The problem of parental nonadherence in clinical behavior analysis: effective treatment is not enough

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

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

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

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

Family-Centric Applied Behavior Analysis Facilitates Improved Treatment Utilization and Outcomes

Background/Objective: Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by lifelong impacts on functional social and daily living skills, and restricted, repetitive behaviors (RRBs). Applied behavior analysis (ABA), the gold-standard treatment for ASD, has been extensively validated. ABA access is hindered by limited availability of qualified professionals and logistical and financial barriers. Scientifically validated, parent-led ABA can fill the accessibility gap by overcoming treatment barriers. This retrospective cohort study examines how our ABA treatment model, utilizing parent behavior technicians (pBTs) to deliver ABA, impacts adaptive behaviors and interfering behaviors (IBs) in a cohort of children on the autism spectrum with varying ASD severity levels, and with or without clinically significant IBs. Methods: Clinical outcomes of 36 patients ages 3-15 years were assessed using longitudinal changes in Vineland-3 after 3+ months of pBT-delivered ABA treatment. Results: Within the pBT model, our patients demonstrated clinically significant improvements in Vineland-3 Composite, domain, and subdomain scores, and utilization was higher in severe ASD. pBTs utilized more prescribed ABA when children initiated treatment with clinically significant IBs, and these children also showed greater gains in their Composite scores. Study limitations include sample size, inter-rater reliability, potential assessment metric bias and schedule variability, and confounding intrinsic or extrinsic factors. Conclusion: Overall, our pBT model facilitated high treatment utilization and showed robust effectiveness, achieving improved adaptive behaviors and reduced IBs when compared to conventional ABA delivery. The pBT model is a strong contender to fill the widening treatment accessibility gap and represents a powerful tool for addressing systemic problems in ABA treatment delivery.

Clinical Outcomes from an Interdisciplinary Outpatient Feeding Treatment Pilot Program

Many children with developmental disabilities experience feeding challenges, including food refusal and food selectivity. Feeding concerns are often multifaceted and, therefore, an interdisciplinary approach to treatment is needed. A pilot of an interdisciplinary outpatient feeding program was conducted in a hospital medical center by psychologists and occupational therapists. The pilot program focused on caregiver training and improvements in targeted feeding goals in both the clinic and home settings. Treatment outcomes from this pilot program found increases in bite acceptance, decreases in inappropriate mealtime behaviors, increases in caregiver-reported number of foods consumed, and mastery of most individualized feeding goals for children who participated in the treatment program. Additionally, caregivers reported decreased concerns related to feeding and increased confidence in addressing their child's feeding concerns after participation in the treatment. Caregivers also reported high levels of satisfaction with this pilot program and reported the intervention to be feasible.

Caregiver involvement in applied behavior-analytic research: A scoping review and discussion

We conducted a scoping review to characterize the role of caregiver involvement in behavior-analytic research. We reviewed eight behavioral-learning journals from 2011-2022 for works that included children or caregivers as participants and characterized caregiver involvement as passive (implications for caregivers, input, social validity) and active (implementation, caregiver behavior, training, caregiver-collected data). The review identified 228 studies, and almost all (96.1%; n = 219) involved caregivers in some capacity; 94.3% (n = 215) had passive involvement (26.8% had only passive involvement; n = 61), 69.3% (n = 158) had active involvement (1.8% had only active involvement; n = 4), and 3.9% (n = 9) had neither passive nor active involvement. Involvement generally increased over publication years. The most common types of involvement were implications for caregivers, implementation, and input; caregiver-collected data were rare. We propose considerations when engaging caregivers in research and suggest new avenues of inquiry related to caregivers' treatment objectives and social validity, treatment implementers, and caregiver-collected data.

Recommendations for Working with Culturally and Linguistically Diverse Families: A Report from the Field

Given the persistent shift in racial and ethnic demographics in the United States, board certified behavior analysts (BCBAs) will increasingly serve culturally and linguistically diverse families. There has been a recent increase in published resources to help behavior analysis practitioners navigate working with diverse populations. The purpose of this article is to add to these resources and demonstrate how these recommendations can be put into action. We outline five recommendations for working with culturally and linguistically diverse families in the context of a small company that has incorporated these practices in their own work focused on serving a large percentage of immigrant families.

Expanding a laboratory model for evaluating relapse of caregiver nonadherence

Caregiver adherence to treatment plans is likely maintained by negative reinforcement and can contact extinction when child responding relapses. When caregiver adherence contacts extinction, caregiver nonadherence, such as reinforcing their child's challenging behavior, relapses, threatening treatment efficacy. Previous laboratory models demonstrating the relapse of caregiver nonadherence only evaluated treatment for behavior maintained by social-positive reinforcement, not that maintained by social-negative reinforcement. These models only measured caregiver nonadherence as discrete events, which cannot capture the magnitude of each error. The present study was an evaluation of the relapse of caregiver nonadherence during simulated treatments for escape-maintained challenging behavior. First, caregivers placed demands in a home-like setting and a research confederate responded to these demands in a manner mimicking clinical clients. Next, caregivers were taught to implement treatment in a clinical setting and the confederate's behavior gradually improved. Last, caregivers returned to the home-like setting and confederate challenging behavior relapsed. Nonadherence relapsed for all caregivers, demonstrating the need for additional research on methods for mitigating caregiver relapse during treatment of children's challenging behavior and the usefulness of the proposed measurement system for future research.

Developing the Parent-Coaching Assessment, Individualization, and Response to Stressors (PAIRS) Tool for Behavior Analysts

Parent engagement in early behavioral intervention is essential to achieving meaningful intervention outcomes. However, parents may experience multiple barriers to engagement. The Parent-coaching Assessment, Individualization, and Response to Stressors (PAIRS) was developed to help practitioners assess families' barriers and facilitators, individualize their intervention, and respond to stressors using a contextual, functional approach. An expert panel of Board Certified Behavior Analysts ® (BCBAs) evaluated the content validity of the PAIRS. Average scale values (S-CVI/Ave) were 0.92 for relevance, 0.85 for effectiveness, and 0.91 for appropriateness. The PAIRS was revised, and a follow-up evaluation was conducted to rate the tool's utility. This led to the final version of the PAIRS. Clinical implications and future directions are discussed.

Using Telehealth to Program Generalization of Caregiver Behavior

Stokes and Baer, Journal of Applied Behavior Analysis, 10(2), 349-367 (1977) provided guidelines to assist practitioners with programming for the generalization of behavior change. Despite the suggestions provided in their seminal paper, generalization remains an often overlooked area within behavior analytic research and practice. In addition, few studies have described explicit strategies to program for the generalization of caregiver behaviors that are consistent with interventions to reduce child challenging behavior. In the current discussion, we describe how telehealth provides a potential avenue for practitioners to focus on generalization. Telehealth helps practitioners access behavior-change agents, materials, and contexts that they may not directly contact in educational and clinical environments. Using telehealth to target these areas early on, and throughout treatment for child challenging behavior, may facilitate more rapid treatment success and maintenance. We provide a case example to demonstrate the use of telehealth to program the generalization of a mother's treatment plan implementation to reduce the severe challenging behavior of an adolescent. We report clinically and socially significant outcomes related to caregiver fidelity and challenging behavior reduction.

Online ACT Matrix Parent Training for Japanese-Speaking Mothers with Distress in the United States

Cultural stigma, shame, self-concealment, and language and socio-economic barriers often keep Asian immigrant parents and children away from mental and behavioral services in the United States. Research shows that increased levels of parent distress suggest a negative impact on parenting practices and correlate child-maltreatment. Therefore, this study aimed to test one functionally contextual strategy to address such issues. The current study evaluated the effects of an online Acceptance and Commitment Training (ACT) Matrix for Japanese-speaking mothers living the United States. A nonconcurrent multiple baseline single-subject design across four mothers was used to assess the effect of ACT Matrix on value-driven behaviors, parental engagement (session attendance and daily assignment completion), parental distress, and psychological flexibility. The study consisted of a baseline, treatment (three ACT Matrix treatment sessions adapted from the six-step protocol), maintenance, and follow-up phases. A visual analysis reporting level, trend, variability, immediacy of change and overlap was used to identify a functional relation between the treatment and observable overt behaviors of value-driven behaviors and daily assignment completion. In addition, a non-overlap of all pairs was used to measure effect sizes for these behaviors. For psychological flexibility and parental distress, we used the reliable change index to assess whether clinically significant improvement occurred or not. The results revealed that the online ACT Matrix parent training program was effective in improving all four dependent variables. Mothers reported that the training was culturally sensitive, effective, and acceptable. The details of findings and the implications for future research as preventive science are discussed.

Teaching Compassion Skills to Students of Behavior Analysis: A Preliminary Investigation

Socially valid practices are at the heart of applied behavior analysis and can influence how interventions are experienced by families. However, the training of practitioners of applied behavior analysis is primarily focused on the implementation of technical procedures with little focus on therapeutic approaches. Empathy and therapeutic rapport have been associated with improved outcomes in allied professions (Beach et al., Journal of the American Board of Family Practice, 15(1), 25-38, 2006; Hojat et al., Academic Medicine, 86(3), 359, 2011; Horst et al., Journal of Child & Family Nursing, 3, 5-14, 2000), but have been minimally studied within the field of behavior analysis. In the present study, several sources were utilized to identify and define empathic and compassionate care skills. These skills were divided into three skill areas (i.e., basic interviewing skills, interest in the family, joining with the family) and taught to ABA master's students using behavioral skills training via a telehealth platform. All four participants significantly improved their engagement in compassionate care skills following training and maintained these skills in follow-up probes and with a different experimenter. Several post-study measures of outcome were taken, including social validity measures from participants, ratings of compassion from consumer and professional experts, as well as comparison measures on the Jefferson Scale of Physician Empathy. Participant reports of social validity were high, as were consumer and professional ratings of compassionate behaviors. Improvements on the Jefferson Scale of Physician Empathy were also observed. Implications for training practitioners and for expanding the focus on compassionate care skill development within the field are explored.

Effects of a Computer Training to Teach Spanish Book-Sharing Strategies to Mothers of Emergent Bilinguals at Risk of Developmental Language Disorders: A Single-Case Design Study

PURPOSE

The purpose of this research is to examine the effects of a computer app-based training program for caregivers on caregiver behavior to enhance Spanish language in emergent bilinguals at risk for developmental language disorders.

METHOD

This study followed a single-case, multiple-baseline design. An app-based language training program was developed based on the Teach-Model-Coach-Review adult learning instructional approach. Six mothers were trained on three language-facilitation strategies (Completion, Distancing, and Questioning) while reading to their children in Spanish. The training focused on one of the three strategies at a time, and mothers were given access to training once a week. Mothers were recorded while they read to their children during three phases: prior to the training (baseline), during 2 training weeks (training phase), and after training was provided (maintenance).

RESULTS

A visual analysis of the data (percent nonoverlapping data complemented with Tau-U analysis) indicated a functional relation between the training program and the use of strategies by the participants for Distancing and Completion, and there was a less robust, moderate effect for Questioning strategy for a couple of participants.

CONCLUSIONS

The computer training may serve as a tool for instructors who want to educate Spanish-speaking mothers in the use of evidence-based language strategies at home. Further research is needed to determine how this parent training could result in long-term use of strategies during reading times and what factors are associated with the learning and subsequent use of these strategies with children.

Culturally Sensitive Behavior Intervention Materials: a Tutorial for Practicing Behavior Analysts

Behavior analytic interventions for people with disabilities often rely on implementation by novice caregivers and staff. However, behavior intervention documents are ineffective at evoking the level of performance needed for behavior change, and intensive training is often needed (Dogan et al., 2017; Ward-Horner & Sturmey, 2012). The cost and time requirements of intensive training may not be viable options for some clients, leading to nonadherence or attrition (Raulston et al., 2019). In addition, others may feel that prescribed interventions are not appropriate or will not work (Moore & Symons, 2011). These barriers may reflect a cultural mismatch (Rathod et al., 2018). One potential way to increase efficacy of intervention materials is to improve the cultural sensitivity and comprehensibility of these documents. Although the body of research on cultural adaptation of behavioral interventions is becoming more robust, adaptation of behavior intervention documents as a means to create effective behavior change when cultural and linguistic diversity are factors, is an area of behavior analytic practice that is not well researched and there remains a need for cultural humility. Because diversity can include expansive differences between individuals, such as race/ethnicity, socioeconomic status, religion, gender and sexuality; understanding and adapting to each of these areas may be best done through separate reviews. It is the intent of this article to focus on ethnic diversity in the United States as a starting point and frame of reference for cultural adaptation. This tutorial includes tips learned from health communication research to give step-by-step guidance on creating comprehensible, culturally adapted intervention plans through the example of training for parents of autistic children.

Effects of environmental distractions on teachers' procedural integrity with three function-based treatments

Past research has demonstrated the effectiveness of teacher-implemented, function-based treatments for problem behavior, but no studies have evaluated the impact of distractions on teachers' procedural integrity. In this proof-of-concept study, the experimenters employed a laboratory analog to examine the impact of distractions on levels of integrity when 5 teachers implemented 3 different treatments. Although integrity was similar across treatments when the setting was free of distractions, integrity declined for all teachers in the presence of student-driven distractions. In general, distractions had a greater impact on the integrity of differential negative reinforcement of alternative behavior (DNRA) compared to differential negative reinforcement of other behavior (DNRO) and noncontingent escape (NCE), particularly for the delivery of reinforcement. However, teachers tended to have lower levels of integrity when responding to problem behavior during DNRO. These findings support the potential viability of this approach for studying factors that impede procedural integrity in the classroom.

Ignorance and Cultural Diversity: the Ethical Obligations of the Behavior Analyst

Applied behavior analysis (ABA) has featured an increasing concern for understanding and considering the cultural diversity of the populations behavior analysts serve in recent years. As an expression of that concern, the new BACB's Ethics Code for Behavior Analysts is more explicit and comprehensive in its inclusion of ethical obligations concerning cultural diversity. The purpose of this paper is to offer a discussion on the limitations of both our capacity and willingness to know and overcome our ignorance about our own and other cultures. We examine different ways in which our ignorance of other cultures plays out even in willful compliance with the BACB ethics code. We suggest part of the problem is that the BACB ethics code seems to operate under the assumption that practitioners are always aware or can be aware of what they do not know and of their biases. In contrast, we offer a reflection on a more complex picture of our understanding of ourselves and other cultures, where we cannot assume people are aware of what they ignore and of their biases. Ethically, we find that in some cases these blindspots are accounted for by the BACB ethics code and should be foreseen and addressed by the behavior analyst (BA). But in other cases, when a person is not aware of what they ignore, understanding the connection between cultural diversity ignorance and professional behavior requires a different approach. Our analysis suggests an attitude of being thoughtfully diligent and humble while learning about cultural diversity issues and examining the areas where we might be ignorant and not aware of our ignorance. We argue that BAs' obligations to respect the dignity of clients and their families and to provide effective treatment call for this attitude of diligence and humility that goes beyond mere compliance.

A translational evaluation of listener interest on the presentation of conversation topics to individuals who exhibit restricted interests

Listener behavior has been shown to influence speaker behavior. However, little is known about the extent to which listener behavior can influence countertherapeutic outcomes. This study evaluated the influence of listener interest on the topics presented by adult participants conversing with an experimenter acting as an individual who exhibited restricted interests. Each session consisted of a 5‐min conversation, during which the participant was instructed to talk about 3 topics. We compared the duration of topic presentation across phases in which the experimenter behaved as an interested listener for 1 topic or for all 3 topics. Results showed that topic presentation was controlled by listener interest and all participants reported that the simulation was believable, acceptable, and useful. Although preliminary, these findings have implications for understanding possible undesirable interactions between individuals diagnosed with autism spectrum disorder who exhibit restricted interests and their peers or caregivers.

Parents Are People Too: Implementing Empirically Based Strategies During Daily Interactions

The outcomes of the COVID-19 pandemic have resulted in decision-making related to in-person versus remote behavior-analytic service delivery. For those service providers who shifted from delivering in-person therapy to remote consultation, parents have presumably, at least at times, assumed a role similar to a registered behavior technician (RBT). We suggest that behavior analysts recommend two empirically based strategies to parents that they could incorporate into their daily lives during service disruptions: environmental enrichment and differential reinforcement of alternative behavior. We provide examples of naturally occurring contexts during which parents could integrate these procedures: (1) self-care or daily living activities, (2) physical activity, and (3) preferred learning activities. We support selecting these strategies and their application during exemplar contexts under the premise that they do not result in additional time expenditure, afford parents opportunities to complete essential (household, work-related, or personal) tasks, and still result in therapeutic gains.

Behavior analytic jargon does not seem to influence treatment acceptability ratings

Some have argued that behavior analysts have insulated themselves by eschewing the vernacular and adopting idiosyncratic and sometimes counterintuitive technical terms to describe their science and practice. Because of this, behavior analysis plays a minor role in psychology and related fields and effective behavior-change interventions go unused. All told, findings about the effects of behavior-analytic jargon are mixed. Studies that provided technical terms independent of context have produced unfavorable results, whereas studies that have provided context have produced positive or neutral results, overall. This study evaluated the effects of behavioral jargon on the acceptability ratings of several applied behavior analysis interventions described in terms of varying target behaviors, populations, and settings. We presented brief vignettes adapted from published research articles that were described in either jargon or nonjargon versions. There were no appreciable differences in the rated acceptability of interventions described with or without jargon.

Evaluating effects of context changes on resurgence in humans

Laboratory models of relapse provide methods for evaluating challenges to behavioral treatments with differential reinforcement of an alternative response (DRA). Resurgence occurs with the worsening of conditions of reinforcement for appropriate behavior and renewal occurs when transitioning out of a treatment context. Across five experiments, participants recruited via online crowdsourcing pressed onscreen buttons to earn points exchangeable for money and contexts sometimes changed through changes in the background image. Returning to the training context (ABA, Experiment 1) and transitioning to a novel context (ABC, Experiment 2) produced greater resurgence when removing alternative reinforcement in comparison with remaining in the treatment context (ABB). In contrast, we observed little difference in resurgence among AAA, ABB, and AAC context manipulations (Experiment 3) and ABA, ABC, and AAC context manipulations (Experiment 4). In Experiment 5, we evaluated relative contributions of the presence versus absence of context changes (ABA vs. ABB) in combination with or without the removal of alternative reinforcement. Both changing context and removing alternative reinforcement increased responding in isolation and the combination produced greater-than-additive effects. Overall, the present findings demonstrate a consistent effect of removing alternative reinforcement on relapse that, under certain conditions, can be enhanced by context change.

Soft Skills: The Case for Compassionate Approaches or How Behavior Analysis Keeps Finding Its Heart

As the field of behavior analysis expands, our need to develop ourselves as more effective collaborators, particularly with families who may be the primary consumers of our science, becomes paramount. As scientists, our training lies primarily in the behavior analytic technologies that we study and apply. But our ability to disseminate our science, collaborate with non-behavior analysts, and ultimately grow our field hinges on our ability to navigate interpersonal situations in a way that puts forth compassion and humanity. We have the opportunity and capability to use our empirical procedures to implement and assess the effectiveness of interventions that target the soft skills of our field. The current article discusses the benefits of empathic and collaborative approaches in fields related to behavior analysis and provides suggestions for current behavior analysts to incorporate compassionate care into their practices. We provide a checklist for compassionate interactions accompanied by possibilities for its use as a tool for self-evaluation, procedural fidelity, and comprehensive training in the area of collaboration with families. Finally, we discuss areas for future research with respect to assessing and improving behavior analysts' compassionate approaches to treatment.

Empirically Deriving Omission and Commission Errors for Relapse Tests: A Demonstration of Reverse Translation

Most studies examine treatment relapse by programming contextual changes with perfect treatment integrity or with omission errors in the absence of a context change (i.e., all alternative responses placed on extinction). Recently, Mitteer et al. (2018) examined caregiver behavior in response to a confederate playing the role of a child with destructive behavior, providing the opportunity for researchers to empirically derive reinforcement schedules and test caregiver error patterns within future relapse tests with children. The present study represents a pilot demonstration of methods for reverse translating findings from caregivers to relapse preparations with children. We used a human-operant arrangement with three children with autism spectrum disorder in which they (a) emitted a target response (i.e., pad touch) for a preferred item in a home-like context, (b) emitted an alternative response (e.g., card touch) for the item in a clinic context while the target response was extinguished, and (c) experienced a relapse test in which the experimenter programmed the same low-rate omission and commission errors that caregivers made in the prior study within the home-like context. During the relapse test, target responding approximated or exceeded baseline ranges for all cases, and alternative behavior extinguished for two of the three cases. We discuss how researchers might incorporate similar translation processes in future relapse research.

Dissemination of Direct Instruction: Ponder These while Pursuing That

We happy few but why so few is a question initially posed by Skinner and subsequently posed by many members of the behavior-analytic community, and advocates for Direct Instruction (DI) are no exception. On the contrary, the limited extent to which DI has been adopted by the educational community is an abiding source of frustration for DI devotees. This article contains little information about DI, which parallels the amount its author has to share. Instead the article focuses on five concepts, attention to which could improve disseminative efforts for behavior analysis in general and DI in particular. The five concepts are social validity, marketing, being behavior analytic, the behavioral dynamics of training, and politics. Failure to address any or all of these could supply at least a partial answer to the question posed by Skinner and subsequently by like-minded behavior analysts and DI advocates.

Using Adaptive Computer-based Instruction to Teach Staff to Implement a Social Skills Intervention

This study evaluated the effectiveness of an adaptive, computer-based staff training software program called Train-to-Code (TTC) to teach the administration of a social skills intervention. The software program actively trained participants to identify whether video models illustrated each step of the procedure effectively or ineffectively. Multiple exemplars of each step of the social skills task analysis were represented. Most-to-least prompting as well as feedback and error correction were embedded into the software program and prompts were faded through seven levels as the participant reached criterion accuracy. A multiple-probe across participants design was used to evaluate the effectiveness of this program by comparing pre- and post-training in vivo probes conducted with a confederate learner. All participant scores increased from pre-training to post-training, indicating that Train-to-Code was effective at teaching administration of the social skills intervention. These results have implications for training staff in applied community settings. Due to Train-to-Code's ability to be internet-based and to measure actual viewing performance, it has the potential for "distance training" deliveries.

A Review of Effective Strategies for Parent-Delivered Instruction

Parent involvement in treatment is an important component of effective behavior-analytic services. Whether parents are expected to act as the primary behavior change agent or support treatment in other ways, behavior analysts must provide them with the resources necessary to encourage lasting behavior change. A critical component of supporting lasting behavior change is the foundational skills related to instruction delivery. Without these skills, parents will not likely benefit from more advanced programs and interventions recommended by behavior analysts. Therefore, the purpose of this article is to describe the foundational skills necessary for parents to successfully establish an instructional environment for further program and intervention delivery. To aid practitioners, a parent-friendly handout is included and discussed.

Behavior Analysis Goes to School: Teacher Acceptability of Behavior-Analytic Language in Behavioral Consultation

Effective communication is a vital component of behavioral consultation. Behavioral consultants (e.g., behavior analysts, school psychologists) are responsible for drafting behavior intervention plans, delivering accessible training, and providing concise and consumable feedback to teachers. Their reliance on technological descriptions to communicate behavioral principles and procedures may yield poor social validity and hinder the consultant-teacher relationship. In this study, we recruited 164 teachers through Amazon Mechanical Turk and administered a survey to (a) evaluate the social acceptability of technical and nontechnical language used in behavioral consultation across a variety of student populations and (b) gain information about teachers' experiences with behavioral consultation. Implications are discussed for training and the provision of behavioral consultation services.

Developing and Enhancing Adherence to a Telehealth ABA Parent Training Curriculum for Caregivers of Children with Autism

The current COVID-19 pandemic poses unique challenges to the delivery of applied behavior analysis (ABA) services, and there has been a growing demand for evidence-based practices on how to develop a telehealth ABA service model. The current article provides a detailed technological guide on how to develop a telehealth ABA parent training curriculum. Our model also includes a series of brief acceptance and commitment training (ACT) protocols to enhance parental adherence. We provide the details for replicating our telehealth model and also demonstrate its effectiveness. To begin, a step-by-step guide on how to develop this curriculum is presented, as well as protocols used in a 60-day telehealth ABA parent training program. Afterward, we describe a randomized controlled trial design to examine the effectiveness of this protocol. Thirteen families from the southern Illinois region participated in the curriculum before the COVID-19 outbreak. Obtained data indicated training was effective to teach skills, and parents with supplemental ACT material made significantly more progress than those in the control group, t(11) = 2.36, p = .038. Halfway through the training, the outbreak of COVID-19 occurred, and parents in the ACT group were more likely to continue the program, whereas parents in the control group were significantly more likely to postpone their participation, χ2 = 6.96, p = .008. Social validity measures indicated that parents rated the curriculum favorably. Limitations and suggestions for practitioners are discussed.

2020 EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice

BACKGROUND

Non-adherence to treatment could preclude reaching an optimal outcome. Thirty to 80% of patients with rheumatic and musculoskeletal diseases (RMDs) do not adhere to the agreed treatment.

OBJECTIVES

The objective was to establish points to consider (PtCs) for the prevention, screening, assessment and management of non-adherence to (non-)pharmacological treatments in people with RMDs.

METHODS

An EULAR task force (TF) was established, and the EULAR standardised operating procedures for the development of PtCs were followed. The TF included healthcare providers (HCPs), comprising rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists and patient-representatives from 12 European countries. A review of systematic reviews was conducted in advance to support the TF in formulating the PtCs. The level of agreement among the TF was established by anonymous online voting.

RESULTS

Four overarching principles and nine PtCs were formulated. The PtCs reflect the phases of action on non-adherence. HCPs should assess and discuss adherence with patients on a regular basis and support patients to treatment adherence. As adherence is an agreed behaviour, the treatment has to be tailored to the patients' needs. The level of agreement ranged from 9.5 to 9.9 out of 10.

CONCLUSIONS

These PtCs can help HCPs to support people with RMDs to be more adherent to the agreed treatment plan. The basic scheme being prevent non-adherence by bonding with the patient and building trust, overcoming structural barriers, assessing in a blame-free environment and tailoring the solution to the problem.

Using telehealth to provide outpatient follow-up to children with avoidant/restrictive food intake disorder

The COVID-19 global health crisis compelled behavior analysts to consider alternatives to face-to-face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day-treatment program; and transitioned to an outpatient follow-up program. In Experiment 1, we analyzed the data of participants who received follow-up both in-clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow-up either in-clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in-clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider

OBJECTIVE

To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

RESULTS

After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

CONCLUSIONS

The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

Multi-level modeling with nonlinear movement metrics to classify self-injurious behaviors in autism spectrum disorder

Self-injurious behavior (SIB) is among the most dangerous concerns in autism spectrum disorder (ASD), often requiring detailed and tedious management methods. Sensor-based behavioral monitoring could address the limitations of these methods, though the complex problem of classifying variable behavior should be addressed first. We aimed to address this need by developing a group-level model accounting for individual variability and potential nonlinear trends in SIB, as a secondary analysis of existing data. Ten participants with ASD and SIB engaged in free play while wearing accelerometers. Movement data were collected from > 200 episodes and 18 different types of SIB. Frequency domain and linear movement variability measures of acceleration signals were extracted to capture differences in behaviors, and metrics of nonlinear movement variability were used to quantify the complexity of SIB. The multi-level logistic regression model, comprising of 12 principal components, explained > 65% of the variance, and classified SIB with > 75% accuracy. Our findings imply that frequency-domain and movement variability metrics can effectively predict SIB. Our modeling approach yielded superior accuracy than commonly used classifiers (~ 75 vs. ~ 64% accuracy) and had superior performance compared to prior reports (~ 75 vs. ~ 69% accuracy) This work provides an approach to generating an accurate and interpretable group-level model for SIB identification, and further supports the feasibility of developing a real-time SIB monitoring system.

Family Accommodation and Severe Problem Behavior: Considering Family-Based Interventions to Expand Function-Based Treatment

Family involvement in routines that exacerbate and maintain child anxiety is referred to as family accommodation. Family involvement is also related to maintenance of severe problem behavior (SPB) demonstrated by children with intellectual and developmental disabilities (IDD). Family members may deliver attention, tangible items, or remove aversive task demands that produce temporary cessation, or avoidance of SPB, but long-term maintenance. This Clinical Perspectives article describes parallels between the treatment of family accommodation in child anxiety and the assessment and treatment process for SPB. Suggestions are described for borrowing the concept of family accommodation to help caregivers of children who demonstrate SPB begin to approach previously avoided contexts. A case vignette is provided to illustrate strategies for targeting family accommodation as an expansion of function-based treatments for SPB.

An Evaluation of Differential Reinforcement in the Treatment of Pica

Common approaches to pica treatment involve intensive staffing and near continuous behavioral monitoring to proactively disrupt any attempts at this potentially life threatening behavior. Including differential reinforcement of discarding pica items as a contingency in such interventions has been suggested as a more practical treatment model, but the evidence base for this approach is limited. We replicated this work by evaluating differential reinforcement for discarding pica items in conjunction with response blocking and differential reinforcement of other behavior in the treatment of pica exhibited by two children. We extended this work by evaluating sustained reductions when therapist and caregiver monitoring was reduced.

School's Out for COVID-19: 50 Ways BCBA Trainees in Special Education Settings Can Accrue Independent Fieldwork Experience Hours During the Pandemic

Due to the COVID-19 pandemic and nationwide executive orders closing schools, many trainees completing their supervised independent fieldwork in educational settings lost the ability to accrue hours linked to restricted activities of a therapeutic and instructional nature with students (i.e., clients). Given the impact on trainees of the pandemic restrictions, we present 50 suggestions for trainees in school settings to continue to accrue hours for both restricted and unrestricted activities throughout the course of the COVID-19 pandemic.

Caregivers can implement play-based instruction without disrupting child preference

Young children diagnosed with autism spectrum disorder often require systematic teaching to learn new skills, and caregivers can teach their children by embedding learning opportunities in a play-based context. However, researchers have not evaluated procedures to train caregivers how to implement a combination of strategies designed to establish rapport and early language skills while maintaining play as a preferred context. Caregiver-child dyads composed of 2 mothers and their sons were recruited to participate. A multiple-probe design across strategies was used to demonstrate the efficacy of behavioral skills training on the mothers' integration of parallel play, child-directed interaction, teaching requests (mands), and teaching labels (tacts). Both children acquired the target requests and labels as a function of their mothers' teaching. By assessing the children's preferences, we confirmed the teaching strategies did not decrease toy engagement or the value of playing with their mother. We obtained stimulus generalization of the mothers' implementation of the strategies from a clinic to their home and maintenance of mother and child performance across a month.

Detecting and Classifying Self-injurious Behavior in Autism Spectrum Disorder Using Machine Learning Techniques

Traditional self-injurious behavior (SIB) management can place compliance demands on the caregiver and have low ecological validity and accuracy. To support an SIB monitoring system for autism spectrum disorder (ASD), we evaluated machine learning methods for detecting and distinguishing diverse SIB types. SIB episodes were captured with body-worn accelerometers from children with ASD and SIB. The highest detection accuracy was found with k-nearest neighbors and support vector machines (up to 99.1% for individuals and 94.6% for grouped participants), and classification efficiency was quite high (offline processing at ~ 0.1 ms/observation). Our results provide an initial step toward creating a continuous and objective smart SIB monitoring system, which could in turn facilitate the future care of a pervasive concern in ASD.

Effectiveness of Parent Education in Pivotal Response Treatment on Pivotal and Collateral Responses

In two studies, we investigated the effectiveness of parent education in Pivotal Response Treatment (PRT) on parent-created opportunities and spontaneous child initiations in two community-based treatment facilities for children with autism spectrum disorder (ASD). Changes in parental stress and self-efficacy were explored. Participants were 26 parents and their children who participated in group (Study 1) or individual (Study 2) parent education in PRT. Results indicated that group-based parent education resulted in moderate increases in opportunities, functional initiations, and empathic social initiations. Furthermore, parental stress reduced and self-efficacy increased. Individual parent education resulted in large increases in opportunities and functional initiations, but parental stress and self-efficacy did not change. Implications for clinical practice and directions for future research are discussed.

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.

Evaluation of an Omnibus Mand in the Treatment of Multiply Controlled Destructive Behavior

Functional communication training is a commonly used and effective treatment for socially reinforced destructive behavior. However, when a functional analysis suggests that destructive behavior is multiply controlled (e.g., by attention, tangibles, and escape), teaching and evaluating separate functional communication responses (FCRs) can be time-consuming or only partially effective when failing to address multiple establishing operations that may occur simultaneously. We evaluated the use of an omnibus FCR or mand that produced access to attention, tangibles, and escape within each functional-analysis test condition for two boys with autism spectrum disorder who displayed multiply controlled destructive behavior. The omnibus-FCR treatment produced low rates of destructive behavior and high percentages of independent FCRs within each condition for both children, suggesting that such a treatment option may reduce destructive behavior and teach communication skills quickly prior to introducing other treatment components, such as teaching individual FCRs to address each unique function of destructive behavior.

Using Schedule-Correlated Stimuli During Functional Communication Training to Promote the Rapid Transfer of Treatment Effects

Prior research has shown that bringing functional communication responses under the discriminative control of schedule-correlated stimuli facilitates rapid reinforcement schedule thinning and the transfer of functional communication training (FCT) treatment effects to other therapists and settings. In Experiment 1, we extended this body of research by rapidly transferring FCT treatment effects to a caregiver, despite the caregiver's unique and lengthy history of reinforcement of the child's destructive behavior. In Experiment 2, we evaluated the degree to which FCT treatment effects transferred to another participant's caregivers when the caregivers implemented FCT with and without schedule-correlated stimuli. Rapid transfer of FCT treatment effects occurred only when caregivers used the schedule-correlated stimuli. We discuss the use of schedule-correlated stimuli within FCT procedures as a method of programming for generalization when extending treatment to caregivers.

The Effects of a Self-Instruction Package and Group Training on Trial-Based Functional Analysis Administration

This study examined the effects of a self-instruction package comprised of a task analysis data sheet, detailed written instructions, and a small group performance feedback training on the training of 12 undergraduate students to conduct trial-based functional analyses (TBFAs). In contrast to previous research, training omitted technical language and did not include didactic instruction on the principles of applied behavior analysis or the underlying rationale for functional analysis methodology. Although the self-instruction package produced significant increases in performance and reliable data collection on the targeted problem behavior, small group performance feedback training was necessary to achieve mastery across all trial types. Results offer a socially valid training package to teach paraprofessionals to assist Board Certified Behavior Analysts® in conducting TBFAs in applied settings.

Modifying a behavior intervention plan according to classroom aides acceptability ratings: effects on treatment integrity and challenging behavior

This study evaluated the effects of an acceptability questionnaire on classroom aides' treatment integrity during implementation of behavioral intervention plans, using a multiple-probe-baseline across-participants design. Four classroom aides in a special education preschool classroom rarely used procedures recommended to manage the challenging behavior of a four-year-old boy with autism spectrum disorder (ASD) during baseline. After using the questionnaire results to create a functionally equivalent behavior intervention plan that was comprised of components the aides rated as more acceptable, three of the four aides greatly improved their use of the procedures and an ancillary reduction in the child's challenging behavior was observed. Overall, results suggest that including staff acceptance measures during the intervention selection process may bolster subsequent intervention integrity.

A Randomised Controlled Trial of an Information Communication Technology Delivered Intervention for Children with Autism Spectrum Disorder Living in Regional Australia

This exploratory randomised controlled trial tested the effectiveness of a tablet-based information communication technology early intervention application to augment existing therapy with the aim of improving visual motor, imitation, language and social skills in young children with ASD who reside in regional areas. Fifty-nine participants were recruited and randomised to either a therapy-as-usual group or intervention group. With the exception of the expressive language subscale on the Mullen Scales of Early Learning, no significant between-group differences were recorded for visual motor, imitation, receptive language and social skills of participants between baseline and post-intervention. When all participants were pooled and measured over time, improvements were shown in receptive and pragmatic language and social skills; these gains were maintained, thus suggesting skill acquisition.

Compassionate Care in Behavior Analytic Treatment: Can Outcomes be Enhanced by Attending to Relationships with Caregivers?

The practice of behavior analysis has become a booming industry with growth to over 30,000 Board Certified Behavior Analysts (BCBAs) who primarily work with children with autism and their families. Most of these BCBAs are relatively novice and have likely been trained in graduate programs that focus primarily on conceptual and technical skills. Successfully working with families of children with autism, however, requires critical interpersonal skills, as well as technical skills. As practitioners strive to respond efficiently and compassionately to distressed families of children with autism, technical skills must be balanced with fluency in relationship-building skills that strengthen the commitment to treatment. The current article provides an outline of important therapeutic relationship skills that should inform the repertoire of any practicing behavior analyst, strategies to cultivate and enhance those skills, and discussion of the potential effects of relationship variables on treatment outcomes.