Clinical decision making and preference assessment for individuals with intellectual and developmental disabilities

Views of parents of children with Down syndrome on Alzheimer's disease vaccination

Individuals with Down syndrome (DS) experience increased risk of Alzheimer's disease (AD). Recent studies suggest that a vaccine against AD may be forthcoming. Parental buy-in is critical to the success of any intervention in this population, as adults with DS often rely on familial support. This study aims to characterize parents' perceptions of a hypothetical vaccine to prevent AD in individuals with DS. A mixed-methods, anonymous survey was distributed via social media. Participants were asked about their experiences with DS and reactions to proposed interventions. Open-ended responses were thematically analyzed using NVivo 12. Of 1,093 surveys initiated, 532 were completed. Of the parents sampled (N = 532), a small majority (54.3%), supported the proposed AD vaccine. All expressed the need for extensive pre-enrollment education and minimal risk. For many, limited research and long-term sequelae were concerns.

Applied Behavior Analysis and the Abolitionist Neurodiversity Critique: An Ethical Analysis

The behavior analytic literature on neurodiversity remains limited. This article aims to begin filling the lacuna. We will introduce the neurodiversity perspective and demonstrate an important congruence between the behavior analytic and neurodiversity perspectives on autism. Despite this congruence, applied behavior analysis is often targeted for criticism by proponents of the neurodiversity perspective. A central concern raises questions about the aims of behavior analytic interventions for clients with autism. Is it appropriate to teach clients with autism to behave as if they were neurotypical? Concerns about the aims of behavior analytic interventions mirror concerns that have been raised about the aims of language education in schools. Drawing on the literature regarding linguistically diverse classrooms, we will critically evaluate the abolitionist neurodiversity critique of ABA. We conclude by considering both concrete and theoretical implications for the ethics of behavior analytic work with autistic clients.

Time Series Analyses of the Responses to Sensory Stimuli of Children with Severe and Multiple Disabilities

Severe and multiple disabilities (SMD) refers to the simultaneous occurrence of intellectual and physical problems. SMD in children is difficult to assess, as they often do not have the proper language or bodily responses to represent their feelings. In this study, we propose a methodology for evaluating reactions of children with SMD to sensory stimuli that does not rely on observations by humans, but rather is based on automatic detection of video-recorded data and quantification by time-series analyses. We present two case studies with typical participants: one with large body movements (P1) and another with subtle body movements (P2). For P1, it was observed that he showed larger bodily movements just before the onset of tactile stimuli, while he became silent for approximately 10 s after the onset, with the stimuli causing him to reduce self-stimulatory behavior and pay attention to his external environment. For P2, two quantitative methodologies – correlation coefficient and Granger causality – were adopted, to compare behavioral difference during the presentation of either sour or sweet taste stimuli. For the sweet conditions, the movement of the mouth was considered to be generated by some internal causes. Through these experiments, we confirmed the authenticity of assessments made by the participants’ caregivers, and also revealed otherwise unseen behavioral patterns and structures.

Diagnosis and Treatment of Childhood Apraxia of Speech Among Children With Autism: Narrative Review and Clinical Recommendations

PURPOSE

Treatment for children with autism spectrum disorder (ASD) and low verbal ability is a largely neglected area of study. Existing research focuses on language abilities; however, a subset of children with ASD also has speech sound disorders (SSDs). The purpose of this tutorial is to provide clinicians with evidence-based recommendations to guide speech assessment and treatment among children with ASD, low verbal ability, and suspected childhood apraxia of speech (CAS).

METHOD

Multifaceted search procedures were used to identify studies that have assessed or treated speech sound production among children with ASD. A narrative review and synthesis of the literature is followed by practical clinical recommendations based on best available evidence.

CONCLUSIONS

It is critically important to consider all possible hindrances to the development of functional communication ability for children with ASD. Speech sound production has been identified as a key predictor of expressive language outcomes, yet there are very few studies that address assessment and treatment of SSDs among children with ASD. Less is known about the presentation of CAS among children with ASD and low verbal ability. More research is needed to determine whether existing speech assessment and treatment methods are appropriate for children with ASD, if modifications are needed, or if new methods should be designed.

Stimulus Preference Assessment Decision-Making System (SPADS): A Decision-Making Model for Practitioners

A stimulus preference assessment (SPA) is a fundamental tool used by practitioners to predict stimuli that function as reinforcers. The Behavior Analyst Certification Board (BACB) requires that all certified behavior analysts and behavioral technicians be trained in SPA methodology (BACB, 2017). SPA procedures are used by nearly 9 out of 10 behavior analysts in the field (Graff & Karsten, 2012). Over the last 4 decades, there has been a litany of research on SPA procedures. Despite the universality of training, application, and research, discussions on the selection of SPA procedures have been sparse. Two peer-reviewed articles have focused on clinical decision making in the selection of SPA procedures. Karsten et al. (2011) introduced an in situ decision-making model, whereas Virues-Ortega et al. (2014) developed an a priori algorithm based on client and stimuli characteristics. The SPADS addresses the limitations of prior models by considering the effects of stimuli dimensions, client characteristics, relative administration times, and the outcomes agreement between two potentially efficacious, context-specfic SPA procedures.

Toward an experimental analysis of verbal shaping in psychotherapy

AbstractObjective. Some authors have suggested that verbal shaping is an active component in cognitive restructuring. The goal of the current study was to provide experimental evidence in support of the shaping hypothesis.

METHOD

Three consecutively admitted adults with symptoms of anxiety and depression participated in the study. Participants underwent baseline, treatment comparison, crossover, and follow-up phases as part of an experimental single-case study. We selected two target irrational beliefs and praised either the client's approximations to a terminal (more adaptive) class of verbalizations (differential reinforcement of approximations) or just the terminal class of verbalizations (terminal reinforcement).

RESULTS

Irrational beliefs exposed to differential reinforcement of approximations was a more effective approach to reducing irrational beliefs.

CONCLUSION

The study provides experimental evidence in support of the verbal shaping hypothesis. Our findings suggest that it may be possible to enhance clinical outcomes by actively engaging in verbal shaping during client-therapist verbal interaction.

Use of an Online Training with Virtual Role Play to Teach Preference Assessment Implementation

Identification of reinforcers is critical to the effectiveness of behavioral interventions. Stimulus preference assessments (SPA) are a frequently used method to identify putative reinforcers. Given the fluctuating nature of individual preferences, there is need for efficient training of providers that may regularly implement SPAs. The present study evaluated the utility of a web-delivered training with virtual role play to train SPA implementation. This study builds upon previous literature by utilizing a larger sample and incorporating role-play, a component often omitted from other efficient methods of training. Study 1 trained 40 undergraduate students to implement an SPA via web or in vivo. Results suggest both trainings were equivalently effective, and the web-delivered training reduced trainer time by approximately 25 min. Live role-play and feedback was still necessary with web-delivered training, consistent with suggestions that rehearsal and feedback is a vital component of training. Results also suggest web-delivered training may identify areas of weakness following training. A follow-up clinical pilot showed that the web-delivered training was also effective at training eight novice providers to competently implement the SPA with children with ASD in a special education school. This study demonstrates that web-delivered training with virtual role-play is likely another efficient training method for implementation of behavioral procedures.

On the BACB's Ethics Requirements: A Response to Rosenberg and Schwartz (2019)

Rosenberg and Schwartz (Behavior Analysis in Practice, 12, 473–482, 2019) criticize a number of aspects of the Behavior Analyst Certification Board’s Professional and Ethical Compliance Code for Behavior Analysts and propose, as an alternative, a decision-making process for evaluating the ethicality of behavior under a particular set of circumstances. We respond to the authors’ main criticisms and discuss the broader professional and legal context of any profession’s ethics code and enforcement activity.

The Use of Stimulus Preference Assessments for Persons with Neurocognitive Disorder: A Literature Review

Objectives: Stimulus preference assessments are a systematic, observation-based approach for identifying preferences among individuals with impaired communication skills. The purpose of this paper is to provide a review of the existing empirical literature that has utilized these methods with persons who have neurocognitive disorder (NCD).Methods: Studies were identified by searching online databases using a variety of search terms. Articles were included in the review if they were peer-reviewed, in English, were empirical in nature, and conducted a stimulus preference assessment with older adults diagnosed with NCD.Results: Eleven articles met the search criteria. Results revealed that data from stimulus preference assessments could increase activity engagement, increase requests for preferred items, identify reinforcers, and reduce behavioral and psychological symptoms.Conclusions: A small body of empirical literature suggests that data derived from stimulus preference assessments can be used to improve the lives of persons with NCD and their caregivers. Additional research is needed, however, to determine how effectively these procedures can be implemented into everyday practice in long-term care facilities.Clinical Implications: Stimulus preference assessments may provide a clinically useful means for efficiently identifying preferences in persons with severe NCD who cannot verbalize their needs.

Clinical Utility of Multisensory Environments for People With Intellectual and Developmental Disabilities: A Scoping Review

IMPORTANCE

Adults with intellectual and developmental disabilities (IDD) are twice as likely as their peers without disabilities to have had a physical exam in the past year; however, as a result of challenging behavior during office visits, they are significantly less likely to have received recommended health screenings. Challenging behaviors in clinical settings have been identified as a barrier to providing adequate care for this population.

OBJECTIVE

This scoping review examined the within-session effects of multisensory environments (MSEs) on people with IDD to determine the clinical utility of MSEs for this population.

DATA SOURCES

Studies published between January 1, 2000, and August 1, 2018, were identified using Summon and Google Scholar.

STUDY SELECTION

Studies were included in the review if they systematically collected and reported data on within-session effects of an MSE intervention on people with IDD.

FINDINGS

Thirteen studies met criteria for this review: 4 with Level I evidence, 2 with Level II evidence, 3 with Level III evidence, and 4 with Level IV evidence. Studies examined the effects of MSEs on maladaptive behaviors, positive behaviors, distress and discomfort, activity and alertness states, and cost of care for people with IDD.

CONCLUSION AND RELEVANCE

Preliminary support was found for the use of MSEs in clinical settings to reduce anxiety and challenging behaviors in patients with IDD during clinical care. Further research is needed to determine the efficacy of MSEs for producing the effects described in this review.

WHAT THIS ARTICLE ADDS

The findings support the potential of MSEs as a tool that occupational therapy practitioners can use to support their clients with IDD who have sensory sensitivities in clinical settings. This article also highlights a multidisciplinary approach whereby medical providers and occupational therapy practitioners could work together in nontraditional ways to support this population.

Proposal for a Framework to Enable Elicitation of Preferences for Clients in Need of Long-Term Care

PURPOSE

Collaborative deliberation comprises personal engagement, recognition of alternative actions, comparative learning, preference elicitation, and preference integration. Collaborative deliberation may be improved by assisting preference elicitation during shared decision-making. This study proposes a framework for preference elicitation to facilitate collaborative deliberation in long-term care consultations.

METHODS

First, a literature overview was conducted comprising current models for the elicitation of preferences in health and social care settings. The models were reviewed and compared. Second, qualitative research was applied to explore those issues that matter most to clients in long-term care. Data were collected from clients in long-term care, comprising 16 interviews, 3 focus groups, 79 client records, and 200 online client reports. The qualitative analysis followed a deductive approach. The results of the literature overview and qualitative research were combined.

RESULTS

Based on the literature overview, five overarching domains of preferences were described: "Health", "Daily life", "Family and friends", "Living conditions", and "Finances". The credibility of these domains was confirmed by qualitative data analysis. During interviews, clients addressed issues that matter in their lives, including a "click" with their care professional, safety, contact with loved ones, and assistance with daily structure and activities. These data were used to determine the content of the domains.

CONCLUSION

A framework for preference elicitation in long-term care is proposed. This framework could be useful for clients and professionals in preference elicitation during collaborative deliberation.

Incorporating Preference Assessment into Transition Planning for People with Autism Spectrum Disorder

Learners with Autism Spectrum Disorder (ASD) often struggle with communicating preferences integral to the transition planning process. Systematic preference assessments (SPAs) are objective methods for observing and documenting learner responses to a variety of environmental stimuli. An extensive literature-base exists supporting the inclusion of SPAs when identifying potentially reinforcing stimuli for educational programming. Although these methodologies are effective, in the transition planning process they may be useful beyond identifying potentially reinforcing stimuli. The following commentary provides an overview of the transition planning process, as well as how preference assessment may enhance that process.

Using Pictures Depicting App Icons to Conduct an MSWO Preference Assessment on a Tablet Device

Identifying preferred content on tablet devices may be important when using such devices in programming. This study included six adults with disabilities and examined using laminated picture cards depicting application (app) icons to conduct multiple-stimulus without replacement (MSWO) preference assessments of iPad content. Following identification of preference hierarchies, we conducted reinforcer assessments to validate preference assessment results by demonstrating that selected apps functioned as reinforcers. We identified preference hierarchies for all participants, and the highest preferred app functioned as a reinforcer for a vocational task in five out of six participants' reinforcer assessments.

Assessing preferences of individuals with developmental disabilities using alternative stimulus modalities: A systematic review

The purpose of this systematic review was to identify investigations comparing the efficacy of alternative modality (e.g., pictorial, verbal, video) stimulus preference assessments for individuals with developmental disabilities. We identified articles by searching peer-reviewed journals using the PsycINFO and ERIC databases, conducting table of contents searches of common behavioral outlets, and conducting ancestral searches of recent reviews and practitioner summaries of preference assessment methodology. A total of 32 articles met our inclusion criteria. These studies were then coded across a variety of features to gain a better understanding of the efficacy of alternative format preference assessments for individuals with developmental disabilities. In addition, we reviewed this literature for the use of prerequisite-skill assessments and contingent-reinforcer access to further investigate the relation between these variables and the accuracy of pictorial, verbal, and video preference assessments. A variety of methodological concerns are discussed as well as suggestions for future research.

An Upgraded Smartphone-Based Program for Leisure and Communication of People With Intellectual and Other Disabilities

Background: People with intellectual disability and sensory or sensory-motor impairments may display serious problems in managing functional daily activities as well as leisure activities and communication with distant partners. Aim: The study assessed an upgraded smartphone-based program to foster independent leisure and communication activity of eight participants with mild to moderate intellectual disability, sensory or sensory-motor impairments, and limited speech skills. Method: The upgraded program was based on the use of (a) a Samsung Galaxy A3 smartphone with Android 6.0 Operating System, near-field communication, music and video player functions, and Macrodroid application, and (b) special radio frequency-code labels. Participants requested leisure and communication activities by placing mini objects or pictures representing those activities and containing frequency-code labels on the smartphone. The smartphone, via the Macrodroid application, read the labels (i.e., discriminated the participants' requests) and provided the participants with the activities requested. Results: During the baseline (i.e., in the absence of the program), the participants failed to request/access leisure and communication activities independently. During the post-intervention phase of the study (i.e., using the program), they succeeded in requesting/accessing those activities independently and spent about 70-90% of their session time busy with those activities. Conclusion: The upgraded smartphone-based program may be highly functional for people like the participants of this study.

Assessing the efficacy of pictorial preference assessments for children with developmental disabilities

Past research has demonstrated that pictorial preference assessments can predict subsequent reinforcement effects for individuals with developmental disabilities only when access to the selected stimulus is provided contingent on a pictorial selection. The purpose of the present investigation was to assess more comprehensively the feasibility of the pictorial format with children with developmental disabilities. In Experiment 1, prerequisite skill assessments were conducted, and the role of a contingent reinforcer was assessed by comparing the results from the pictorial assessment without contingent access to a reinforcer assessment. If contingent access was found to be necessary, the effects of schedule thinning were evaluated to determine whether a pictorial format could be made more practical in Experiment 2. The pictorial format without contingent access was successful with only some participants. However, schedule thinning was found to be an effective method to establish conditioned reinforcement properties for pictorial stimuli to create a more practical assessment for a subset of participants.

A translational approach to the functional analysis of language in psychotherapy

The functional analysis of verbal behavior has been successful in establishing basic and advanced forms of language in individuals with developmental disabilities. The development of behavioral approaches to psychotherapy, such as the functional-analytic psychotherapy, have advanced the implementation of operant analyses of verbal behavior among typical adults. The field of behavior-analytic approaches to psychotherapy departs from the applied experimental research in behavior analysis in various ways: (a) minimal use of molecular analyses of behavioral processes using single-subject experimentation, (b) confined use of functional analysis and function-driven intervention, and (c) metaphoric use of mainstream behavioral concepts and methods. The breakthroughs brought about by behavioral approaches to psychotherapy may be supplemented by way of translating some of the findings of the applied experimental literature. The present analysis illustrates how behavioral processes demonstrated in the context of experimental research, often with individuals with developmental and intellectual disabilities, may be relevant to psychotherapy with typically-developed adults. This translational approach is discussed with reference to basic language processes: echoics, mands, tacts, and intraverbal dynamics. This approach could prompt programmatic translational research in the field of behavioral psychotherapies.