The efficacy of noncontingent escape for decreasing children's disruptive behavior during restorative dental treatment

Virtual Training of Medical Students to Promote the Comfort and Cooperation of Patients with Neurodevelopmental Disabilities

Patients with neurodevelopmental disabilities generally have less access to necessary medical care compared to those without disabilities. Barriers to adequate care include patient fear and uncooperative behavior during routine medical procedures and inadequate preparation of medical professionals to treat this population. Researchers have identified multiple behavior-analytic procedures for promoting comfort and cooperation during medical treatments. Efficient, cost-effective training programs are needed to widely disseminate behavior-analytic procedures to medical students and professionals. The purpose of this study was to assess the efficacy of a virtual training to prepare medical students to implement behavioral procedures that could be easily incorporated into typical wellness examinations. Seven medical students received behavioral skills training (BST) delivered remotely via the Internet. Results showed that the training successfully increased students' correct implementation of the procedures in roleplay with the experimenter and with patients with neurodevelopmental disabilities. Responding also maintained at high levels 2 weeks after the training. These findings suggest that virtual BST is an efficient, practical approach for training health care professionals to implement general behavior management strategies to increase the comfort and cooperation of patients with NDD.

Putting the power of behavior analysis in the hands of nonbehavioral professionals: Toward a blueprint for dissemination†

Behavior analysts have much to offer nonbehavioral professionals who work with the communities that we serve. Successful dissemination of behavior-analytic technologies to these professionals could potentially improve their practice. Although the literature contains some exemplary examples of successful dissemination, our discipline would benefit from a blueprint for conducting this important work. In this article, I share our experiences disseminating behavioral technologies to educators, law enforcement officers, and health care providers who engage with neurodiverse individuals. These experiences form the basis of a recommended blueprint for dissemination, which awaits empirical support. After describing this tentative blueprint, I provide suggestions for future research on how best to disseminate our technologies to nonbehavioral professionals, the ideal content of those dissemination activities, and the conditions under which professionals may be more likely to embed our technologies into their best practices.

Remote Training of Dental Students and Professionals to Promote Cooperative Behavior in Patients with Intellectual and Developmental Disabilities

Many individuals diagnosed with intellectual and developmental disabilities (IDD) are uncooperative during routine dental exams, leading to poor oral health in this population. Few studies have evaluated methodologies for preparing dental students and professionals to work effectively with patients diagnosed with IDD. In this study, experimenters used remote behavioral skills training (BST) to train dental students and professionals how to implement a practical intervention that included tell-show-do, contingent praise, and noncontingent reinforcement. Results suggested that group training conducted via videoconferencing was effective for teaching six of seven participants to implement the intervention in the absence of post-training feedback. This approach appears useful for quickly and efficiently training current and future dental professionals to implement behavior techniques to promote patient compliance.

Opportunities for ABA intervention in Phelan-McDermid syndrome

Phelan-McDermid syndrome (PMS), also called 22q13.3 deletion syndrome, is a rare genetic disorder affecting at least 2,000 people worldwide (Phelan-McDermid Syndrome Foundation, 2019, How rare is Phelan-McDermid?). PMS has many distinguishing characteristics and many medical specialties have been recommended to treat the clinical features. While many therapies, including behavioral therapy, have been speculated to be beneficial in treating PMS, there is little known regarding their effectiveness [Costales, J. L. and Kolevzon, A. 2015. Phelan-McDermid syndrome and SHANK3: Implications for treatment. Neurotherapeutics: The Journal of the American Society for Experimental Neurotherapeutics, 12, 620-630.]. Behavior analysis has the capability to help in many areas of treatment for PMS either directly through, for example, behavior treatment to address aggressive behavior, or through collaborating with other specialties treating PMS by combining, for example, behavioral principles in the alleviation of medical issues such as constipation. Currently, there is a role for the behavior analyst to expand our field and identify effective treatments for those with PMS while we wait for a cure. In this paper, we discuss how medical considerations may affect behavior interventions and make recommendations for the behavior analyst working with PMS.

Noncontingent reinforcement: Arbitrary versus maintaining reinforcers for escape-maintained problem behavior

Noncontingent reinforcement (NCR) involves the delivery of maintaining reinforcers on a time-dependent schedule and often includes extinction. However, arbitrary reinforcers may be equally efficacious during NCR without extinction for treating escape-maintained problem behavior. The purpose of this study was to extend previous research on NCR by evaluating the relative efficacy of NCR without extinction and comparing maintaining versus arbitrary reinforcers for 4 individuals with escape-maintained problem behavior. Two different NCR conditions, NCR using the maintaining reinforcer (escape) and NCR using an arbitrary reinforcer (an edible), were evaluated using multielement and reversal designs. Treatment effects varied across participants. Results for 2 participants showed a reduction in problem behavior during NCR without extinction with both the arbitrary and maintaining reinforcers. For 1 participant, results showed a reduction in problem behavior with both the arbitrary and maintaining reinforcers only when extinction was added to NCR. For the 4th participant, the maintaining reinforcer was effective during NCR without extinction, but the arbitrary reinforcer was ineffective.

[Dental anxiety in preschool children: How helpful are behavioral control management strategies?]

Dental anxiety in preschool children: How helpful are behavioral control management strategies? Abstract. Objective: Dental anxiety is a frequent problem in the dental treatment of young children. Control management methods are widely used in pediatric dental care as coping strategies. This study compares two control management strategies regarding their reduction of dental anxiety and treatment success. Method: A group of 60 preschool children with known dental fear in their medical history underwent professional dental cleaning in which the Tell-Show-Do Method (TSDM) was applied. Patients were randomized into two groups according to the controlling method employed: (1) limited controlling method (L-K) and (2) standardized controlling method (S-K). The efficacy of the two control methods was tested using pulse rate as an objective measure of anxiety and self-rating as a subjective indicator. Results: Both the S-K and the L-K condition showed a significant reduction in pulse rate, and there was no difference in physiological arousal and treatment success. However, independent of the group disposition, there was a noticeable increase in pulse rate in children after TSDM. Conclusion: The results of this study indicate that even limited options for controlling dental treatment do not lead to greater burdens on the children in question with dental anxiety. However, further studies are necessary to investigate the use of control methods independent of TSDM.

The oral health of dentally anxious five- and eight-year-olds: a secondary analysis of the 2013 Child Dental Health Survey

Introduction Little research has been conducted into the relationships between dental anxiety and factors relating to oral health in small children. This research takes advantage of data from the Child Dental Health Survey 2013 to perform a secondary analysis for the five- and eight-year-old age groups. Aim To compare the oral health of groups of children aged five and eight years old, classified into three levels of anxiety.Design Secondary analysis of data from 2,289 children aged five and eight years in the Child Dental Health Survey 2013.Materials and methods Participants were divided into three groups, depending on the parent's report of their child's dental anxiety. Descriptive analyses compared the three groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact. Results Dentally anxious children were more likely to have active decay and decay experience. Parents of children with dental anxiety were more likely to report that the child's oral health had a negative effect on family life. Highly anxious children were less likely to attend the dentist or engage in oral health-related behaviours. Conclusions Dentally anxious children have more dental disease and their parents express that the child's oral health has a greater impact on their family's quality of life.

The oral health of dentally phobic 12- and 15-year-olds: a descriptive analysis of the 2013 Child Dental Health Survey

Introduction Dental anxiety has been shown to be related to poorer oral health. Limited data exist exploring the relationship between oral health status and dental anxiety in non-clinical populations in children.Aim To compare the oral health of phobic and non-phobic children aged 12 and 15 years.Design Secondary analysis of data from 12-year-old and 15-year-old children in the Child Dental Health Survey 2013.Materials and methods Participants were grouped into non-phobic and phobic groups, depending on their self-reported dental anxiety (MDAS). Descriptive analyses compared the two groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact.Results A total of 601 children were classed as dentally phobic with 4,144 classed as non-phobic. Dental phobic children were more likely to be female, had more active decay and untreated dental disease, and rated their dental health as poorer. Phobic children were more likely to report that their oral health had a negative effect on their everyday life. This group were less likely to brush their teeth regularly or attend the dentist for check-ups.Conclusions Dentally phobic children have more dental disease and express greater impact on their everyday life.

Psychological Intrusion - An Overlooked Aspect of Dental Fear

Dental fear/anxiety is a widely recognised problem affecting a large proportion of the population. It can result in avoidance and/or difficulty accepting dental care. We believe that psychological intrusion may play a role in the aetiology and maintenance of dental fear for at least some individuals. In this narrative review we will take a developmental perspective in order to understand its impact across the lifespan. We will consider the nature of 'self,' parenting styles, the details of intrusive parenting or parental psychological control, and briefly touch upon child temperament and parental anxiety. Finally, we draw together the supporting (largely unrecognised) evidence available in the dental literature. We illustrate the paper with clinical examples and discuss possibly effective ways of addressing the problem. We conclude that psychological intrusion appears to play an important role in dental fear, for at least some individuals, and we call for detailed research into the extent and exact nature of the problem. A simple means of identifying individuals who are vulnerable to psychological intrusion would be useful for dentists.

Noncontingent reinforcement without extinction plus differential reinforcement of alternative behavior during treatment of problem behavior

The effects of noncontingent reinforcement (NCR) without extinction during treatment of problem behavior maintained by social positive reinforcement were evaluated for five individuals diagnosed with autism spectrum disorder. A continuous NCR schedule was gradually thinned to a fixed-time 5-min schedule. If problem behavior increased during NCR schedule thinning, a continuous NCR schedule was reinstated and NCR schedule thinning was repeated with differential reinforcement of alternative behavior (DRA) included. Results showed an immediate decrease in all participants' problem behavior during continuous NCR, and problem behavior maintained at low levels during NCR schedule thinning for three participants. Problem behavior increased and maintained at higher rates during NCR schedule thinning for two other participants; however, the addition of DRA to the intervention resulted in decreased problem behavior and increased mands.

Knowledge of behavioural management principles amongst specialist paediatric dental practitioners in the United Kingdom

BACKGROUND

Paediatric specialist dental practitioners are often faced with the challenge of disruptive behaviour or refusal to comply with treatment. Behaviour management skills are an essential component of their role. However, little is known of the confidence or competence of practitioners in these approaches.

AIM

To identify paediatric dentists' knowledge of behavioural management principles as applied to paediatric dentistry.

METHOD

Postal questionnaire survey of all specialists in Paediatric Dentistry on the General Dental Council UK register (n = 234), using the Knowledge of Behavioural Principles as Applied to Children Questionnaire (KBPACQ; O'Dell, 1979) adapted for the dental setting. Information was also gathered on experience in using behavioural management techniques and demographics.

RESULTS

Responses were received from 105 practitioners (45%). Participants gave the correct answer, on average, to 38% of the items (range 0 to 75%).

CONCLUSION

Knowledge of behavioural principles amongst paediatric dentists in the United Kingdom is poor, despite their widespread reported use of such techniques.

Beyond the drugs: nonpharmacologic strategies to optimize procedural care in children

PURPOSE OF REVIEW

Painful and/or stressful medical procedures mean a substantial burden for sick children. There is good evidence that procedural comfort can be optimized by a comprehensive comfort-directed policy containing the triad of nonpharmacological strategies (NPS) in all cases, timely or preventive procedural analgesia if pain is an issue, and procedural sedation.

RECENT FINDINGS

Based both on well-established theoretical frameworks as well as an increasing body of scientific evidence NPS need to be regarded an inextricable part of procedural comfort care.

SUMMARY

Procedural comfort care must always start with a child-friendly, nonthreatening environment in which well-being, confidence, and self-efficacy are optimized and maintained. This requires a reconsideration of the medical spaces where we provide care, reduction of sensory stimulation, normalized professional behavior, optimal logistics, and coordination and comfort-directed and age-appropriate verbal and nonverbal expression by professionals. Next, age-appropriate distraction techniques and/or hypnosis should be readily available. NPS are useful for all types of medical and dental procedures and should always precede and accompany procedural sedation. NPS should be embedded into a family-centered, care-directed policy as it has been shown that family-centered care can lead to safer, more personalized, and effective care, improved healthcare experiences and patient outcomes, and more responsive organizations.

Noncontingent Reinforcement in After-School Settings to Decrease Classroom Disruptive Behavior for Students with Autism Spectrum Disorder

Noncontingent reinforcement (NCR) is the response-independent delivery of a reinforcer (Vollmer, Iwata, Zarcone, Smith, and Mazaleski in Journal of Applied Behavior Analysis 26: 9-21 1993). Two staff members (preservice education majors) implemented NCR procedures for two students with autism spectrum disorder (ASD) who exhibited problem behavior and attended an after-school program. The amount of training on NCR and procedural fidelity was measured for each staff member, and the effects of the treatment on problem behavior were evaluated. Results indicate NCR is a low-effort procedure that reduced problem behavior of two participants with ASD. • NCR can both reduce problem behaviors of clients who engage in difficult behaviors (Carr, Severtson, & Lepper, 2009). • NCR can be used for clients for whom extinction-induced behaviors are dangerous (Tucker, Sigafoos, and Bushell in Behavior Modification, 22: 529-547, 1998). • Nonbehavioral providers can implement NCR with high fidelity, making it a good procedure to use when collaborating with other professionals (teachers, SLP, parents, etc.; Matson, 2009). • NCR can be used when clinicians first begin working with a client until more detailed interventions are created.

Child's anxiety preceding the dental appointment: evaluation through a playful tool as a conditioning feature

Objective: The aim of this study was to evaluate the emotional reactions before and after the application of a child audiovisual book that illustrates the trigger fear and anxiety points in the dental appointment. Moreover, the educational effect of this book as preconditioning to dental care was also verified. Methods: The study is a prospective pilot study conducted at the University of Western Santa Catarina with a convenience sample of 20 children aged 4-6 years old, with and without previous dental experience. All these children received the book and they were assessed before and after the presentation by responsible attendants. The projective test FIS (Facial Image Scale) was applied in 2 stages on the same day of assistance. Both tests were applied at the reception waiting room: before the child came into contact with the book in the dental clinic room and after the child came into contact with the playful instrument. Anamnesis and clinical examination were performed in the dental office by the dentist to start or continue the treatment. Results: The children were able to answer the projective test with self -analysis. The idealized audiovisual book was successfully constructed and used in the research. The comparison between FIS 1 and FIS 2 made with paired t-test showed significant improvements by comparing the results before the presentation of the playful instrument and after the use of it (p <0.0001), with no differences in childhood anxiety between genders and ages. Conclusion: The result of the conditioning technique using the book before the dental treatment was highly significant in reducing anxiety.

Effects of fixed-time reinforcement schedules on resurgence of problem behavior

Resurgence of problem behavior following the discontinuation of differential reinforcement of alternative behavior (DRA) may be prevented by response-independent reinforcer delivery. In basic research, response-independent reinforcer delivery following DRA prevented resurgence of the initially reinforced response and maintained alternative responding (Lieving & Lattal, 2003, Experiment 3). We evaluated the generality of these results by assessing if fixed-time (FT) reinforcer delivery following DRA would prevent resurgence of problem behavior and maintain appropriate behavior with 4 children with disabilities. For all participants, extinction following DRA produced resurgence of previously reinforced problem behavior and reduced appropriate requests, but FT reinforcer delivery following DRA mitigated resurgence of problem behavior and maintained appropriate requests.

A relação mãe-criança durante o atendimento odontológico: contribuições da análise do comportamento

O presente artigo visou analisar a interação entre mães e crianças durante o atendimento odontológico. Participaram cinco pacientes (idade entre 2 e 7 anos) com seus acompanhantes. Os atendimentos foram filmados e observadores registraram os comportamentos infantis e maternos. Dentre os dados quantitativos, houve maior índice de não colaboração associado ao menor índice de interação materna. A análise qualitativa dos dados, feita pela análise funcional, indicou que as mães podem exercer função de estímulos antecedentes e consequentes para o comportamento infantil no atendimento odontológico e podem exercer função de variável histórica pela modelagem de comportamentos de autocontrole e de seguir regras. Analisando as contingências, é possível prever e controlar o comportamento. Pais podem ser instruídos e treinados para agirem de forma mais adequada durante o atendimento odontológico, em benefício da saúde de seu filho.

The motivating operation and negatively reinforced problem behavior: a systematic review

The concept of motivational operations exerts an increasing influence on the understanding and assessment of problem behavior in people with intellectual and developmental disability. In this systematic review of 59 methodologically robust studies of the influence of motivational operations in negative reinforcement paradigms in this population, we identify themes related to situational and biological variables that have implications for assessment, intervention, and further research. There is now good evidence that motivational operations of differing origins influence negatively reinforced problem behavior, and that these might be subject to manipulation to facilitate favorable outcomes. There is also good evidence that some biological variables warrant consideration in assessment procedures as they predispose the person's behavior to be influenced by specific motivational operations. The implications for assessment and intervention are made explicit with reference to variables that are open to manipulation or that require further research and conceptualization within causal models.

Single-case experimental designs: a systematic review of published research and current standards

This article systematically reviews the research design and methodological characteristics of single-case experimental design (SCED) research published in peer-reviewed journals between 2000 and 2010. SCEDs provide researchers with a flexible and viable alternative to group designs with large sample sizes. However, methodological challenges have precluded widespread implementation and acceptance of the SCED as a viable complementary methodology to the predominant group design. This article includes a description of the research design, measurement, and analysis domains distinctive to the SCED; a discussion of the results within the framework of contemporary standards and guidelines in the field; and a presentation of updated benchmarks for key characteristics (e.g., baseline sampling, method of analysis), and overall, it provides researchers and reviewers with a resource for conducting and evaluating SCED research. The results of the systematic review of 409 studies suggest that recently published SCED research is largely in accordance with contemporary criteria for experimental quality. Analytic method emerged as an area of discord. Comparison of the findings of this review with historical estimates of the use of statistical analysis indicates an upward trend, but visual analysis remains the most common analytic method and also garners the most support among those entities providing SCED standards. Although consensus exists along key dimensions of single-case research design, and researchers appear to be practicing within these parameters, there remains a need for further evaluation of assessment and sampling techniques and data analytic methods.

Reducing and eliminating restraint of people with developmental disabilities and severe behavior disorders: an overview of recent research

This paper provides a brief overview of the most recent research (1999-2009) on restraint reduction and elimination efforts in the literature and also examines the characteristics of restraint along with the risks and benefits. Some earlier papers were included in this review because of their importance to the topic. The results of this literature review are discussed in terms of implications for practitioners and researchers.

Understanding basic behavioral support techniques as an alternative to sedation and anesthesia

Patients with special needs often present a challenge for the dental care team. The exacting and surgical nature of dental procedures requires significant patient cooperation to ensure the safe delivery of care. Some individuals who have special care needs have difficulty cooperating during treatment, thus creating a potentially harmful situation. Modern dentistry, particularly pediatric dentistry, provides the dental team with a variety of strategies designed to enable the team to safely provide comprehensive care in the least restrictive manner. These techniques range from tell-show-do, to medical stabilization, to general anesthesia. The effective use of noninvasive, nonpharmacologic behavioral guidance/support techniques cannot only avoid the need for sedation or general anesthesia, they can teach the patient to develop coping skills that may enable them to receive comprehensive care in a traditional dental setting over a lifetime. Unfortunately, many providers are inadequately trained in behavioral support strategies. This paper presents a review of noninvasive, nonpharmacologic behavioral support techniques with discussion regarding their application to persons with special care needs.

Contribuições da análise do comportamento em odontopediatria

Controlar o comportamento de crianças durante o tratamento odontológico é um dos grandes desafios para os dentistas. A falta de cooperação infantil em odontopediatria é um tópico de debate entre pesquisadores, que buscam explicações como medo, ansiedade e experiências aversivas para o fato. Pesquisas de análise do comportamento em contextos de odontopediatria fornecem evidências de que os estímulos aversivos, com função de operações estabelecedoras, alteram o valor de outras contingências presentes no contexto odontológico, como o reforço positivo ou a distração, sendo essa uma possível razão para a dificuldade do manejo de comportamentos não-colaborativos das crianças. Uma breve revisão bibliográfica é apresentada neste trabalho, incluindo a conceituação de operações estabelecedoras, de fuga e de esquiva. Além disso, é feita uma análise da função das operações estabelecedoras no contexto odontopediátrico, sugerindo-se que elas estabelecem condições para a manutenção da não-colaboração de crianças nos consultórios odontológicos. Também são discutidas possibilidades de intervenção com contingências que diminuem as propriedades aversivas da situação.

Fixed-time teacher attention to decrease off-task behaviors of typically developing third graders

Evidence to validate the use of fixed-time (FT) reinforcer delivery (i.e., noncontingent reinforcement) with typically developing populations has been relatively rare in the behavioral literature. In those studies that have provided validation, reinforcer delivery schedules appeared to be prohibitively dense for sustained implementation of procedures. This study demonstrated the efficacy of using FT reinforcer delivery to reduce off-task behavior of 2 typically developing third graders using a teacher-selected schedule (FT 4 min). Immediate reductions in off-task behavior were observed for both children. Challenges in identifying the operative mechanism of FT schedules in natural settings are discussed.