Treatment of self-injury and hand mouthing following inconclusive functional analyses

Evaluations of heart rate during functional analyses of destructive behavior

Previous research has examined the predictive validity of heart rate on destructive behavior; however, such research has yet to improve clinical practice or enhance our understanding of the relation between physiology and destructive behavior. The purpose of this study was to examine the predictive validity of heart rate on varying topographies and functions of destructive behavior while controlling antecedent and consequent events through functional analysis. We first demonstrated the reliability of the Polar H10 heart rate monitor and assessed the feasibility of its use in simulated functional analysis sessions. However, across four consecutively enrolled patients, heart rate was not found to be a reliable predictor of destructive behavior, regardless of its topography or function. Instead, functional reinforcer presence and absence was sufficient to predict socially reinforced destructive behavior. This study may provide a framework for the future assessment of other biological measures in relation to destructive behavior occurrence and nonoccurrence.

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.

Applying the evolutionary theory of behavior dynamics to model the subtypes of automatically reinforced self-injurious behavior

The delineation of the subtypes of automatically reinforced self-injurious behavior improved the utility of functional analysis results in predicting treatment efficacy. However, the mechanisms underlying subtype differences remain unclear and difficult to study in clinical populations. Morris and McDowell (2021) attempted to elucidate subtype differences by developing and evaluating models of the subtypes within the evolutionary theory of behavior dynamics. In the current study, we applied techniques from precision medicine to further evaluate the models developed by Morris and McDowell. This evaluation highlighted shortcomings of the existing models and suggested ways they could be improved. Thus, we conducted more extended modeling within the framework of precision medicine to identify models that were more quantitatively similar to available clinical data. Improved models that more closely approximate clinical data were identified. The implications of these models for research, practice, and further applications of the evolutionary theory of behavior dynamics are discussed.

Functional Analysis in Public School Settings: A Systematic Review of the Literature

Previous studies have shown that variations of experimental functional analysis (FA) can be used effectively as part of the functional behavioral assessment process in educational settings. The purpose of the current study was to review the literature pertaining to FA of problem behavior in schools focusing on method, topographies, and results. Results of this review showed that analog functional analysis (AFA) are conducted most often in school settings; but recent trends show that use of adapted formats (e.g., trial-based FA and brief FA) are increasing. Analysis of FA results identified most frequent topographies and maintaining variables of problem behavior in the reviewed studies. Trends in teacher-implemented FA are discussed, as well as discrepancies surrounding the terminology of FA in the literature base. Implications for further research, such as social validity of FA in public schools and use of multiple targeted topographies within school-based FA are presented.

Activity Preferences Among Older People With Dementia Residing in Nursing Homes

The study aimed to examine the influence of personal characteristics on activity preferences using decision tree analysis and examine the effects of the variables using conventional approaches (logistic regression analysis). A descriptive study was conducted with 251 nursing home residents with dementia in Korea (76.9% female) to examine the relationship between their personal characteristics and activity preferences. Decision tree analysis was used to classify participants’ activity preferences, and preference levels were examined using logistic regression analysis. Activities were classified as either physical and social activities or cognitive and affective activities. This model showed an accuracy rate of 85.7% for positively predicting physical and social activity preference and 30.3% for positively predicting cognitive and affective activity preference. Gender was the strongest determinant of activity preference. The odds of preferring physical and social activities were 3.179 times higher among women, while the odds for preferring cognitive and affective activities were 0.412 times higher among men. Notably, cognitive and affective activity preference increased to 58.8% for married male participants. This study’s findings can contribute to the development of programs to decrease behavioral and psychological symptoms among older people with dementia residing in nursing homes and provide scientific evidence for integrating these activities into long-term services for this population.

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.

Adapting Direct Services for Telehealth: A Practical Tutorial

Due to the pandemic brought on by the novel coronavirus (COVID-19), consumers of applied behavior-analytic interventions may be experiencing disrupted access to services. In response to the need for services, behavior analysts and therapists may find themselves treading unchartered waters as they use telehealth to provide direct intervention to consumers. Direct service provision via telehealth extends beyond the bounds of existing telehealth research, which primarily focuses on caregiver training and consultation. In the transition to telehealth, behavior analysts can consider how to adapt an existing evidence base of behavior-analytic strategies from a face-to-face format to intervention via a teleconferencing platform (i.e., Zoom). In this tutorial, we provide practice recommendations, task analyses, and a curated list of Zoom walk-throughs to help behavior analysts construct conceptually systematic learning opportunities in their direct telehealth services. Leveraging teleconferencing features to provide behavior-analytic intervention directly to consumers could spur future research to support these need-inspired practices and guide telehealth applications during and beyond the current pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-020-00529-5.

Reducing Stereotypies for a Student With Deafblindness

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

Integration of experimental functional analysis procedural advancements: Progressing from brief to extended experimental analyses

Despite the utility of experimental functional analysis methodology, not all applications produce differentiated results. Factors such as interaction effects or methodological inefficiencies may compromise the likelihood of obtaining differentiated outcomes. Various studies have addressed methods to improve the efficiency of experimental functional analysis methodology (e.g., analysis of within-session responding). In the current study, we describe an updated model for progressing from brief to extended experimental analyses. The model incorporates several procedural refinements developed over the past 20+ years of experimental functional analysis research and additional conditions to confirm or annul findings. We present data for 20 participants who were referred for assessment and treatment of a variety of behavior problems (e.g., stereotypy, aggression, self-injury). We generally terminated the analyses when response patterns were consistent with established best-practice functional analysis methodology. Results showed conclusive interpretations were obtained for 100% of participants.

Competing stimulus assessments: A systematic review

The current review summarizes the literature on competing stimulus assessments (CSAs). CSAs are pretreatment assessments designed to systematically identify stimuli that reduce problem behavior (PB), ostensibly through reinforcer competition or substitution. We report on the participant characteristics, outcomes, and predictive validity of published CSAs that included (a) no-stimulus control trial(s), (b) test trials during which each stimulus was available singly and noncontingently, and (c) measurement of PB and stimulus engagement or contact. Results showed that CSAs have broad utility across a variety of topographies and functions of PB. In the majority of CSA applications for which extended analyses, or validations, were performed, stimuli shown to reduce PB during the CSA produced similar reductions during extended analysis. This was the case regardless of topography or function of PB, or whether the stimuli were assumed to be "matched" to the stimulation thought to be produced by PB. Implications for future research are discussed.

Sensitivity to Changing Environmental Conditions across Individuals with Subtype 2 Automatically Reinforced and Socially Reinforced Self-injury

Automatically reinforced Subtype 2 self-injurious behavior (ASIB) has been characterized as showing insensitivity to competing reinforcement contingencies in the contexts of both functional analyses and in treatment using reinforcement alone (Hagopian, Rooker, &Yenokyan, 2018). One question is whether this insensitivity is specific to Subtype 2 ASIB as response class in these contexts or whether it is represents a generalized response tendency of the individual that is evident across other response classes. To examine this question, we compared responding on a single-operant task under changing reinforcement schedules for three individuals with Subtype 2 ASIB, relative to a comparison group of three individuals with socially reinforced SIB (which is characterized by sensitivity to changes in reinforcement contingencies). As hypothesized, all individuals showed sensitivity to changes in contingencies. These results provide preliminary support that the insensitivity of Subtype 2 ASIB is a property specific to that response class in these contexts rather than a generalized response tendency of the individual.

Increasing item engagement and decreasing automatically reinforced problem behavior within a modified competing stimulus assessment

A competing stimulus assessment (CSA) is commonly used to identify leisure items for use in treatments designed to decrease automatically reinforced problem behavior. However, this type of assessment may not yield useful information if participants do not readily engage with leisure items. The purpose of this study was to evaluate a modified CSA that included additional treatment components (i.e., prompting, prompting plus differential reinforcement of alternative behavior). The modified CSA identified the treatment components and leisure items that were most effective for increasing leisure-item engagement and decreasing problem behavior for each participant. Modified CSA outcomes maintained during an extended treatment analysis in a natural setting and when intervention components were faded.

Comparing response blocking and response interruption/redirection on levels of motor stereotypy: Effects of data analysis procedures

Autism spectrum disorder (ASD) is marked by deficits in social communication and the presence of restrictive and/or repetitive behaviors or interests. Motor stereotypy is a form of repetitive behavior that is common in ASD. Response Interruption and Redirection (RIRD) and response blocking (RB) are two interventions found to be efficacious in reducing motor stereotypy. However, the current literature presents with inconsistencies regarding the relative efficacy of these two procedures. Thus, we sought to replicate and extend previous literature by evaluating the efficacy of both interventions on reducing motor stereotypy among 3 individuals with ASD. We also sought to evaluate how variations in data analysis affected the interpretation of treatment outcomes. Results indicated that both interventions were equally efficacious at reducing stereotypy when analyzing data exclusive of treatment-implementation time. However, when analyzing total session time data, RB produced greater and more sustained reductions in stereotypy across all participants. These results emphasize the importance of data analysis decision-making in evaluating intervention outcomes.

A comparison of differential reinforcement procedures for treating automatically reinforced behavior

Children diagnosed with autism spectrum disorder (ASD) often exhibit stereotypy, which can be socially stigmatizing, interfere with daily living skills, and affect skill acquisition. We compared differential reinforcement of alternative behavior (DRA) and differential reinforcement of other behavior (DRO) when neither procedure included response blocking or interruption for (a) reducing stereotypy, (b) increasing task engagement, and (c) increasing task completion. DRA contingencies yielded superior outcomes across each measure when evaluated with 3 individuals with autism spectrum disorder.

Predicting Imminent Aggression Onset in Minimally-Verbal Youth with Autism Spectrum Disorder Using Preceding Physiological Signals

We test the hypothesis that changes in preceding physiological arousal can be used to predict imminent aggression proximally before it occurs in youth with autism spectrum disorder (ASD) who are minimally verbal (MV-ASD). We evaluate this hypothesis through statistical analyses performed on physiological biosensor data wirelessly recorded from 20 MV-ASD youth over 69 independent naturalistic observations in a hospital inpatient unit. Using ridge-regularized logistic regression, results demonstrate that, on average, our models are able to predict the onset of aggression 1 minute before it occurs using 3 minutes of prior data with a 0.71 AUC for global, and a 0.84 AUC for person-dependent models.

Behavioral treatment of automatically reinforced SIB: 1982 - 2015

Some individuals diagnosed with intellectual and developmental disabilities engage in automatically reinforced self-injurious behavior (SIB). For these individuals, identifying effective treatments may be difficult due to the nature of the reinforcement contingency. The purpose of this study was to review the literature on the treatment of automatically reinforced SIB to determine commonalities in procedures that produced effective and ineffective treatment outcomes, as well as historical trends in the treatment of this class of SIB. Results of this review indicated that there were many high-quality studies on this topic, but also a wide range in the quality of studies. As for effective treatments, noncontingent reinforcement (the most common treatment component) was found to be more effective when informed by a competing stimulus assessment rather than a preference assessment. Suggestions to improve the quality of the published record and areas in which additional research is needed are discussed.

A Review and Treatment Selection Model for Individuals with Developmental Disabilities Who Engage in Inappropriate Sexual Behavior

Some individuals with developmental disabilities develop inappropriate sexual behaviors such as public masturbation, disrobing, and touching others in an unwanted sexual manner. Such acts are problematic given the taboo nature of the behaviors and the potential for significant negative consequences, such as restricted community access, injury, and legal ramifications. Therefore, it is necessary to equip caregivers and practitioners with effective treatment options. The purpose of this paper is to review studies that have evaluated behavioral treatments to reduce inappropriate sexual behavior in persons with developmental disabilities. The strengths and weaknesses of each treatment are reviewed, and a model for treatment selection is provided.

An integrated model for guiding the selection of treatment components for problem behavior maintained by automatic reinforcement

We evaluated the usefulness of 2 assessments to guide treatment selection for individuals whose prior functional analysis indicated that automatic reinforcement maintained their problem behavior. In the 1st assessment, we compared levels of problem behavior during a noncontingent play condition and an alone or ignore condition. In the 2nd, we assessed participants' relative preferences for automatic reinforcement and social reinforcers in a concurrent-operants arrangement. We used the results of these 2 assessments to assign 5 participants to a treatment based on noncontingent access to social reinforcers or to a treatment based on differential access to social reinforcers. We conducted monthly probes with the participants over 10 to 12 months to evaluate the effects of the treatment procedures. All participants showed reductions in problem behavior over this period.

Multidisciplinary assessment and treatment of self-injurious behavior in autism spectrum disorder and intellectual disability: integration of psychological and biological theory and approach

The objective of this review is to consider the psychological (largely behavioral) and biological [neurochemical, medical (including genetic), and pharmacological] theories and approaches that contribute to current thinking about the etiology and treatment of self-injurious behavior (SIB) in individuals with autism spectrum disorder and/or intellectual disability. Algorithms for the assessment and treatment of SIB in this context, respectively, from a multidisciplinary, integrative perspective are proposed and challenges and opportunities that exist in clinical and research settings are discussed.

Delineating subtypes of self-injurious behavior maintained by automatic reinforcement

Self-injurious behavior (SIB) is maintained by automatic reinforcement in roughly 25% of cases. Automatically reinforced SIB typically has been considered a single functional category, and is less understood than socially reinforced SIB. Subtyping automatically reinforced SIB into functional categories has the potential to guide the development of more targeted interventions and increase our understanding of its biological underpinnings. The current study involved an analysis of 39 individuals with automatically reinforced SIB and a comparison group of 13 individuals with socially reinforced SIB. Automatically reinforced SIB was categorized into 3 subtypes based on patterns of responding in the functional analysis and the presence of self-restraint. These response features were selected as the basis for subtyping on the premise that they could reflect functional properties of SIB unique to each subtype. Analysis of treatment data revealed important differences across subtypes and provides preliminary support to warrant additional research on this proposed subtyping model.

Functional analysis screening for problem behavior maintained by automatic reinforcement

A common finding in previous research is that problem behavior maintained by automatic reinforcement continues to occur in the alone condition of a functional analysis (FA), whereas behavior maintained by social reinforcement typically is extinguished. Thus, the alone condition may represent an efficient screening procedure when maintenance by automatic reinforcement is suspected. We conducted a series of 5-min alone (or no-interaction) probes for 30 cases of problem behavior and compared initial predictions of maintenance or extinction to outcomes obtained in subsequent FAs. Results indicated that data from the screening procedure accurately predicted that problem behavior was maintained by automatic reinforcement in 21 of 22 cases and by social reinforcement in 7 of 8 cases. Thus, results of the screening accurately predicted the function of problem behavior (social vs. automatic reinforcement) in 28 of 30 cases.

A multimethod assessment of anxiety and problem behavior in children with autism spectrum disorders and intellectual disability

Despite the increased risk for anxiety disorders in children with autism spectrum disorders (ASD), there is a lack of research on the assessment and treatment of anxiety in this population, particularly for those with an intellectual disability (ID). The present study evaluated a multimethod strategy for the assessment of anxiety and problem behavior in three children with ASD and ID. Anxiety was operationally defined using: (1) behavioral data from anxious behaviors, (2) affective/contextual data from parent-report and observer ratings of overall anxiety, and (3) physiological data (heart rate [HR] and respiratory sinus arrhythmia [RSA]). A functional assessment of problem behavior during high- and low-anxiety conditions was conducted. Higher levels of problem behavior and HR and lower RSA were found in the high-anxiety than in the low-anxiety conditions.

The utility of assessing musical preference before implementation of noncontingent music to reduce vocal stereotypy

We conducted a modified paired-choice preference assessment and used a multielement design to examine the effects of noncontingent access to high- and low-preference music on vocal stereotypy exhibited by children with autism. For 3 of the 4 participants, high-preference music (a) produced lower levels of vocal stereotypy than low-preference music and (b) reduced vocal stereotypy when compared to a no-interaction condition. Results underscore the potential importance of assessing musical preference prior to using noncontingent music to reduce vocal stereotypy.

Evidence-based behavioral interventions for repetitive behaviors in autism

Restricted and repetitive behaviors (RRBs) are a core symptom of autism spectrum disorders (ASD). There has been an increased research emphasis on repetitive behaviors; however, this research primarily has focused on phenomenology and mechanisms. Thus, the knowledge base on interventions is lagging behind other areas of research. The literature suggests there are evidence-based practices to treat "lower order" RRBs in ASD (e.g., stereotypies); yet, there is a lack of a focused program of intervention research for "higher order" behaviors (e.g., insistence on sameness). This paper will (a) discuss barriers to intervention development for RRBs; (b) review evidence-based interventions to treat RRBs in ASD, with a focus on higher order behaviors; and (c) conclude with recommendations for practice and research.

Functional analysis and treatment of arranging and ordering by individuals with an autism spectrum disorder

Of the diagnostic features of autism, relatively little research has been devoted to restricted and repetitive behavior, particularly topographically complex forms of restricted and repetitive behavior such as rigidity in routines or compulsive-like behavior (e.g., arranging objects in patterns or rows). Like vocal or motor stereotypy, topographically complex forms of restricted and repetitive behavior may be associated with negative outcomes such as interference with skill acquisition, negative social consequences, and severe problem behavior associated with interruption of restricted and repetitive behavior. In the present study, we extended functional analysis methodology to the assessment and treatment of arranging and ordering for 3 individuals with an autism spectrum disorder. For all 3 participants, arranging and ordering was found to be maintained by automatic reinforcement, and treatments based on function reduced arranging and ordering.

Treating Vocal Stereotypy With Environmental Enrichment and Response Cost

The authors describe the assessment and treatment of vocal stereotypy in two children diagnosed with an autism spectrum disorder. Both the case studies evaluated the effectiveness of response cost (RC). The RC interventions quickly reduced and eventually eliminated the vocal stereotypy in one participant and reduced it to near-zero levels in the second. Postintervention probes for one participant confirmed the continued reduction of vocal stereotypy 1 month after treatment and its elimination 8 months after treatment. Directions for future research are also discussed.

Aggression as positive reinforcement in people with intellectual disabilities

From an applied behavior-analytic perspective, aggression in people with intellectual disabilities is mostly maintained by social reinforcement consequences. However, nonsocial consequences have also been identified in functional assessments on aggression. Behaviors producing their own reinforcement have been labeled "automatic" or "nonsocial" in the behavior-analytic literature, a label that bares a striking resemblance to biobehavioral explanations of reward-seeking behaviors. Biobehavioral studies have revealed that aggression activates the same endogenous brain mechanisms as primary reinforcers like food. Therefore, integrating brain-environment explanations would result in a better understanding of the functional mechanisms associated with nonsocial aggression. The purpose of this paper was to explore aggression as a reinforcing consequence for reinforcement-seeking behaviors in people with intellectual disabilities. First, the literature establishing aggression as reinforcement for arbitrary responding will be reviewed. Next, the reward-related biological process associated with aggression was described. Finally, the paper discusses what might be done to assess and treat aggression maintained by nonsocial reinforcement.

Description of a practitioner model for identifying preferred stimuli with individuals with autism spectrum disorders

The rich technology of stimulus preference assessment (SPA) is a product of 40 years of experimental research. Basic principles of reinforcement and a modest empirical literature suggest that high-preference stimuli identified via SPA may enhance treatment efficacy and decrease problem behavior more effectively than less-preferred stimuli. SPAs can be conducted using one of several methods associated with different time requirements and outcomes. Despite the broad applicability of preference assessments, we are unaware of widely available practitioner guidelines that prescribe when to use SPAs, how to select and modify specific SPA procedures, and how to supplement SPAs with other procedures for maximizing performance. The purpose of the current article is to describe a model for practitioners to select and conduct preference assessments based on practical considerations and research findings. Data are also reported from the application of the proposed model to preference assessments for 20 individuals diagnosed with autism spectrum disorders.

Response competition and stimulus preference in the treatment of automatically reinforced behavior: a comparison

Clinicians are particularly challenged by the development of interventions for behavior maintained by automatic reinforcement because reinforcers that maintain the responses often cannot be directly observed or manipulated. Researchers have conducted either preference assessments or competing items assessments when developing effective treatments for behavior maintained by automatic reinforcement. However, interventions based on these assessments have not been directly compared. The current study evaluated procedures to make such a comparison. High-competition items resulted in greater reductions in vocal stereotypy than did high-preference items for a preschool boy with autism.

Further evaluation of response interruption and redirection as treatment for stereotypy

The effects of 2 forms of response interruption and redirection (RIRD)-motor RIRD and vocal RIRD-were examined with 4 boys with autism to evaluate further the effects of this intervention and its potential underlying mechanisms. In Experiment 1, the effects of motor RIRD and vocal RIRD on vocal stereotypy and appropriate vocalizations were compared for 2 participants. In Experiment 2, the effects of both RIRD procedures on both vocal and motor stereotypy and appropriate vocalizations were compared with 2 additional participants. Results suggested that RIRD was effective regardless of the procedural variation or topography of stereotypy and that vocal RIRD functioned as a punisher. This mechanism was further explored with 1 participant by manipulating the schedule of RIRD in Experiment 3. Results were consistent with the punishment interpretation.

Assessment and treatment of elopement maintained by access to stereotypy

We evaluated a treatment for elopement maintained by access to stereotypic door play. First, we conducted a functional analysis of elopement that produced undifferentiated results. Next, we conducted an assessment in which we evaluated the relation between elopement and door play. Results suggested a functional relation between the 2 behaviors (i.e., elopement was maintained by contingent access to door play). Finally, we implemented functional communication training as a treatment for elopement in which access to door play was made contingent on a target appropriate communication response.

Evaluation of a multicomponent intervention for diurnal bruxism in a young child with autism

Bruxism, forceful grinding of one's teeth together, can produce destructive outcomes such as wear on the teeth and damaged gums and bone structures. The current study implemented a multicomponent intervention that consisted of vocal and physical cues to decrease rates of bruxism. A partial component analysis suggested that the vocal cue was only effective at decreasing levels of bruxism when paired with a simultaneous physical cue.