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.

Resurgence of ethanol seeking following voluntary abstinence produced by nondrug differential reinforcement of other behavior.

Resurgence refers to the relapse of a target behavior following the worsening of a source of alternative reinforcement that was made available during response elimination. Most laboratory analyses of resurgence have used a combination of extinction and alternative reinforcement to reduce target behavior. In contingency-management treatments for alcohol use disorder, however, alcohol use is not placed on extinction. Instead, participants voluntarily abstain from alcohol use to access nondrug alternative reinforcers. Inasmuch, additional laboratory research on resurgence following voluntary abstinence is warranted. The present experiment evaluated resurgence of rats' ethanol seeking following voluntary abstinence produced by differential reinforcement of other behavior (DRO). Lever pressing produced ethanol reinforcers during baseline phases. During DRO phases, lever pressing continued to produce ethanol and food reinforcers were delivered according to resetting DRO schedules. Ethanol and food reinforcers were suspended during resurgence test phases to evaluate resurgence following voluntary abstinence. Lever pressing was elevated during baseline phases and occurred at near-zero rates during DRO phases. During the resurgence test phases, lever pressing increased, despite that it no longer produced ethanol. The procedure introduced here may help researchers better understand the variables that affect voluntary abstinence from ethanol seeking and resurgence following voluntary abstinence.

A Preliminary Evaluation of a Brief Behavioral Parent Training for Challenging Behavior in Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) often exhibit challenging behaviors. Existing behavioral parent trainings (BPT) address ASD symptomology, but are lengthy and associated with significant attrition. In the current pilot study, a longitudinal randomized controlled trial was used to evaluate a novel brief BPT targeting caregivers of children with ASD ages 5-9. The 6-session BPT, delivered in a group format, focused on high-frequency challenging behaviors (e.g., problem behaviors, feeding and sleep issues). Caregivers who received BPT (n = 29), relative to an active control (psychoeducation/supportive therapy; n = 9), reported higher treatment satisfaction and acceptability. Challenging behaviors were reduced in the BPT and active control groups. The novel BPT was a feasible and acceptable intervention to target challenging behaviors in youth with ASD.

Resurgence following differential reinforcement of alternative behavior implemented with and without extinction.

In the clinic, differential reinforcement of alternative behavior (DRA) often involves programming extinction for destructive behavior while reinforcing an alternative form of communication (e.g., a functional communication response); however, implementing extinction can be unsafe or impractical under some circumstances. Quantitative theories of resurgence (i.e., Behavioral Momentum Theory and Resurgence as Choice) predict differences in the efficacy of treatments that do and do not involve extinction of target responding when reinforcement conditions maintaining alternative responding worsen. We tested these predictions by examining resurgence following two DRA conditions in which we equated rates of reinforcement. In DRA without extinction, target and alternative behavior produced reinforcement. In DRA with extinction plus noncontingent reinforcement, only alternative behavior produced reinforcement. We conducted this study in a reverse-translation sequence, first with participants who engaged in destructive behavior (Experiment 1) and then in a laboratory setting with rats (Experiment 2). Across both experiments, we observed proportionally lower levels of target responding during and following the DRA condition that arranged extinction for the target response. However, levels of resurgence were similar following both arrangements.

Treating destructive behavior reinforced by increased caregiver compliance with the participant's mands.

Functional analyses sometimes do not identify momentary fluctuations in the function of destructive behavior (Bowman, Fisher, Thompson, & Piazza, 1997). In such cases, individuals may mand for the reinforcer that is currently most preferred and display destructive behavior if that mand goes unreinforced. In this study, we conducted a mand analysis to test whether destructive behavior functioned as a precurrent response that increased reinforcement for the participant's mands. We then evaluated a treatment that matched this function of destructive behavior by providing differential or time-based reinforcement of participant mands in accordance with multiple or chained schedules with reinforcement-schedule thinning. Decreases in destructive behavior averaged 97.4% across cases. We discuss these results relative to the importance of matching treatments for destructive behavior to operant functions for both traditional and idiosyncratic functions of destructive behavior.

Measurement of nontargeted problem behavior during investigations of resurgence.

Resurgence occurs when a previously extinguished behavior reemerges once a more recently reinforced behavior is placed on extinction. Previous research has suggested that nontargeted responses within the same response class recur alongside target-response resurgence (e.g., da Silva, Maxwell, & Lattal, 2008; Lieving, Hagopian, Long, & O'Connor, 2004). The purpose of this two-experiment investigation was to examine target response resurgence while simultaneously measuring the occurrence of nontargeted responses. Three children diagnosed with autism spectrum disorder who displayed multiple topographies of problem behavior participated. In Experiment 1, a three-phase resurgence procedure was conducted and all three participants displayed target-response resurgence accompanied by the emergence of nontargeted forms of problem behavior. These findings were replicated in Experiment 2 using a 30-min assessment procedure. The implications of these findings as they pertain to the treatment of severe problem behavior and utility of a brief relapse assessment are discussed.

Re-exposure to reinforcement in context a during treatment in context b reduces ABC renewal.

Previous work from our laboratory showed that intermittently re-exposing rats to reinforcement for lever pressing in a training (A) context, while eliminating lever pressing in a second (B) context, increased ABA renewal of lever pressing relative to rats that experienced only Context B during response elimination. In the current study, we replicated these procedures while assessing renewal in the presence of a novel context (i.e., ABC renewal). Unlike the findings described above, renewal was reduced in the group that experienced re-exposure to Context A during lever-press elimination relative to rats that experienced only Context B. These findings suggest that alternating between contexts associated with reinforcement and extinction during treatment reduces the probability that organisms will respond in novel contexts. These outcomes may be the result of discrimination and/or generalization processes. Moreover, this training procedure may offer a potential mitigation strategy for ABC renewal.

Further evaluation of a nonsequential approach to studying operant renewal.

Basic-laboratory assessments of renewal may inform clinical efforts to maintain reduction of severe destructive behavior when clients transition between contexts. The contextual changes arranged during standard renewal procedures, however, do not necessarily align with those that clients experience during outpatient therapy. More specifically, clients transition between clinical (associated with extinction for target behavior) and home/community (associated with reinforcement for target behavior) contexts during outpatient treatment. Standard renewal assessments do not incorporate these contextual alternations during treatment. The present experiment aimed to directly compare renewal of rats' lever pressing following a standard ("sequential") ABA renewal procedure (i.e., baseline in Context A, extinction in Context B, renewal test in Context A) and a "nonsequential" renewal assessment wherein treatment consisted of daily alternation between Context A (associated with reinforcement for lever pressing) and Context B (associated with extinction). Lever pressing renewed to a greater extent for rats in the Nonsequential group than for rats in the Sequential group, suggesting the contextual changes that clients experience during outpatient treatment for severe destructive behavior may be a variable that is important to consider in translational research on renewal. Potential implications of these findings for basic and clinical research on renewal 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.

A systematic review of functional analysis in pediatric feeding disorders.

We conducted a systematic review of the functional analysis of inappropriate mealtime behavior in peer-reviewed studies in PsycINFO, ERIC, PubMed, and the Journal of Applied Behavior Analysis between 2000-2016. We identified 18 studies involving 86 functional analyses. We coded descriptive data and calculated summary statistics in addition to conducting a quality appraisal of the literature. We identified escape, exclusively or in part, as the maintaining reinforcer for inappropriate mealtime behavior in 92% of cases. Results indicate that differentiated functional analyses of inappropriate mealtime behavior can be obtained, and outcomes are consistent with etiological theories of food refusal behavior. We discuss procedural differences across studies as well as directions for future research.

Evaluation of word recognition following typing produced through facilitated communication.

The extant literature on facilitated communication suggests facilitator control rather than independent communication. We used a novel assessment to evaluate a participant's correct identification of words produced during facilitated communication sessions. The participant was unable to recognize common words that she was being facilitated to type, with correct responding varying as a function of the number of distracter stimuli available. These findings are discussed in relation to behavior-analytic evaluations for alternative medical treatments for autism and related disorders.

Baseline reinforcement rate and resurgence of destructive behavior.

Concepts from behavioral momentum theory, along with some empirical findings, suggest that the rate of baseline reinforcement may contribute to the relapse of severe destructive behavior. With seven children who engaged in destructive behavior, we tested this hypothesis in the context of functional communication training by comparing the effects of different baseline reinforcement rates on resurgence during a treatment challenge (i.e., extinction). We observed convincing resurgence of destructive behavior in four of seven participants, and we observed more resurgence in the condition associated with high-rate baseline reinforcement (i.e., variable-interval 2 s in Experiment 1 or fixed-ratio 1 in Experiment 2) compared to a low-rate baseline reinforcement condition. We discuss the implications of these results relative to schedules of reinforcement in the treatment of destructive behavior and strategies to mitigate resurgence in clinical settings.

A nonsequential approach to the study of operant renewal: a reverse translation.

ABA renewal is a model of treatment relapse that describes the recurrence of severe problem behavior when behavior learned in one context (e.g., home; A) and treated in a separate context (e.g., clinic; B) reemerges when the original context is reintroduced (A). However, in the typical environment and during the usual course of treatment for severe problem behavior, the target behavior is exposed to the baseline context periodically (e.g., the child returns home after several hours in a clinic setting). Due to the difficulty of studying what effect this may have on treatment relapse during ABA renewal in a strictly applied investigation, we developed a human-laboratory translation to study renewal in a nonsequential manner. Using undergraduate students as subjects, we directly compared levels of recurrence using the standard ABA renewal procedure and a modified nonsequential ACA procedure, one modeled from the typical course of treatment for problem behavior. Both methods produced renewal at comparable levels, and patterns during nonsequential ACA renewal were similar to those during sequential ABA renewal. We discuss the implications of these findings in the framework of treatment for severe problem behavior.

Renewal during functional communication training.

Functional communication training (FCT) is one of the most commonly prescribed interventions for the treatment of severe destructive behavior exhibited by individuals with intellectual disabilities. Although highly effective, FCT has been shown to fail in some cases when treatment is introduced into the child's typical environment. Basic and translational research on renewal provides a model for studying the relapse of destructive behavior following successful response to treatment in clinic settings using FCT. In the present study, we evaluated whether relapse of destructive behavior could be attributed to the discriminative control of the home context, which was historically correlated with reinforcement for destructive behavior. We implemented baseline contingencies in the home setting with caregivers acting as interventionists (i.e., Context A). We then implemented FCT in a treatment clinic with trained therapists (i.e., Context B). Finally, we introduced FCT in the home setting with caregivers implementing the treatment procedures (i.e., return to Context A). For three of four participants we observed the relapse of destructive behavior consistent with operant renewal. We discuss the implications of these findings with respect to strategies designed to promote generalization of FCT across settings during the treatment of severe destructive behavior.

The combined effects of noncontingent reinforcement and punishment on the reduction of rumination.

The current study extends the literature on the assessment and treatment of rumination through the evaluation of a combined reinforcement- and punishment-based intervention. The study included a single participant with a history of rumination maintained by automatic reinforcement, as identified via a functional analysis. Both noncontingent reinforcement (NCR) with preferred edible items and punishment, in the form of a facial screen, were implemented separately to evaluate their independent effects on the occurrence of rumination. The final treatment package included both NCR and punishment procedures. Implementation of the combined treatment resulted in a 96.5% reduction in rumination relative to baseline. Procedural modifications and integrity errors also were evaluated.

Effects of arm-splint rigidity on self-injury and adaptive behavior.

The current study replicated and extended previous research on the use of a rapid assessment to identify effective arm-splint rigidity with 2 participants who had been diagnosed with autism and who engaged in self-injurious behavior (SIB). We varied rigidity levels within a multielement design across several adaptive tasks and identified the most effective rigidity level in terms of reductions in SIB and levels of compliance.

Analysis of self-feeding in children with feeding disorders.

In the current investigation, we evaluated a method for increasing self-feeding with 3 children with a history of food refusal. The children never (2 children) or rarely (1 child) self-fed bites of food when the choice was between self-feeding and escape from eating. When the choice was between self-feeding 1 bite of food or being fed an identical bite of food, self-feeding was low (2 children) or variable (1 child). Levels of self-feeding increased for 2 children when the choice was between self-feeding 1 bite of food or being fed multiple bites of the same food. For the 3rd child, self-feeding increased when the choice was between self-feeding 1 bite of food or being fed multiple bites of a less preferred food. The results showed that altering the contingencies associated with being fed increased the probability of self-feeding, but the specific manipulations that produced self-feeding were unique to each child.

Reduction of emergent dropping behavior during treatment of elopement.

Although treatments for elopement (leaving an assigned area or a caregiver without permission) and dropping (falling to the floor) have been reported in the literature, there are no studies that have examined the concurrent treatment of these behaviors. The current investigation reports on the emergence and treatment of dropping during the treatment of elopement.