Behaviour support in dentistry: A Delphi study to agree terminology in behaviour management.

OBJECTIVES: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e-Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. METHODS: Following a registered protocol, a modified e-Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. RESULTS: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. DISCUSSION: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care.

Using behavioural skills training to treat aggression in adults with mild intellectual disability in a forensic setting.

BACKGROUND: Previous studies of anger management in people with intellectual disability failed to control for the effects of the number of provocative stimuli presented and lacked direct measures of behaviour and treatment integrity data. METHODS: This experiment systematically assessed and presented discriminative stimuli for aggressive behaviour, taught alternative behaviour in response to discriminative stimuli for aggressive behaviour and used behavioural skills training with three adults with mild intellectual disability. RESULTS: Following behavioural skills training, the adult's percentage of aggressive responses declined and replacement responses increased in response to provocative stimuli. Treatment gains generalized to novel antecedent events, novel staff and novel settings and were socially valid. After intervention, community trips increased for all three participants. CONCLUSIONS: Behavioural skills training to teach alternate behaviour to aggression with carefully planned procedures to promote generalization caused a socially valid increase in alternate behaviour and a socially valid decrease in aggression.

Treatment of psychopathology in people with intellectual and other disabilities.

OBJECTIVE: To review the psychosocial, pharmacological, and other treatments of psychopathology in people with intellectual disabilities (IDs), autism, and other developmental disabilities (DDs). METHOD: Systematic reviews and meta-analyses of psychosocial, pharmacological, and other treatments for people with DDs are reviewed. RESULTS: There is strong evidence for applied behaviour analysis (ABA) and other behavioural treatments of some forms of psychopathology. There is little good evidence to support the effectiveness of cognitive-behavioural therapy, cognitive therapy, sensory interventions, and other forms of psychosocial interventions. Recently, more randomized controlled trials (RCTs) of psychopharmacology have been published, especially with people with autism spectrum disorders. Most RCTs were for externalizing behaviour problems, rather than for psychopathology. These RCTs offer only preliminary support for the effectiveness of pharmacotherapy. No evidence was found for the effectiveness of other biological treatments. CONCLUSIONS: Current research supports the use of ABA and other behavioural interventions for some forms of psychopathology. Evidence for the effectiveness of other interventions is limited or absent.

Reinforcing efficacy of interactions with preferred and nonpreferred staff under progressive-ratio schedules.

Research has not systematically assessed and validated preferences for staff in adults with developmental disabilities. Three adults with developmental disabilities (aged 32 to 43 years) identified preferred and nonpreferred staff using verbal and pictorial preference assessments. During break-point analyses with progressive-ratio schedules, all 3 had higher break points when working for positive social interaction with their preferred staff mamber than with their nonpreferred staff member.

Effects of a Contingency for Quiz Accuracy on Exam Scores.

Completing frequent quizzes can improve exam scores; however, there is a lack of research on variables that influence quiz accuracy and whether there is an effect on exam scores. This study evaluated the effects of a contingency for quiz accuracy on quiz accuracy and exam performance. Eighty-one students enrolled in an introductory Learning course participated. For each class meeting and its related readings, the instructor assigned an online quiz due just before each class. During the no-contingency condition, the instructor assigned quizzes, but quiz accuracy did not result in points toward the final grade. During the accuracy-contingency condition, students earned points based on quiz accuracy. In a reversal design, the accuracy-contingency increased quiz accuracy and exam scores relative to no-contingency. Although many students benefited from the contingency, low-performing students were least likely to show a meaningful improvement in exam scores.

Correction to: Effects of a Contingency for Quiz Accuracy on Exam Scores.

[This corrects the article DOI: 10.1007/s40617-018-0226-z.].

Behaviour management problems as predictors of psychotropic medication and use of psychiatric services in adults with autism.

We examined behaviour management problems as predictors of psychotropic medication, use of psychiatric consultation and in-patient admission in a group of 66 adults with pervasive developmental disorder (PDD) and intellectual disability (ID) and 99 controls matched in age, gender and level of ID. Overall, people with PDD had higher rates of most DAS behaviour problems and more frequent use of anti-psychotics than matched controls. Logistic regression analyses showed that physical aggression and problems such as pestering staff independently predicted use of anti-psychotics. Physical aggression and overactivity predicted further involvement of psychiatric services. PDD diagnosis predicted admission to an in-patient unit. The results suggest that externalizing problem behaviours in adults with autism can predict type of treatment intervention.

Referral trends in mental health services for adults with intellectual disability and autism spectrum disorders.

Researchers have paid increasing attention to mental health issues in adults with autism spectrum disorders (ASDs) over the last decades. However, little is known about how rates of clinical referrals, types of mental health diagnoses and treatment in adults with ASDs and intellectual disability have changed. We examined patterns of change in referral trends to specialist mental health services in south London from 1983 to 2000 (N = 137). The majority of the cases (58.4%) did not have a diagnosable psychiatric disorder. Schizophrenia was the most frequent psychiatric diagnosis followed by depression, adjustment reaction and anxiety. There was a significant change in the rate of referrals, an increase in the diagnosable psychiatric disorders over time and a significant reduction of medication at time of referral. There were no significant changes in the use of other therapeutic interventions. The proportion of participants living independently increased. Implications for services and future research are discussed.

The effects of verbal instruction, modeling, rehearsal, and feedback on correct posture during flute playing.

A behavioral skills training package, including verbal instruction, modeling, rehearsal, and feedback, was used to teach children correct posture, defined as keeping feet on the floor, legs parallel to each other, and the back and neck perpendicular to the floor, during flute lessons. Three typically developing girls aged 8 to 9 years participated. All three students' posture improved from 0% during baseline to nearly 100% after training for all sessions, generalization probes, and after a 1- to 2-month follow-up. The training package was proven effective in the acquisition, generalization, and maintenance of correct posture for flute playing.

Reducing student stereotypy by improving teachers' implementation of discrete-trial teaching.

Discrete-trial teaching is an instructional method commonly used to teach social and academic skills to children with an autism spectrum disorder. The purpose of the current study was to evaluate the indirect effects of discrete-trial teaching on 3 students' stereotypy. Instructions, feedback, modeling, and rehearsal were used to improve 3 teaching aides' implementation of discrete-trial teaching in a private school for children with autism. Improvements in accurate teaching were accompanied by systematic decreases in students' levels of stereotypy.

Training parent implementation of discrete-trial teaching: effects on generalization of parent teaching and child correct responding.

Behavioral skills training was used to teach 3 parents to implement discrete-trial teaching with their children with developmental disabilities. Parents learned to implement discrete-trial training, their skills generalized to novel programs, and the children's correct responding increased, suggesting that behavioral skills training is an effective and efficient method of teaching discrete-trial teaching to parents.

The effects of errorless learning and backward chaining on the acquisition of Internet skills in adults with developmental disabilities.

An important area in the learning and development of individuals with disabilities is the acquisition of independent, age-appropriate leisure skills. Three adults with autism and mental retardation were taught to access specific Internet sites using backward chaining and most-to-least intrusive prompting. The number of independent steps completed in the task analysis increased following training.

Generalized imitation of facial models by children with autism.

Imitation is an essential skill in the acquisition of language and communication skills. An initial phase in teaching young children with autism to engage in appropriate affective responding may be to teach the imitation of facial models. Using a multiple baseline across participants design, imitation training (consisting of modeling, prompting, differential reinforcement, and error correction) was introduced successively across 3 participants. Low and inconsistent rates of imitation of facial models were observed in baseline. All of the participants learned to imitate some of the facial models presented during imitation training, but only 2 of the 3 participants demonstrated generalized responding across stimuli.

The Use of Behavioral Skills Training to Teach Graph Analysis to Community Based Teachers.

In this study, the experimenter trained three teachers to implement data decision rules to detect when instructional changes should be made during the visual analysis of discrete-trial percentage graphs. The experimenter used a concurrent, multiple-baseline design across participants. The experimenter trained the teachers to follow decision-making rules using instruction, modeling, rehearsal, and feedback. Following intervention, participants increased the percentage of correct data-based decisions and decreased the percentage of errors.

The effects of lag schedules and preferred materials on variable responding in students with autism.

Effects of a Lag 1 reinforcement schedule on appropriate and varied responding to the social question, "What do you like to do?" and effects of the proportion of preferred stimuli present during training on the amount of varied responding in each session were investigated with students with autism. An ABAB reversal design and a multielement design were used to evaluate the effects of the Lag schedule and proportion of preferred stimuli, respectively. Results showed that a Lag 1 schedule was effective at increasing varied vocal responding for 2 of 3 participants. The proportion of stimuli that were preferred did not affect the amount of varied responding emitted.

Psychopathology in adults with autism and intellectual disability.

There have been few studies of psychopathology in adult with autism. This study examined psychiatric co-morbidity in 147 adults with intellectual disability (ID) and autism and 605 adults with ID but without autism. After controlling for the effects of gender, age, psychotropic medication and level of ID, people with autism and ID were no more likely to receive a psychiatric diagnosis than people with ID only. People with autism were less likely to receive a diagnosis of personality disorder. These findings cast doubts on the hypothesis that adults with ID and autism are more vulnerable to certain psychiatric disorders than non-autistic adults with ID.

Behavioral treatment of challenging behaviors in individuals with mild mental retardation: meta-analysis of single-subject research.

A meta-analytic study on effectiveness of behavioral and psychotherapeutic treatments for challenging behaviors in individuals with mild mental retardation is reported. Eighty articles were examined. For each comparison, several study variables and two effect sizes (percentage of nonoverlapping data-PND and percentage of zero data-PZD) were evaluated (Ms = 75% and 35%, respectively). Studies in which experimental designs and methods of experimental functional analysis were used had significantly larger PNDs than those with AB designs and descriptive methods, respectively. Functional analysis, reliability of recording, generalization, and internally valid designs resulted in larger PZDs. We found that behavioral interventions for challenging behaviors are effective with people with mild mental retardation.

A comparison of the impact of information from a clinician and research-based information on patient treatment choice in dentistry.

OBJECTIVES: There is an imperative that clinicians should employ an evidence-based approach to both clinical care and treatment, and involve patients in the decision-making process. In Britain, public policy emphasizes the importance of patient involvement, participation and partnership in health care, however little is known of the effect of evidence-based information on this. This study compares treatment decisions made by dental patients on the basis of two sources of evidence: clinician and research. METHOD: Vignette method with the two sources of evidence as experimental variables. The study population was a convenience sample of dental patients recruited from a clinic waiting area at a Dental Hospital (n=100). Each participant read a vignette describing a visit to the dentist for treatment of severe toothache in a back tooth. The nature and purpose of the visit was identical in each vignette. The participants indicated their decision about possible treatment, based on the information they had been given in the vignette and rated their confidence in the decision on a three point Likert scale. Additionally participants' were asked to rate their own oral health. RESULTS: Research evidence influences the confidence patients have in their in decision especially when it supports clinical judgement and where individuals value their oral health. Research evidence does not replace the confidence that patients have in the dentist's clinical judgement. CONCLUSION: Dental patients' willingness to engage in treatment is influenced by the dentist's clinical recommendation and the importance of oral health to the patient.

Psychiatric inpatient admissions of adults with intellectual disabilities: predictive factors.

Information on admission to psychiatric inpatient units is lacking from the literature on contemporary services for people with intellectual disability and mental health needs. Here we report on predictors of admission for a cohort of 752 adults from this population living in community settings; 83 were admitted. We also report on two subsamples of this cohort for whom different psychometric measures concerned with psychiatric symptoms and behavior had been completed. Schizophrenia spectrum disorders and mild intellectual disabilities independently predicted admission for the total cohort. The presence of symptoms associated with psychosis and the presence of physical aggression predicted admission in the subsamples.

Secretin is an ineffective treatment for pervasive developmental disabilities: a review of 15 double-blind randomized controlled trials.

In 1998, Horvath et al. [Horvath, K., Stefanatos, G., Sokolski, K. N., Wachtel, R., Nabors, L., & Tildon, J. T. (1998). Improved social and language skills after secretin administration in patients with autism spectrum disorders. Journal of the Association of the Academy of Minority Physicians, 9, 9-15] reported an uncontrolled trial of secretin with three participants with autism, which apparently resulted in significant behavioral improvement. Subsequently, secretin was widely used. Sandler et al. [Sandler, A. D., Sutton, K. A., SeWeese, J., Girardi, M. A., Sheppard, V., & Bodfish, J. W. (1999). Lack of benefit of a single dose of synthetic human secretin in the treatment of autism and pervasive and developmental disorder. The New England Journal of Medicine, 341, 1801-1806] reported the first double-blind trial of secretin with negative results. This article is a review of 15 double-blind trials of secretin. Almost none of the studies reported any significant effects and none concluded that secretin was effective. Transient effects of secretin, including both minor benefits and behavioral deterioration were reported, probably due to multiple statistical tests. Four papers reported data on differential responding in sub-groups of participants, including those with gastrointestinal symptoms. These effects were not replicable. At this time there is no robust evidence that secretin is an effective treatment for pervasive developmental disorders.