Psychometric characteristics of the mental health crisis assessment scale in youth with autism spectrum disorder.

BACKGROUND: Youth with autism spectrum disorder (ASD) exhibit high rates of psychopathology. These symptoms can pose a risk of injury to self or others when the child is in crisis. Despite this danger, there are no instruments available to identify those with ASD who are at risk or actively in crisis. This study examined the psychometric properties of the Mental Health Crisis Assessment Scale (MCAS), a 28 item parent report measure. METHODS: The MCAS was administered to the parents of 606 children and young adults (aged 3-25 years, M age = 13 years, SD = 5 years) enrolled in the Interactive Autism Network, an online registry of families raising a child with ASD. The MCAS asks parents to rate the severity of various emotional and behavioral symptoms exhibited by their child. The parent then selects the behavior they perceive as the most dangerous behavior and rates the acuity of as well as their efficacy in managing this behavior. The MCAS was tested for internal consistency, construct validity, criterion validity, and convergent validity. RESULTS: The MCAS demonstrated strong internal consistency (Total Scale Cronbach's α = .88). The exploratory and confirmatory factor analyses suggested that a two factor (acuity and behavioral efficacy) model fit the data well, providing evidence of construct validity. Criterion validity, which was assessed by comparing the MCAS to clinician determination of crisis, indicated high levels of agreement (ROC = .85). Strong positive relationships emerged between the MCAS and measures of family distress (r = .56), parental stress, and frustration (r = .48), and use of emergency psychiatric services (OR = 24.2, 95% CI: 8.6-68.2), indicating convergent validity of the measure (all p < .05). CONCLUSIONS: Results of the psychometric analyses suggest the MCAS appears to be a promising tool that can measure mental health crises in youth with ASD.

Treatment of severe problem behaviour in children with autism spectrum disorder and intellectual disabilities.

Children with autism spectrum disorder (ASD) and intellectual disabilities (ID) present with problem behaviour at rates disproportionately higher than their typically-developing peers. Problem behaviour, such as self-injury, aggression, pica, disruption, and elopement result in a diminished quality-of-life for the individual and family. Applied behaviour analysis has a well-established research base, detailing a number of assessment and treatment methods designed to address behaviour problems in children with ASD and ID. Although the variables that lead to the emergence of problem behaviour are not precisely known, those that are currently responsible for the maintenance of these problems can be identified via functional behaviour assessment, which is designed to identify events that occasion problem behaviour, consequences that maintain it, as well as other environmental factors that exert influence on the behaviour. Corresponding function-based treatment is implemented when environmental determinants are identified, with the aim of decreasing or eliminating problem behaviour, as well as teaching the individual to engage in more appropriate, alternative behaviour. In some cases, when problem behaviour is under the control of both environmental and biological variables, including psychiatric conditions, combining behavioural and pharmacological interventions is viewed as optimal, although there is limited empirical support for integrating these approaches.

Description and Validation of a Computerized Behavioral Data Program: "BDataPro".

BDataPro is a Microsoft Windows®-based program that allows for real-time data collection of multiple frequency- and duration-based behaviors, summary of behavioral data (in terms of average responses per min, percentage of 10-s intervals, and cumulative responses within 10-s bins), and calculation of reliability coefficients. The current article describes the functionality of the program. BDataPro is freely available for download from the authors' institution websites.

Application of the evolutionary theory of behavior dynamics to severe challenging behavior.

The evolutionary theory of behavior dynamics (ETBD) is a genetic algorithm that applies the Darwinian principles of evolutionary biology to model how behavior changes dynamically via selection by contingencies of reinforcement. The ETBD is a complexity theory where low-level rules of selection, reproduction, and mutation operate iteratively to animate "artificial organisms" that generate emergent outcomes. Numerous studies have demonstrated the ETBD can accurately model behavior of live animals in the laboratory, and it has been applied recently to model automatically maintained self-injury. The purpose of the current series of studies was to further extend the application of the ETBD to model additional functional classes of challenging behavior and clinical procedures. Outcomes obtained with artificial organisms generally corresponded well with outcomes observed with clinical cases sourced from consecutive controlled case series studies. Conceptual and methodological considerations on the application of the ETBD to model challenging behavior are discussed.

Modeling and quantifying resurgence in the Evolutionary Theory of Behavior Dynamics.

McDowell's Evolutionary Theory of Behavior Dynamics (ETBD) has been shown to model a wide range of live organism behavior with excellent descriptive accuracy. Recently, artificial organisms (AOs) animated by the ETBD were shown to replicate the resurgence of a target response following downshifts in the density of reinforcement for an alternative response and across repeated iterations of the traditional three-phase resurgence paradigm in a manner commensurate with nonhuman subjects. In the current investigation, we successfully replicated an additional study that used this traditional three-phase resurgence paradigm with human participants. We fitted two models based on the Resurgence as Choice (RaC) theory to the data generated by the AOs. Because the models had varying numbers of free parameters, we used an information-theoretic approach to compare the models against one another. We found that a version of the Resurgence as Choice in Context model that incorporates aspects of Davison and colleague's Contingency Discriminability Model provided the best description of the resurgence data emitted by the AOs when accounting for the models' complexity. Last, we discuss considerations when developing and testing new quantitative models of resurgence that account for the ever-growing literature of resurgence.

Efficacy of competing stimulus assessments: A summary of 35 consecutively encountered cases.

Competing stimulus assessments (CSAs) are designed to identify stimuli that reduce challenging behavior through competition with its maintaining reinforcers. Recently, Haddock and Hagopian (2020) found that over 92% of CSAs described in published studies identified at least one high-competition stimulus (i.e., a stimulus correlated with at least an 80% reduction in challenging behavior). The current study describes the outcomes of CSAs in a retrospective consecutive controlled case series study of 35 cases (individuals) admitted to an inpatient setting. Findings on the limited relation between the level of stimulus engagement and reductions in challenging behavior were replicated; however, the efficacy of CSAs was lower (only 47% of CSAs were successful in identifying one or more high-competition stimuli). Discrepant findings across studies on the efficacy of CSAs are discussed in terms of differences in the sample participants and how outcomes are reported, which vary depending on the study's research questions.

A Neurobehavioral Continuum of Care for Individuals with Intellectual and Developmental Disabilities with Severe Problem Behavior.

The Neurobehavioral Programs at Kennedy Krieger Institute constitute a comprehensive continuum of care designed to serve individuals with intellectual and developmental disabilities with co-occurring problem behavior. This continuum includes inpatient, intensive outpatient, outpatient, consultation, and follow-up services. The mission of these programs is to fully integrate patient care, research, training, and advocacy to achieve the best possible outcomes with patients, and to benefit the broader community of individuals with severe behavioral dysfunction. The primary treatment approach utilized across all programs is applied behavior analysis, however the inpatient unit also provides fully integrated interdisciplinary care. Factors driving the development and expansion of these programs are described, as are the processes and systems by which the mission objectives are achieved.

A replication and extension of the augmented competing stimulus assessment.

Augmenting competing stimulus assessments by embedding tactics to increase stimulus engagement and disrupt challenging behavior can improve outcomes of treatments for automatically maintained self-injurious behavior, even for treatment-resistant subtypes. This study replicated and extended research on augmented competing stimulus assessments by reporting outcomes for 16 consecutively encountered cases with automatically maintained self-injurious behavior (19 total applications); six participants had treatment-responsive Subtype 1 and 10 had treatment-resistant Subtypes 2 or 3. Fewer high-competition stimuli were identified for individuals with treatment-resistant subtypes. When response-promotion and disruption tactics were applied and withdrawn, outcomes improved for six of eight applications. At least one high-competition stimulus was still effective when maintenance probes were conducted for a subset of participants. Ultimately, at least one high-competition stimulus was identified for each participant. Although augmenting tactics may not be necessary for all individuals, these findings provide additional support for their efficacy with treatment-resistant self-injurious behavior.

Simplified methods for identifying subtypes of automatically maintained self-injury.

Subtypes of automatically maintained self-injurious behavior (SIB) have been defined based on response patterns observed during the functional analysis, which are thought to reflect each subtype's distinct mechanisms. Current practice for identifying subtypes involves using structured criteria to identify whether SIB is automatically maintained, followed by the application of additional criteria to identify the subtype. We describe a series of studies directed at simplifying these methods to facilitate wider application of the subtyping model in research and practice. In Studies 1 and 2, we demonstrate the accuracy of modified criteria using the level of differentiation of SIB across the play and no-interaction conditions at distinguishing between two subtypes (i.e., Subtypes 1 and 2). We then demonstrate visual analysis (without structured criteria) can accurately identify SIB as automatically maintained in Study 3, which can be used in combination with level of differentiation to enable application of the subtyping model in practice.

Modeling resurgence with an evolutionary theory of behavior dynamics.

McDowell's (2004) Evolutionary Theory of Behavior Dynamics (ETBD) is a computational theory that has reproduced a wide variety of behavioral phenomena observed in material reality. Here, we extended the generality of the ETBD by successfully replicating laboratory studies of resurgence with live animals using artificial organisms (AOs) animated by the theory. We ran AOs on concurrent random-interval random-interval (conc RI RI) schedules of reinforcement wherein one alternative (i.e., a target behavior) was reinforced while the other alternative (i.e., an alternative behavior) was not reinforced. Then, we placed the target behavior on extinction and reinforced the alternative response, producing a shift in allocation of responding from the target behavior to the alternative response. Finally, schedule thinning of the alternative response (i.e., downshifts) resulted in resurgence of target behavior. Our findings indicated that resurgence increased as a function of the relative downshift in reinforcement rate and magnitude, replicating findings from previous studies with live animals. These results further illustrate the utility of the ETBD for generating dynamic behavioral data and serve as a proof-of-concept for a novel computational approach for studying and understanding resurgence in future studies.

Further Analysis of Advanced Quantitative Methods and Supplemental Interpretative Aids with Single-Case Experimental Designs.

Reliable and accurate visual analysis of graphically depicted behavioral data acquired using single-case experimental designs (SCEDs) is integral to behavior-analytic research and practice. Researchers have developed a range of techniques to increase reliable and objective visual inspection of SCED data including visual interpretive guides, statistical techniques, and nonstatistical quantitative methods to objectify the visual-analytic interpretation of data to guide clinicians, and ensure a replicable data interpretation process in research. These structured data analytic practices are now more frequently used by behavior analysts and the subject of considerable research within the field of quantitative methods and behavior analysis. First, there are contemporaneous analytic methods that have preliminary support with simulated datasets, but have not been thoroughly examined with nonsimulated clinical datasets. There are a number of relatively new techniques that have preliminary support (e.g., fail-safe k), but require additional research. Other analytic methods (e.g., dual-criteria and conservative dual criteria) have more extensive support, but have infrequently been compared against other analytic methods. Across three studies, we examine how these methods corresponded to clinical outcomes (and one another) for the purpose of replicating and extending extant literature in this area. Implications and recommendations for practitioners and researchers are discussed.

Examining resurgence and repetition with the evolutionary theory of behavior dynamics.

Recently, Redner et al. (2022) examined the nature of resurgence across repeated iterations of the traditional three-phase resurgence procedure with four pigeons. Although extant research findings in this area are mixed, Redner et al. found that resurgence generally increased in magnitude with repetition. These findings provide a baseline against which future research examining resurgence using this three-phase procedure can be compared and contrasted. The purpose of the present investigation was to examine resurgence via concurrent schedule arrangements similar to those described by Redner et al. with 30 artificial organisms (AOs) animated by the Evolutionary Theory of Behavior Dynamics (McDowell, 2004). We quantified the prevalence of resurgence across iterations and found that resurgence occurred in 86.7 % (156 of 180) iterations across all 30 AOs. This is strikingly similar to the resurgence prevalence estimates of 87.5 % reported by both Redner et al. (2022). However, we also found that the magnitude of target responding generally did not change significantly with repetition. This finding is inconsistent with Redner et al. but is consistent with the predictions of prominent quantitative models of behavioral persistence and a number of relevant studies (Volkert et al., 2009; Gratz et al., 2019). We also conducted exploratory analyses to examine how several variables (e.g., sensitivity to reinforcement, reinforcer magnitude, number of sessions of exposure to various phases) affect the prevalence and magnitude of resurgence among AOs.

Quantifying increases in problem behavior following downshifts in reinforcement: A retrospective analysis and replication.

The recurrence of a previously eliminated or reduced behavior following a downshift in alternative reinforcement is referred to as resurgence. Resurgence as Choice (RaC) is a quantitative model of behavioral persistence that posits that resurgence is governed by the same behavioral principles that underlie choice behavior. Consistent with the predictions of RaC, extant basic research with animals indicates that resurgence increases as an exponential function of the size of the downshift in alternative reinforcement. Recently, Shahan and Greer (2021) extended this finding to resurgence of problem behavior during schedule thinning following functional communication training (FCT). They found that when resurgence occurred, it increased exponentially as a function of relative decrements in reinforcer availability during schedule thinning with compound schedules of reinforcement. The purpose of the current study was to directly replicate the analytic procedures described in Shahan and Greer to examine resurgence of problem behavior during schedule thinning following FCT using two novel clinical datasets. Our results closely replicate the findings from Shahan and Greer, providing additional support for the generality of resurgence during downshifts in alternative reinforcement in clinical contexts. These results also highlight the potential applicability of RaC for modeling resurgence of problem behavior during FCT schedule thinning.

Analysis of unexpected disruptive effects of contingent food reinforcement on automatically maintained self-injury.

Research has identified treatment-responsive and treatment-resistant subtypes of automatically maintained self-injurious behavior (ASIB) based on patterns of responding in the functional analysis (FA) reflecting its sensitivity to disruption by alternative reinforcement, and the presence of self-restraint. Rooker et al. (2019) unexpectedly observed reductions in treatment-resistant self-injury while participants performed an operant task. The current study further examined this in nine participants with treatment-resistant ASIB in an example of discovery-based research. An operant task engendering high rates of responding (switch-pressing) to produce food, reduced self-injury across all participants, and eliminated self-injury for some participants under certain schedules. Although this finding must be replicated and evaluated over longer time periods, it provides some evidence that alternative reinforcement can disrupt self-injury in these treatment-resistant subtypes under some conditions. Reinforcer and response competition are discussed as possible mechanisms underlying these disruptive effects, as are the potential implications of these findings regarding treatment.

Decreasing motor stereotypy with competing stimuli and tasks: Analysis of prompted engagement and response blocking.

Competing stimulus assessments (CSAs) are used to empirically identify stimuli associated with low levels of problem behavior. For some individuals with automatically maintained behavior, it can be difficult to identify effective competing stimuli. Recent research shows that prompting engagement and response blocking can be employed during the CSA to obtain significant reductions in problem behavior. The purpose of the present study was to replicate and extend prior research on the use of these tactics not only with competing stimuli, but also competing tasks, which require the active completion of a discrete response or response sequence. In addition, the current study validated the results of these pretreatment assessments in an extended treatment analysis, and examined the isolated and combined effects of prompting and response blocking within a component analysis. Future research directions and implications for clinical practice are discussed.

The consecutive controlled case series: Design, data-analytics, and reporting methods supporting the study of generality.

Single-case experimental designs (SCEDs) have proven invaluable in research and practice because they are optimal for asking many experimental questions relevant to the analysis of behavior. The consecutive controlled case series (CCCS) is a type of study in which a SCED is employed in a series of consecutively encountered cases that undergo a common procedure or share a common characteristic. Additional design elements, data-analytic, and reporting methods enable researchers to ask experimental questions relevant to the study of generality of procedures and processes. The current paper discusses the CCCS methodologies, including the retrospective, prospective, and randomized CCCS. These methodologies can be applied to examine the generality of clinical procedures (including their general efficacy, the limits of their generality, and variables that may mediate generality); study the epidemiology and phenomenology of clinical problems; and compare the efficacy of 2 clinical procedures within a randomized controlled trial combining SCEDs with randomized group designs.

Further extensions of precision medicine to behavior analysis: A demonstration using functional communication training.

The potential applicability of concepts and methods of the paradigm of precision medicine to the field of applied behavior analysis is only beginning to be explored. Both precision medicine and applied behavior analysis seek to understand and classify clinical problems through identification of their causal pathways. Both aim to develop treatments directly targeting those causal pathways, which also requires an understanding of the mechanisms by which treatments produce change (treatment-action pathways). In the current study, we extend the data-analytic methods and concepts described by Hagopian et al. (2018) toward the identification of variables that predict response to functional communication training (FCT). We discuss emerging conceptual issues, including the importance of distinguishing predictive behavioral markers from predictor variables based on their purported involvement in the causal or treatment-action pathways. Making these discriminations is a complex undertaking that requires knowledge of these mechanisms and how they interact.

Competing stimulus assessments: A systematic review.

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

Behavioral Approaches to Assessment and Early Intervention for Severe Problem Behavior in Intellectual and Developmental Disabilities.

This article summarizes the literature on prevalence and establishment of severe problem behavior in individuals with intellectual and developmental disabilities, empirical support for applied behavior analysis, and evidence-based behavioral assessment and treatment procedures. Early intervention and prevention approaches and the role of the pediatrician with regard to surveillance, early intervention, and coordination of care are discussed.

Investigating mental health crisis in youth with autism spectrum disorder.

Evidence suggests that youth with autism spectrum disorder (ASD) are at increased risk for experiencing a mental health crisis. Yet, limited systematic research exists on this topic. This study examines the prevalence, phenomenology, and correlates of mental health crisis in children, adolescents, and young adults with ASD. Participants included 462 parents of individuals with ASD (83% male, 86% Caucasian, M = 13.7 years, SD = 4.7) who were enrolled in the Interactive Autism Network, a large online registry of families of individuals with ASD. Parents completed the Mental Health Crisis Assessment Scale, a psychometrically sound measure of mental health crisis for youth with ASD, as well as measures of parental depression, family quality of life, and mental health treatment history. Overall, 32% of parents reported that their child had experienced a mental health crisis during the last 3 months. In the younger group, elopement (88%) and self-injury (81%) were the most frequent behaviors contributing to crisis; physical (60%) and verbal (42%) aggression were the most frequent crisis behaviors in the older group. Correlates of crisis included younger age, increased parental depressive symptoms, and lower family quality of life. Approximately 75% of individuals in crisis had seen a psychiatrist or behavioral therapist/psychologist within the last 3 months and 25% were not engaged in any mental health treatment. In summary, mental health crises were quite prevalent in this online sample of youth with ASD. Identification and treatment of these serious events is critical to reduce morbidity in this population. Autism Res 2020, 13: 112-121. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examines the prevalence and characteristics of mental health crisis in children, adolescents, and young adults with autism spectrum disorder. We found that 32% of individuals in our study had experienced a mental health crisis within the last 3 months. Younger age, increased parental depression, and lower quality of life were associated with crisis. These findings emphasize the importance of developing child and family-based interventions to prevent and treat the mental health crisis in this population.