Response to ABAI Task Force on the Use of Contingent Electric Skin Shock.

In this article, the authors provide their response to the Association for Behavior Analysis International (2022) position statement on the use of contingent electric skin shock (CESS). In this response, we address concerns raised by the task force regarding limitations of the Zarcone et al. (2020) review article in which both methodological and ethical concerns were raised about the quality of research in the use of CESS with people with disabilities in the treatment of challenging behavior. We note that with the exception of the Judge Rotenberg Center in Massachusetts, no state or country currently supports the use of CESS as it is not recognized as the standard of care in any other program, school, or facility.

Rules and Statements of Reinforcer Loss in Differential Reinforcement of Other Behavior.

Providing a rule regarding consequences for behavior can increase the efficacy of differential reinforcement of other behavior (DRO) procedures in the treatment of severe problem behavior (Watts, Wilder, Gregory, Leon, and Ditzian, Journal of Applied Behavior Analysis, 46, 680-684, 2013). The purpose of the current study was to replicate and extend the literature on DRO procedures by evaluating the efficacy of rules and statements of reinforcer loss (SRL) in the treatment of severe problem behavior. Conditions included baseline, no rule DRO, rule DRO, and rule DRO with SRL. For 2 of 3 participants, neither the no rule DRO nor the rule DRO condition reduced problem behavior. The rule DRO with SRL condition produced a substantial decrease in problem behavior for all participants, suggesting that a consequent rule enhances the efficacy of DRO. The current study extends the literature on DRO procedures by providing data on nontargeted ("other") behavior. An increase in other behavior was observed for 2 participants.

Initial outcomes of an augmented competing stimulus assessment.

Competing stimulus assessments (CSAs) are designed to identify stimuli that, when made freely available, reduce problem behavior. Although CSAs have demonstrated utility, identifying competing stimuli can be difficult for some individuals. The current study describes outcomes from an augmented CSA (A-CSA) for 6 consecutively encountered cases with treatment-resistant subtypes of automatically maintained problem behavior. When test stimuli were made freely available, only between 0 and 1 effective competing stimuli were identified for each case. Prompting and response blocking were temporarily employed in succession to promote engagement with stimuli and disrupt problem behavior. When those procedures were withdrawn and stimuli made freely available, the number of effective competing stimuli increased in all 6 cases. Findings suggest that procedures designed to promote engagement and disrupt problem behavior may allow the A-CSA to be a platform not only for identifying competing stimuli, but also for actively establishing competing stimuli.

Functional analysis and treatment of problem behavior related to mands for rearrangement.

This study is a systematic replication of a functional analysis (FA) of the relation between mands and problem behavior. We extended treatment approaches for this problem behavior function, and describe the treatment of problem behavior related to mands for rearrangement demonstrated by a 12-year-old girl with autism spectrum disorder and Smith-Magenis syndrome. The mands consisted of requests for others to change their body positioning or proximity, or rearrange items back to their original position. An FA confirmed the relation between problem behavior and mand compliance, and functional communication training with extinction decreased problem behavior and increased functional communication responses. Problem behavior remained low as gradually longer nonreinforcement periods were introduced using a multiple schedule.

Behavioral treatment of automatically reinforced SIB: 1982 - 2015.

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

Further analysis of subtypes of automatically reinforced SIB: A replication and quantitative analysis of published datasets.

Hagopian, Rooker, and Zarcone (2015) evaluated a model for subtyping automatically reinforced self-injurious behavior (SIB) based on its sensitivity to changes in functional analysis conditions and the presence of self-restraint. The current study tested the generality of the model by applying it to all datasets of automatically reinforced SIB published from 1982 to 2015. We identified 49 datasets that included sufficient data to permit subtyping. Similar to the original study, Subtype-1 SIB was generally amenable to treatment using reinforcement alone, whereas Subtype-2 SIB was not. Conclusions could not be drawn about Subtype-3 SIB due to the small number of datasets. Nevertheless, the findings support the generality of the model and suggest that sensitivity of SIB to disruption by alternative reinforcement is an important dimension of automatically reinforced SIB. Findings also suggest that automatically reinforced SIB should no longer be considered a single category and that additional research is needed to better understand and treat Subtype-2 SIB.

Intervention for Anxiety and Problem Behavior in Children with Autism Spectrum Disorder and Intellectual Disability.

There is little research on the functional assessment and treatment of anxiety and related problem behavior in children with autism spectrum disorder (ASD), particularly those with intellectual and developmental disability (IDD). In a recent study, we evaluated a multimethod strategy for assessing anxiety in children with ASD and IDD (Am J Intellect Dev Disabil 118:419-434, 2013). In the present study, we developed treatments for the anxiety and associated problem behavior in these same children. A multiple baseline design was used to evaluate the effectiveness of a multicomponent intervention package, incorporating individualized strategies from Positive Behavior Support and Cognitive Behavioral Therapy. During intervention, all three participants showed substantial decreases in anxiety and problem behavior and significant increases in respiratory sinus arrhythmia in the situations that had previously been identified as anxiety-provoking.

A crossover study of risperidone in children, adolescents and adults with mental retardation.

Risperidone has shown safety and efficacy for aggressive and destructive behaviors in short-term studies. This longer-duration study includes a broad sample. Forty subjects, aged 8-56 years (mean=22), all with mental retardation and 36 with autism spectrum disorders participated in this 22-week crossover study, with 24 weeks of open maintenance thereafter. Of 40 subjects, 23 (57.5%) responded fully (50% decrease in Aberrant Behavior Checklist-Community Irritability subscale score), while 35 subjects (87.5%) showed a 25% decrease. Gender, mood disorder, and antiseizure medications did not alter response. Increased appetite and weight gain were common. Low dose risperidone was effective for aggressive behavior in persons with MR. More long-term studies are needed, incorporating weight control interventions.

Risperidone-induced prolactin elevation in a prospective study of children, adolescents, and adults with mental retardation and pervasive developmental disorders.

OBJECTIVE: Risperidone is widely prescribed for aggression and self-injury in children, adolescents, and adults with mental retardation (MR) and pervasive developmental disorders (PDD). Risperidone elevates prolactin more than other atypical antipsychotic medications. Females may show greater prolactin elevation than males. METHOD: In this relatively long-term study of risperidone efficacy and safety for aggression and self-injury in children, adolescents, and adults with MR and PDDs, serum prolactin was measured in a 21-subject subset during the course of a double-blind, placebo-controlled trial. Prolactin was measured in ng/mL at baseline, once during acute treatment, and once during maintenance. RESULTS: In children and adolescents (n=10), mean age of 12.5 years, prolactin increased from mean 13.2+/-8.6 at baseline to 31.0+/-11.6 acutely and remained elevated at 37.9+/-10.4 in maintenance. In adults, mean age of 35.3 years, prolactin increased more markedly from 11.6+/-7.4 baseline (n=11) to 93.3+/-54.2 acutely but decreased to 67.8+/-62.9 in maintenance (n=7). Prolactin remained significantly elevated above normal in all subjects for at least 26 weeks. Mean prolactin of adult females, while similar to that of adult males at baseline, was 2.2 times male levels acutely and 3.7 times greater in maintenance. CONCLUSION: In this small subset, mean prolactin elevation persisted for at least 26 weeks. In adults, females showed significantly greater elevations than males.

A double-blind, placebo-controlled study of valproate for aggression in youth with pervasive developmental disorders.

OBJECTIVE: The aim of this study was to study valproate efficacy and safety for aggression in children and adolescents with pervasive developmental disorders (PDD). METHODS: In this prospective double-blind, placebo-controlled study, 30 subjects (20 boys, 10 girls) 6-20 years of age with PDD and significant aggression were randomized and received treatment with valproate (VPA) or placebo (PBO) for 8 weeks as outpatients. Mean VPA trough blood levels were 75.5 mcg/mL at week 4 and 77.8 mcg/mL at week 8. RESULTS: No treatment difference was observed statistically between VPA and PBO groups. The Aberrant Behavior Checklist--Community Scale (ABC-C) Irritability subscale was the primary outcome measure (p = 0.65), and CGI--Improvement (p = 0.16) and OAS (p = 0.96) were secondary outcome measures. Increased appetite and skin rash were significant side effects. Only 1 subject was dropped from the study owing to side effects, notably a spreading skin rash, which then resolved spontaneously. Two subjects receiving VPA developed increased serum ammonia levels, one with an associated parent report of slurred speech and mild cognitive slowing. Poststudy, of 16 VPA and PBO subjects receiving VPA, 10 subjects demonstrated sustained response, 4 of whom later attempted taper, with significant relapse of aggression. CONCLUSION: The present negative findings cannot be viewed as conclusive, partly owing to the large placebo response, subject heterogeneity, and size of the groups. Larger studies are needed to expand upon these findings.

Use of an antecedent analysis and a force sensitive platform to compare stereotyped movements and motor tics.

Stereotyped movements displayed by 6 participants and tics displayed by 6 children were evaluated using an antecedent behavioral analysis and a force sensitive platform. We found that tics occurred more often in an alone condition when compared to high preference toy and play conditions, whereas stereotyped movements were more variable across conditions. Using temporal measures and spectral analysis data from the force sensitive platform, we found that stereotyped movements tended to be longer in duration and displayed more rhythmic qualities when compared to tics. Results indicate that stereotyped movements and tics differ both quantitatively and qualitatively and support the use of new technologies, such as force plate technology, to more accurately evaluate these differences.

Delineating subtypes of self-injurious behavior maintained by automatic reinforcement.

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

Use of functional analysis methodology in the evaluation of medication effects.

The atypical antipsychotic medication risperidone was evaluated using a double-blind, placebo-controlled design in the treatment of destructive behavior in two individuals with autism. Pre-medication functional analyses indicated that destructive behavior was maintained by escape from demands, attention, or access to tangible items. For both individuals, destructive behavior during the demand condition was significantly reduced during the medication phases, whereas destructive behavior continued to occur to obtain tangible items (Reggie) and attention (Sean). In addition, there appeared to be a differential effect of the medication on self-injurious behavior (SIB) versus aggression for Sean. Results of the study demonstrate how functional analysis may provide information on those conditions and behaviors that are most likely to be affected by a specific medication.

Multimodal evaluation of risperidone for destructive behavior: functional analysis, direct observations, rating scales, and psychiatric impressions.

Risperidone, an atypical neuroleptic, has become a popular option for treating destructive behaviors of persons with developmental disabilities. A few studies have been conducted that evaluate the effects of risperidone on destructive behavior; however, none of these studies have combined objective measures with rating scales to evaluate the effects of risperidone on destructive behavior across home and clinical settings. This study evaluated the wide range of effects of risperidone on destructive behavior of 2 persons with developmental disabilities using weekly functional analysis sessions, daily observations, hourly home data, weekly rating scales, and monthly psychiatric impressions. Results indicate that risperidone does decrease destructive behavior and that, for the most part, all of the various measures yielded similar results.

Effects of risperidone on aberrant behavior in persons with developmental disabilities: II. Social validity measures.

Consumer satisfaction and social validity were measured during a double-blind, placebo-controlled evaluation of the atypical neuroleptic risperidone in treating severe aberrant behavior of persons with developmental disabilities. First, a satisfaction survey was completed after a medication trial by each participant's caregiver. Results showed that 100% of the caregivers felt that participation was a positive experience for themselves and participants. Second, 52 community members viewed videotapes of 5 participants during a clinical interview when they were taking either placebo or risperidone. Raters also indicated that when on the medication, participants displayed fewer aberrant behaviors, were less irritable, in a better mood, and were more responsive to their environment.

Effects of risperidone on destructive behavior of persons with developmental disabilities: III. Functional analysis.

Functional analyses were conducted during a double-blind, placebo-controlled study of the atypical antipsychotic medication risperidone with 13 individuals. Risperidone was effective in reducing destructive behavior (compared to placebo) for 10 participants. For 7 of these responders, an undifferentiated pattern of responding occurred across their baseline functional analysis conditions (i.e., a similar rate of responding across conditions), and risperidone treatment produced nonspecific reductions of their destructive behavior across functional analysis conditions. For the remaining 3 responders, a differentiated pattern of responding occurred across their baseline functional analysis conditions (i.e., an elevated rate of responding occurred in a specific condition), and risperidone treatment produced function-specific reductions of their destructive behavior.

A comparison of multiple reinforcer assessments to identify the function of maladaptive behavior.

Functional analysis results indicated that maladaptive behaviors displayed by a 25-year-old man with profound mental retardation were maintained by attention from caregivers and possibly, to a lesser degree, by access to tangible items. A concurrent-schedules procedure was then used to study the relative reinforcing value for maladaptive behavior of attention versus tangible items. Results of the concurrent-schedules assessment and subsequent functional communication training indicated that preference for attention versus access to a tangible object varied.

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

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

Increasing response diversity in children with autism.

Repetitive and invariant behavior is a diagnostic feature of autism. We implemented a lag reinforcement schedule to increase response diversity for 6 participants with autism aged 6 to 10 years, 4 of whom also received prompting plus additional training. These procedures appeared to increase the variety of building-block structures, demonstrating that an intervention that includes differential reinforcement can increase response diversity for children with an autism spectrum disorder.

Neural mechanisms associated with food motivation in obese and healthy weight adults.

One out of three adults in the United States is clinically obese. Excess food intake is associated with food motivation, which has been found to be higher in obese compared to healthy weight (HW) individuals. Little is known, however, regarding the neural mechanisms associated with food motivation in obese compared to HW adults. The current study used functional magnetic resonance imaging (fMRI) to examine changes in the hemodynamic response in obese and HW adults while they viewed food and nonfood images in premeal and postmeal states. During the premeal condition, obese participants showed increased activation, compared to HW participants, in anterior cingulate cortex (ACC) and medial prefrontal cortex (MPFC). Moreover, in the obese group, self-report measures of disinhibition were negatively correlated with premeal ACC activations and self-report measures of hunger were positively correlated with premeal MPFC activations. During the postmeal condition, obese participants also showed greater activation than HW participants in the MPFC. These results indicate that brain function associated with food motivation differs in obese and HW adults and may have implications for understanding brain mechanisms contributing to overeating and obesity, and variability in response to diet interventions.