol gel has demonstrated efficacy for reducing social avoidance in a sub-group of children with Fragile X syndrome. Studies of medicinal cannabis are planned or underway for children and/or adolescents with autism, intellectual disability, Tourette's syndrome, anxiety, psychosis, anorexia nervosa and a number of specific neurodevelopmental syndromes. High quality evidence from double-blind placebo-controlled trials is needed to guide clinical practice.

Parent-reported factors associated with the emergency department presentation of children and adolescents with autism spectrum disorder and/or intellectual disability with behaviours of concern: a qualitative study

OBJECTIVE

We aimed to examine the parent-reported factors contributing to the emergency department (ED) presentation of children and adolescents with autism spectrum disorder (autism) and/or intellectual disability (ID) with behaviours of concern (BOC).

DESIGN

Qualitative study using semistructured interviews. Data were analysed phenomenologically using inductive thematic analysis.

SETTING

The ED of the Royal Children's Hospital, Melbourne, Australia, a tertiary paediatric hospital.

PARTICIPANTS

14 parents and/or carers of children and adolescents with autism and/or ID who presented to ED for management of BOC.

RESULTS

Three themes emerged from the data: (1) Parents and carers had difficulties navigating the healthcare system and accessing appropriate community supports prior to their child's ED presentation; (2) Families presented to ED due to an inability to manage risk and/or contain their child's behaviour, compounded by carer burn-out; (3) Presentation to ED was considered a last resort option for many families. The ED was generally unable to assist families in the ongoing management of their child's BOC, leading to a potential need to re-present in future.

CONCLUSIONS

This study highlights the need for families of children with autism and ID and associated BOC to have improved access to appropriately skilled community health professionals, allowing their BOC to be addressed as they emerge rather than at crisis point. The findings additionally highlight the need for changes to the delivery of acute care in the management of BOC, to minimise patient distress and maximise safe and satisfactory patient outcomes.

Perceptions of Saudi Arabian school teachers in private general education schools toward the inclusion of students with disabilities

BACKGROUND

Teachers' attitudes and perceptions are of significance to the inclusion of students with disabilities in the general education classroom with their typical peers.

AIMS

This study quantitatively investigated the perceptions of private elementary school teachers regarding the inclusion of students with disabilities in the general education classroom.

METHODS AND PROCEDURE

The study sample comprised 213 teachers working in private elementary schools in Riyadh, Saudi Arabia that offer inclusive special education programming alongside a general education curriculum. The Opinions Relative to the Integration of Students with Disabilities (ORI) survey, was utilized to adapt the survey instrument for this study.

RESULTS AND OUTCOMES

We concluded that private school teachers have a slightly negative attitude toward the inclusion of students with disabilities. Although the results did not reveal a relationship between teachers' attitudes and their age or education level, a relationship was found between their perceptions toward inclusion of students with disabilities and the type of disability, the individual teacher's gender, the role of the teacher (general vs. special education), and the individual's training in inclusive education.

CONCLUSIONS AND IMPLICATIONS

The implications of the results to Saudi and beyond and suggestions for further research including outside of the urban context are discussed.

Assessment of Challenging Behavior Exhibited by People with Intellectual and Developmental Disabilities: A Systematic Review

The assessment of challenging behavior exhibited by people with intellectual and developmental disabilities is essential for the planning of prevention and intervention programs. This review aimed to identify and analyze the standardized instruments that exclusively focus on the assessment of challenging behavior. We identified and organized 141 articles into four categories: original instrument studies, validation studies, relational studies, and intervention studies. The results identified 24 instruments that generally show high-quality psychometric properties and other utilities beyond the observation of the presence of challenging behavior and diagnostic categorization. Age, level of adaptive behavior, disability, presence of autism spectrum disorder, and medication are some of the variables that were found to be possibly related to the occurrence of challenging behavior. Additionally, the results suggest that interventions focused on supporting positive behavior or providing training on behavior to professionals and caregivers significantly reduced the occurrence of these behaviors. Instruments that help us to understand and measure the challenging behavior exhibited by people with intellectual and developmental disabilities are essential for the design of effective evaluation and intervention protocols.

Preliminary Development and Testing of the Risk Assessment Checklist for Self-Injury in Autism-Medical (RACSA-M)

Self-injurious behavior (SIB) is a major treatment focus for clinicians treating children with autism spectrum disorder (ASD). A review of the literature identified medical conditions that may be risk factors for an individual engaging in SIB. This study involved the creation and preliminary validation of a standardized assessment checklist: Risk Assessment Checklist for Self-Injury in Autism-Medical (RASCA-M) for the physical, behavioral, and diagnostic evaluation of non-verbal children with autism and SIB living in a residential setting. Preliminary content validity, criterion-related validity, and interobserver agreement were established. The RACSA-M is a promising instrument to assess underlying medical issues in non-verbal children with ASD and SIB.

Iterative redesign of a caregiver-mediated intervention for use in educational settings

LAY ABSTRACT

Teachers often report concerns about behavior challenges in their students with autism spectrum disorder (ASD) in the school setting. Furthermore, teachers often report that they do not have adequate training in how to manage these challenging behaviors effectively. The RUBI program is an intervention initially developed for parents of children with ASD and co-occurring challenging behavior in clinic settings. The present project used school staff input to systematically redesign RUBI to be used with educators in schools. School staff gave input at multiple stages of development to ensure the adapted intervention was appropriate to use in a school setting. Responses were coded and analyzed to identify strengths and weaknesses of the RUBI manual in schools and adaptations were made accordingly. Scores of how appropriate, possible, likable, and usable RUBI would be in schools rose after the intervention was redesigned. The redesigned RUBIES manual may give school staff the tools they need to manage disruptive behaviors. In addition, collaborating with providers over multiple stages to redesign established interventions for new contexts may be a promising way to help bring research tools to practice in the future.

Disruptive Behaviors and Intellectual Disability: Creating a New Script

BACKGROUND

Terms currently used to describe the so-called challenging and disruptive behaviors (CBDs) of children with intellectual disabilities (ID) have different connotations depending on guiding contextual frameworks, such as academic and cultural settings in which they are used. A non-judgmental approach, which does not attempt to establish existing categorical diagnoses, but which describes in a neutral way, is missing in the literature. Therefore, we tried to describe CDBs in youth with ID in an explorative study.

METHODS

Interviews with families investigated the CDBs of five youth with Down syndrome. At home, families tracked youth's sleep/wake behaviors and physical activity. Youth were observed in a summer school classroom. The collected information and suggested explanatory models for observed CDBs were reviewed with the families.

RESULTS

We grouped CDBs as challenging, if they were considered to be reactive or triggered, or unspecified, if no such explanatory model was available. A third category was created for light-hearted CDBs: goofy, acknowledging the right to laugh together with peers. We found some relationships between sleep, physical activity, and CDBs and developed an explorative approach, supporting a child-centered perspective on CDBs.

CONCLUSION

The controversial discussions on terminology and management of CDBs in the literature demonstrate the need for a non-judgmental approach. Such an explorative approach, allowing non-professionals to not label, has been missing. The fact that, up to now, the light-hearted behaviors of an individual with ID have not been integrated in commonly-used behavioral checklists as their natural right, proves our concept and indicates that a paradigm change from judgment-based to exploratory-driven approaches is needed.

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

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

Development of the Fearless, Tearless Transition model of care for adolescents with an intellectual disability and/or autism spectrum disorder with mental health comorbidities

AIM

First, to understand the barriers to achieving effective transition and the supports required from the perspective of parents and carers, adolescents with intellectual disability and/or autism spectrum disorder and co-existing mental health disorders (often termed 'dual disability'), and those who provide services to this group. Second, to develop an informed model of shared care to improve the transition of adolescents with dual disabilities.

METHOD

Carers and a young adult with a dual disability were surveyed about their experience of transition care. Other key stakeholders including paediatricians, general practitioners, and policy makers were also interviewed. These data informed the model of care.

RESULTS

Paediatricians and general practitioners reported difficulties establishing working relationships to foster smooth transitions, and carers reported lacking a regular general practitioner with adequate expertise to care for people with dual disabilities. A process of shared care between paediatricians and general practitioners was developed and initiated by a dedicated transition manager, who assisted with care coordination and service linkages. Standardized clinical assessment tools were also introduced to determine patient and carer support needs.

INTERPRETATION

This study highlights the potential to improve transition outcomes for adolescents with dual disabilities and their carers through early transition planning, consistent methods of assessing patient and carer needs, and shared care.

WHAT THIS PAPER ADDS

Adolescents with co-occurring disabilities require a collaborative health and disability service interface. Fearless, Tearless Transition is a new approach to transitioning adolescents with dual disabilities from paediatric to adult care. Carers of adolescents with dual disabilities require support navigating and negotiating services. Engaging general practitioners and paediatricians in shared care early during the transition process is essential.

Many Young Children with Autism Who Use Psychotropic Medication Do Not Receive Behavior Therapy: A Multisite Case-Control Study

OBJECTIVES

To explore how many pre-school aged children with autism spectrum disorder (ASD) used psychotropic medication, child and geographic factors associated with psychotropic medication use, and how many children who used psychotropic medication did or did not ever receive behavior therapy.

STUDY DESIGN

Children 2-5 years of age were enrolled from 2012 to 2016 in a multisite case-control study designed to investigate the development and risk factors of ASD. Children with a positive ASD screen or ASD diagnosis upon enrollment were asked to complete a comprehensive evaluation to determine ASD status and developmental level. Caregivers completed a Services and Treatments Questionnaire and multiple self-administered questionnaires to determine child use of psychotropic medication, ever receipt of behavior therapy, and presence of co-occurring symptoms.

RESULTS

There were 763 children who were classified as ASD and had data collected on the Services and Treatments Questionnaire. Of those, 62 (8.1%) used psychotropic medication to treat behavioral symptoms and 28 (3.7%) were ≤3 years of age when medication was first started. Attention problems (aOR, 7.65; 95% CI, 3.41-16.1; P < .001) and study site (aOR, 2.62; 95% CI, 1.04-6.56; P = .04) were significantly associated with psychotropic medication use after controlling for maternal race/ethnicity. More than one-half (59.7%) of those who used psychotropic medication did not ever receive behavior therapy.

CONCLUSIONS

Many preschool-aged children with ASD who use psychotropic medication do not receive behavior therapy. Pediatricians are an important resource for children and families and can help facilitate behavioral treatment for children with ASD and other disorders.

On the Occurrence of Dangerous Problem Behavior during Functional Analysis: An Evaluation of 30 Applications

Functional analyses are often conducted by behavior analysts to understand the environmental variables contributing to an individual's problem behavior to better inform treatment implementation. While functional analyses are integral for designing function-based interventions, they often arrange contingencies to evoke and reinforce dangerous problem behavior. In Study 1 we reviewed 22 functional analyses with open-contingency classes including non-dangerous topographies of problem behavior and we found that participants were more likely to exhibit the non-dangerous behavior in 82% of the applications. We then conducted a single-subject comparison of closed and open-contingency classes with four additional participants in Study 2. Our results suggest that the functional analyses with the open-contingency class reduced the likelihood of observing dangerous problem behavior.

Growing Up Fast: Managing Autism Spectrum Disorder and Precocious Puberty

CASE

John is a 4-year-old boy with autism spectrum disorder (ASD) and developmental delay who presented with concerns about increasing aggressive behavior at a follow-up visit with his developmental-behavioral pediatrician. Diagnosis of ASD was made via Diagnostic and Statistical Manual of Mental Disorders, 5th version criteria at initial evaluation at 34 months. Medical history at that time was pertinent for rapid linear growth since the age of 1 and recent pubic hair growth and penile enlargement. Family history was significant for early puberty in a maternal uncle and 4 distant maternal relatives. Standardized testing included administration of the Childhood Autism Rating Scale 2-Standard, which was consistent with severe symptoms of ASD, and the Mullen Scales of Early Learning, which indicated moderate delay in fine motor skills and expressive language and severe delay in receptive language and visual receptive skills.At initial assessment, John's parents also reported a pattern of aggressive behavior, which included frequent hitting of other children at childcare, consistently forceful play with peers and family members, and nightly tantrums with hitting and throwing at bedtime. Triggers of aggressive behavior included other children taking his toys, transition away from preferred activities, and being told "no."John was concurrently evaluated by a pediatric endocrinologist at 34 months. At that assessment, his height Z-score was +2.5, and he had Tanner 2 pubic hair, Tanner 3 genitalia, and 6 cc testicular volumes. Radiograph of the hand revealed a bone age of 6 years (+7.8 S.D.). Laboratory studies revealed a markedly elevated testosterone level and low gonadotropin (luteinizing hormone [LH] and follicle-stimulating hormone) levels and a normal dehydroepiandrosterone sulfate, suggestive of peripheral precocious puberty. Targeted genetic testing with sequencing of the LHCGR gene revealed a heterozygous D578G mutation resulting in the rare condition Familial Male-Limited Precocious Puberty (FMPP), characterized by constitutive activation of the LH receptor. FMPP, also referred to as testotoxicosis, was attributed as the cause of John's peripheral precocious puberty.By the age of 4, John's height Z-score was +3.1, his genitalia larger, and his bone age 10 years (+10.3 S.D.). His parents elected to start off-label therapy with bicalutamide (a nonsteroidal antiandrogen) and anastrazole (an aromatase inhibitor), recommended by the endocrinologist. Unexpectedly, as John's hyperandrogenism was treated, John's family reported intensified aggression toward other children and adults, especially at school, in addition to multiple daily instances of biting when upset. What is your next step in John's treatment of his challenging behavior?

REFERENCE

1. Shenker A, Laue L, Kosugi S, et al. A constitutively activating mutation of the luteinizing hormone receptor in familial male precocious puberty. Nature. 1993;365:652-654.

An Investigation of Functional Communication Training and Schedule Thinning Using a Multiple Schedule on Elopement to Access Stereotypy

Individuals diagnosed with autism spectrum disorder (ASD) who engage in stereotypy may also emit a prior, temporally contiguous, high-risk response to access stereotypic behaviors. For example, the participant in this study who was diagnosed with ASD engaged in a chained response that included elopement, often in unsafe locations, to access light switch flipping. Previous research indicates that functional communication training (FCT) with delay fading is a viable approach to reduce chained problem behavior. In this study, we extended previous research by (a) evaluating the generalized effect of FCT and schedule thinning using multiple schedule technology for an automatically maintained chained response, and (b) evaluating whether intervention effects maintained in the participant's optimal context. Results for the participant suggested that FCT with schedule thinning mitigated high-risk chained responding across settings and discrimination training using a multiple schedule assessment effectively signaled available and unavailable times for the participant to emit the chained response which matched the participant's natural schedule parameters.

The evolution of self-injurious behaviors in people with intellectual disability and epilepsy: A follow-up study

PURPOSE

Longitudinal studies of the evolution of Self-Injurious Behaviors (SIBs) in people with Intellectual Disability (ID) and epilepsy are not common. This study aimed to analyze the evolution (in terms of remission and persistence) and changes in the type, localization, frequency, and intensity of SIBs.

METHODS

SIBs were assessed in a sample of 52 people with ID and epilepsy, and re-evaluated after a seven-year interval, using the "Scale for the Assessment of Self-Injurious Behaviors". The scale was administered to caregivers (parents or health professionals) through a semi-structured interview conducted by a specifically trained psychologist.

RESULTS

The most frequent types of SIBs identified were: self-biting, self-hitting with objects, self-hitting with hand, object-finger in cavities. The main localizations of SIBs were: hands, mouth, head and cheeks. SIBs were found to be maintained after seven years, for type, localization, frequency, and intensity, in 90.4% of the sample. SIB types were stable over time, as were the affected areas. Global SIB frequency and intensity scores were found to be unchanged. Finally, a positive correlation was found between the frequency of SIBs and levels of intellectual disability. SIBs (frequency and intensity) and seizure frequency showed no correlation.

CONCLUSION

Given the negative impact of SIBs on the adaptation and quality of life of people with ID and epilepsy, we believe that further studies on biological, psychological and environmental aspects are needed in order to identify any potential factors that might explain the persistence of SIBs and to find effective interventions to reduce them.

Value-Driven Care in Developmental-Behavioral Pediatrics, Part 2: Measuring Quality and Meeting the Challenge

The drive to improve quality and reduce cost of health care is leading to a value-driven transformation of the US health care landscape. This is the second of a 2-part series on value-driven care and its implications for developmental-behavioral pediatrics (DBP). Part 1 addressed costs of care and enhancing value of care, with a particular focus on the value proposition of the field of DBP. This study begins with a discussion of the Donabedian's model of quality, including structure, process, patient satisfaction, and outcomes. The challenges of measuring process and outcomes in DBP are discussed, with a focus on (1) children 0 to 3 years of age identified as having global developmental delay, (2) recent diagnosis of complex attention-deficit hyperactivity disorder (ADHD) (ADHD plus comorbid conditions), and (3) children with autism spectrum disorder (ASD) and disruptive behavior. The study concludes with some of the important next steps for DBP providers, researchers, health care systems, professional societies, and families. With a discussion of national trends and a local example of a DBP program's response to these trends, the series is intended to provoke discussion and action in the field, contribute to the demonstration of value of a DBP approach to care, and help to chart a course toward growth and sustainability of DBP in an era of value-based care.

Examining the Specificity of Forms and Functions of Aggressive Behavior in Boys With Fragile X Syndrome

Limited information is available concerning the specificity of the forms and functions of aggressive behavior exhibited by boys with fragile X syndrome (FXS). To investigate these relationships, we conducted indirect functional assessments of aggressive behavior exhibited by 41 adolescent boys with FXS and 59 age and symptom-matched controls with intellectual and developmental disability (IDD) and compared the data between groups. Results showed that boys with FXS were more likely to exhibit specific forms of aggressive behavior (i.e., scratching others and biting others) compared to controls, but the sources of reinforcement identified for aggression were similar across groups. Boys with FXS who were prescribed psychotropic medications were more likely to be older and to exhibit more forms of aggression. The implications for the treatment of aggressive behavior during this critical developmental period in FXS are discussed.

A Meta-analysis of Challenging Behavior Interventions for Students with Developmental Disabilities in Inclusive School Settings

Challenging behavior is a significant barrier in accessing the general education curriculum for students with developmental disabilities. This necessitates the identification of evidence-based practices for addressing challenging behavior in inclusive settings. The purpose of our meta-analysis is to (a) quantify the magnitude of effect of interventions targeting the reduction of challenging behavior in students with developmental disabilities in inclusive educational settings and (b) determine if participant and intervention characteristics moderate intervention effects. A systematic search of academic databases was conducted to identify studies, which were evaluated for methodological rigor and analyzed for effects using Tau-U. Results indicate a strong overall effect of .94 (95% CI [.87, 1]) and moderating variables associated with behavior topography, interventionist, and intervention components were identified.

Evaluation of agomelatine for the treatment of sleep problems in adults with autism spectrum disorder and co-morbid intellectual disability

PURPOSE

Intellectual disability (ID) and autism spectrum disorder (ASD) are common, co-occurring developmental disorders and are frequently associated with sleep problems. This study aimed to assess the effectiveness and tolerability of agomelatine as a pharmacotherapy for sleep problems in ASD adults with ID.

METHOD

A randomised, crossover, triple-blind, placebo-controlled clinical trial, with two three-month periods of treatment starting with either agomelatine or placebo and a washout period of two weeks. Ambulatory circadian monitoring (24 hours/7 days) evaluated total sleep time (TST) as the primary outcome variable.

RESULTS

Participants (N=23; 35±12 years old; 83% male) had a median of three (interquartile range (IQR) 1-4) co-morbidities and were taking a median of five (IQR 2-7) prescribed drugs. Before agomelatine or placebo treatment, all subjects presented with insomnia symptoms, including sleep latency (100% abnormal, 55±23 minutes) or TST (55% abnormal, 449±177 minutes), and 66% had circadian rhythm sleep-wake abnormalities with rhythm phase advancements according to the M5 sleep phase marker values. During the three-month agomelatine treatment, night TST significantly increased by a mean of 83 minutes (16% abnormal, 532±121 minutes), together with a phase correction (M5 1:45±2:28 hours vs. 3:15±2:20 hours), improving sleep stability in wrist temperature rhythm (0.43±0.29 vs. 0.52±0.18 AU). Adverse events were mild and transient.

CONCLUSIONS

Agomelatine was effective and well tolerated for treating insomnia and circadian rhythm sleep problems present in adults with ASD and ID.

Animal Models of Self-Injurious Behavior: An Update

Although self-injurious behavior is a common comorbid behavior problem among individuals with neurodevelopmental disorders, little is known about its etiology and underlying neurobiology. Interestingly, it shows up in various forms across patient groups with distinct genetic errors and diagnostic categories. This suggests that there may be shared neuropathology that confers vulnerability in these disparate groups. Convergent evidence from clinical pharmacotherapy, brain imaging studies, postmortem neurochemical analyses, and animal models indicates that dopaminergic insufficiency is a key contributing factor. This chapter provides an overview of studies in which animal models have been used to investigate the biochemical basis of self-injury and highlights the convergence in findings between these models and expression of self-injury in humans.