Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial.

IMPORTANCE: Disruptive behavior is common in children with autism spectrum disorder. Behavioral interventions are used to treat disruptive behavior but have not been evaluated in large-scale randomized trials. OBJECTIVE: To evaluate the efficacy of parent training for children with autism spectrum disorder and disruptive behavior. DESIGN, SETTING, AND PARTICIPANTS: This 24-week randomized trial compared parent training (n = 89) to parent education (n = 91) at 6 centers (Emory University, Indiana University, Ohio State University, University of Pittsburgh, University of Rochester, Yale University). We screened 267 children; 180 children (aged 3-7 years) with autism spectrum disorder and disruptive behaviors were randomly assigned (86% white, 88% male) between September 2010 and February 2014. INTERVENTIONS: Parent training (11 core, 2 optional sessions; 2 telephone boosters; 2 home visits) provided specific strategies to manage disruptive behavior. Parent education (12 core sessions, 1 home visit) provided information about autism but no behavior management strategies. MAIN OUTCOMES AND MEASURES: Parents rated disruptive behavior and noncompliance on co-primary outcomes: the Aberrant Behavior Checklist-Irritability subscale (range, 0-45) and the Home Situations Questionnaire-Autism Spectrum Disorder (range, 0-9). On both measures, higher scores indicate greater severity and a 25% reduction indicates clinical improvement. A clinician blind to treatment assignment rated the Improvement scale of the Clinical Global Impression (range, 1-7), a secondary outcome, with a positive response less than 3. RESULTS: At week 24, the Aberrant Behavior Checklist-Irritability subscale declined 47.7% in parent training (from 23.7 to 12.4) compared with 31.8% for parent education (23.9 to 16.3) (treatment effect, -3.9; 95% CI, -6.2 to -1.7; P < .001, standardized effect size = 0.62). The Home Situations Questionnaire-Autism Spectrum Disorder declined 55% (from 4.0 to 1.8) compared with 34.2% in parent education (3.8 to 2.5) (treatment effect, -0.7; 95% CI, -1.1 to -0.3; P < .001, standardized effect size = 0.45). Neither measure met the prespecified minimal clinically important difference. The proportions with a positive response on the Clinical Global Impression-Improvement scale were 68.5% for parent training vs 39.6% for parent education (P < .001). CONCLUSIONS AND RELEVANCE: For children with autism spectrum disorder, a 24-week parent training program was superior to parent education for reducing disruptive behavior on parent-reported outcomes, although the clinical significance of the improvement is unclear. The rate of positive response judged by a blinded clinician was greater for parent training vs parent education. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01233414.

Accuracy of the Screening Tool for Autism in Toddlers and Young Children in the primary care setting.

LAY SUMMARY: Specialists conduct autism evaluations using tools that are expensive and difficult to get trained on. Families often wait a long time and travel far to get a diagnosis for their child. To help with this problem, primary care practitioners can be trained to provide evaluations in local communities. However, usable and accurate tools developed for non-specialists are needed. The Screening Tool for Autism in Toddlers and Young Children (STAT) was created for this purpose, but limited research has been done on accuracy of the tool in community primary care. This study tested the STAT when used by primary care practitioners as part of a diagnostic evaluation in 130, 14- to 48-month-old children. We tested (1) STAT agreement with the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), and diagnosis based on an expert research evaluation, and (2) the relationship between STAT classification, primary care practitioner diagnosis, and expert diagnosis. STAT classification matched the ADOS-2 in 77% of cases and expert diagnosis in 78% of cases. Autistic children incorrectly classified by the STAT were older, had higher developmental and adaptive skills, and fewer autism symptoms. In 86% of cases, the STAT classification agreed with primary care practitioner diagnosis. STAT classification, primary care practitioner diagnosis, and expert diagnosis agreed in 73% of cases. Overall, the STAT shows good accuracy when used by primary care practitioners as part of a community primary care autism evaluation.

Behavioral assessment and treatment of self-injurious behavior in autism.

Self-injurious behaviors (SIB) are common in individuals who have autism and related developmental disabilities. When an individual engages in SIB, these behaviors frequently become the primary treatment target because of the potential for injury. A thorough behavioral assessment aimed at determining the function of the behaviors is the first step to developing a treatment plan. This article presents a brief background of SIB and a discussion of the behavioral assessment and treatment of these behaviors to familiarize readers with the behavioral perspective on SIB in individuals who have autism and other developmental disabilities.

Functional assessment of challenging behavior: toward a strategy for applied settings.

The development of experimental functional analysis and more recently functional analysis checklists have become common technologies for evaluating antecedent events and the consequences of problematic behaviors. Children and developmentally disabled persons across the life span with challenging behaviors have been the primary focus of this research. The primary purpose of this paper is to present an overview the developments in this rapidly expanding research literature, particularly as it involves the application of the functional assessment paradigm in applied settings where resources and time are scarce. Implication of the functional assessment research for clinical practice are discussed along with strengths and weakness of the current technology.

d-Cycloserine enhances durability of social skills training in autism spectrum disorder.

BACKGROUND: d-Cycloserine (DCS) enhances extinction learning across species, but it has proven challenging to identify consistent benefit of DCS when added to therapeutic interventions. We conducted a placebo-controlled trial of DCS to potentiate social skills training in autism spectrum disorder (ASD) but found substantial improvement in both the DCS and placebo groups at the conclusion of active treatment. Here, we assess the impact of DCS 11 weeks following active treatment to evaluate the impact of DCS on treatment response durability. METHODS: Study participants included 60 outpatient youth with ASD, ages 5-11 years, all with IQ above 70, and significantly impaired social functioning who completed a 10-week active treatment phase during which they received weekly single doses of 50 mg of DCS or placebo administered 30 min prior to group social skills training. Following the 10-week active treatment phase, blinded follow-up assessments occurred at week 11 and week 22. The primary outcome measure for our durability of treatment evaluation was the parent-rated social responsiveness scale (SRS) total raw score at week 22. RESULTS: Analysis of the SRS total raw score demonstrated significant decrease for the DCS group compared to the placebo group (p = 0.042) indicating greater maintenance of treatment effect in the DCS group. DCS was well tolerated, with irritability being the most frequently reported adverse effect in both groups. CONCLUSIONS: The findings of this study suggest that DCS may help youth with ASD to maintain skills gained during sort-term social skills training. Larger-scale studies with longer follow-up will be necessary to further understand the long-term impact of DCS paired with structured social skills training. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01086475.

The relationship of comorbid problem behaviors to social skills in persons with profound mental retardation.

Research into behavior problems among individuals with mental retardation has been well developed. However, few studies have addressed the effect of multiple problem behaviors on social skills. In the present study, the authors examined the relationship between two problem behaviors, stereotypy and self-injury, and social skills among individuals with profound mental retardation. A total of 120 participants were divided into four groups based on the presence of stereotypic and self-injurious behavior. Persons with comorbid stereotypy and self-injury evinced more negative nonverbal social skills than did those with self-injury alone or no problem behaviors. In the past, researchers examined behavior problems as isolated phenomena. However, a recent shift in the conceptualization of problem behaviors has exposed the lack of research regarding the nature of social and adaptive skills in the face of multiple topographies of problem behaviors using broader conceptualizations.

A randomized, placebo-controlled trial of D-cycloserine for the enhancement of social skills training in autism spectrum disorders.

BACKGROUND: Researchers have demonstrated that d-cycloserine (DCS) can enhance the effects of behavioral interventions in adults with anxiety and enhances prosocial behavior in animal models of autism spectrum disorders (ASD). This study extended upon this background by combining DCS with behavioral social skills therapy in youth with ASD to assess its impact on the core social deficits of ASD. We hypothesized that DCS used in combination with social skills training would enhance the acquisition of social skills in children with ASD. METHODS: A 10-week, double-blind, placebo-controlled trial of DCS (50 mg) given 30 min prior to weekly group social skills training was conducted at two sites. Children with ASD were randomized to receive 10 weeks (10 doses) of DCS or placebo in a 1:1 ratio. RESULTS: No statistically significant difference attributable to drug treatment was observed in the change scores for the primary outcome measure, the Social Responsiveness Scale (SRS), total score (p = 0.45), or on secondary outcome measures. CONCLUSIONS: The results of this trial demonstrated no drug-related short-term improvement on the primary outcome measure, or any of the secondary outcome measures. However, an overall significant improvement in SRS total raw score was observed from baseline to end of treatment for the entire group of children with ASD. This suggests a need to further study the efficacy of the social skills training protocol. Limitations to the current study and areas for future research are discussed. TRIAL REGISTRATION: ClinicalTrials.govNCT01086475.

Effect of Parent Training on Adaptive Behavior in Children With Autism Spectrum Disorder and Disruptive Behavior: Results of a Randomized Trial.

OBJECTIVE: This study examined the impact of parent training on adaptive behavior in children with autism spectrum disorder (ASD) and disruptive behavior. METHODS: This was a 24-week, 6-site, randomized trial of parent training versus parent education in 180 children with ASD (aged 3-7 years; 158 boys and 22 girls) and moderate or greater behavioral problems. Parent training included specific strategies to manage disruptive behavior over 11 to 13 sessions, 2 telephone boosters, and 2 home visits. Parent education provided useful information about autism but no behavior management strategies over 12 core sessions and 1 home visit. In a previous report, we showed that parent training was superior to parent education in reducing disruptive behavior in young children with ASD. Here, we test whether parent training is superior to parent education in improving daily living skills as measured by the parent-rated Vineland Adaptive Behavior Scales II. The long-term impact of parent training on adaptive functioning is also presented. RESULTS: At week 24, the parent training group showed a 5.7-point improvement from baseline on the Daily Living domain compared to no change in parent education (p = .004; effect size = 0.36). On the Socialization domain, there was a 5.9-point improvement in parent training versus a 3.1-point improvement in parent education (p = .11; effect size = 0.29). Gains in the Communication domain were similar across treatment groups. The gain in Daily Living was greater in children with IQ of >70. However, the interaction of treatment-by-IQ was not significant. Gains in Daily Living at week 24 were maintained upon re-evaluation at 24 weeks posttreatment. CONCLUSION: These results support the model that reduction in disruptive behavior can lead to improvement in activities of daily living. By contrast, the expected trajectory for adaptive behavior in children with ASD is often flat and predictably declines in children with intellectual disability. In the parent training group, higher-functioning children achieved significant gains in daily living skills. Children with intellectual disability kept pace with time. Clinical trial registration information-Randomized Trial of Parent Training for Young Children With Autism (RUBI); http://clinicaltrials.gov/; NCT01233414.

Clinical psychology Ph.D. program rankings: evaluating eminence on faculty publications and citations.

Program rankings and their visibility have taken on greater and greater significance. Rarely is the accuracy of these rankings, which are typically based on a small subset of university faculty impressions, questioned. This paper presents a more comprehensive survey method based on quantifiable measures of faculty publications and citations. The most frequently published core clinical faculty across 157 APA-approved clinical programs are listed. The implications of these data are discussed.

Multidisciplinary assessment and treatment of self-injurious behavior in autism spectrum disorder and intellectual disability: integration of psychological and biological theory and approach.

The objective of this review is to consider the psychological (largely behavioral) and biological [neurochemical, medical (including genetic), and pharmacological] theories and approaches that contribute to current thinking about the etiology and treatment of self-injurious behavior (SIB) in individuals with autism spectrum disorder and/or intellectual disability. Algorithms for the assessment and treatment of SIB in this context, respectively, from a multidisciplinary, integrative perspective are proposed and challenges and opportunities that exist in clinical and research settings are discussed.

Drug-refractory aggression, self-injurious behavior, and severe tantrums in autism spectrum disorders: a chart review study.

Aggression, self-injurious behavior, and severe tantrums are impairing symptoms frequently experienced by individuals with autism spectrum disorders. Despite US Food and Drug Administration approval of two atypical antipsychotics targeting these symptoms in youth with autistic disorder, they remain frequently drug refractory. We define drug-refractory aggression, self-injurious behavior, and severe tantrums in people with autism spectrum disorders as behavioral symptoms requiring medication adjustment despite previous trials of risperidone and aripiprazole or previous trials of three psychotropic drugs targeting the symptom cluster, one of which was risperidone or aripiprazole. We reviewed the medical records of individuals of all ages referred to our clinic for autism spectrum disorder diagnostic evaluation, as well as pharmacotherapy follow-up notes for all people meeting autism spectrum disorder criteria, for drug-refractory symptoms. Among 250 consecutively referred individuals, 135 met autism spectrum disorder and enrollment criteria, and 53 of these individuals met drug-refractory symptom criteria. Factors associated with drug-refractory symptoms included age 12 years or older (p < 0.0001), diagnosis of autistic disorder (p = 0.0139), and presence of intellectual disability (p = 0.0273). This pilot report underscores the significance of drug-refractory aggression, self-injurious behavior, and severe tantrums; suggests the need for future study clarifying factors related to symptom development; and identifies the need for focused treatment study of this impairing symptom domain.

The development and factor structure of the Functional Assessment for multiple causaliTy (FACT).

Since behavioral intervention is linked to the findings of a functional assessment, the reality of behaviors maintained by multiple functions is a frequent and troublesome issue for clinicians and researchers. Current methods of functional assessment provide little help in the way of providing information useful for prioritizing intervention strategies for problematic behaviors maintained by multiple functions. In an effort to account for this deficiency, we developed the Functional Assessment for multiple CausaliTy (FACT). The FACT is an informant-based, forced-choice measure designed to identify the most prominent function associated with the occurrence of problem behaviors. In the present study, we describe the factor structure and internal consistency of the FACT. Suggestions are provided for future validation strategies.

The association between self-injurious behaviors and autism spectrum disorders.

A key area of concern in children with autism spectrum disorders (ASDs) are self-injurious behaviors (SIBs). These are behaviors that an individual engages in that may cause physical harm, such as head banging, or self-biting. SIBs are more common in children with ASD than those who are typically developing or have other neurodevelopmental disabilities. Therefore, it is important that clinicians who work with children with ASD have a solid understanding of SIB. The purpose of this paper is to review the research on the epidemiology of SIB in children with ASD, factors that predict the presence of SIB in this population, and the empirically supported behavioral treatments available.

Toward an exportable parent training program for disruptive behaviors in autism spectrum disorders.

Autism spectrum disorders (ASD) are chronic conditions of early childhood onset characterized by profound deficits in social interaction, impaired communication, and repetitive behavior. The prevalence of ASD is now estimated to be 1 in 88 children. As the number of identified cases of ASD has grown, so have the challenges of serving these children and their families. Unfortunately, the empirical foundation for many interventions for this population is not firmly established. Thus, there is a pressing need to conduct trials that will expand the evidence base and guide clinical treatment. Investigators from the Research Units in Pediatric Psychopharmacology (RUPP; Indiana University, Ohio State University, University of Pittsburgh, Yale University) followed a treatment development model outlined by an NIMH ad hoc committee to develop and test a parent training (PT) treatment manual for children with ASD accompanied by disruptive behavior problems. This article describes the process of manual development and cross-site therapist training, establishment and maintenance of treatment integrity, assessment of treatment acceptance by families as well as primary outcomes of three trials. Results suggest the structured PT program can be delivered with a high degree of fidelity within and across therapists, is acceptable to parents and can produce significant reductions in disruptive behaviors in children with ASD.

Behavioral Therapy with an Individual with Asperger's Disorder.

Individuals with autism spectrum disorders have deficits in communication, social interactions, and emotional regulation and exhibit repetitive behaviors. These individuals can become very reactive to their environment and at times may engage in emotional outbursts. The social deficits seen in autism spectrum disorders are in part caused by the difficulty these individuals have with modulating their own anger and interpreting their own emotions and those of people around them. Individuals with autism spectrum disorders tend to learn and process visual information more effectively than auditory information. Thus, visual supports can help individuals with autism spectrum disorders process information more effectively. This article discusses the use of one particular visual support, an "emotions thermometer," in helping instruct individuals with autism spectrum disorders on recognizing and modulating their own emotions. The article also discusses anger management techniques that can be utilized once individuals have begun to recognize more subtle signs of irritability within themselves.